This a ppt presentation which gives an introduction to Rb diagnosis and treatment in a simple, concise way. This presentation was prepared by me to be presented for doctoral degree students, pediatric coarse at the Department of Clinical Oncology & Nuclear Medicine, Alexandria University, Egypt.

1. Retinoblastoma..Retinoblastoma..
a brief overviewa brief overview!!
ByBy
Osama El-ZaafaranyOsama El-Zaafarany
Assistant lecturer of clinical oncologyAssistant lecturer of clinical oncology
Medical Research instituteMedical Research institute
Alexandria UniversityAlexandria University
April 2013April 2013

2. BackgroundBackground
• Retinoblastoma is the most commonRetinoblastoma is the most common intraocularintraocular
tumor and the Seventh most common solid tumortumor and the Seventh most common solid tumor
in childhood.in childhood.
• Occurring in approximately 1 in 15,000 live birthsOccurring in approximately 1 in 15,000 live births
in the United States.in the United States.
• Approximately 95 % before the age of five.Approximately 95 % before the age of five.
• The incidence is similar in boys and girls andThe incidence is similar in boys and girls and
among blacks and whites.among blacks and whites.
• bilateral in 30% ;bilateral in 30% ; < 12 months.< 12 months.

3. SPORADICSPORADIC
(Non-hereditary)(Non-hereditary)
FAMILIALFAMILIAL
(Hereditary)(Hereditary)
Unilateral, unifocal.Unilateral, unifocal. 85% bilateral, multifocal.85% bilateral, multifocal.
60% of all cases.60% of all cases. 40% of all cases.40% of all cases.
Present later.Present later. Present earlierPresent earlier..
Children of the affected areChildren of the affected are
normal.normal.
Children of the affected have 45%Children of the affected have 45%
chance of inheritance.chance of inheritance.
Chromosomal anomaly is aChromosomal anomaly is a
somatic mutation.somatic mutation.
Chromosomal anomaly is a germlineChromosomal anomaly is a germline
mutation.mutation.
Relatives have a low risk of RBRelatives have a low risk of RB
development.development.
Relatives have a high risk of RBRelatives have a high risk of RB
development.development.
Increased risk for secondIncreased risk for second
malignanciesmalignancies ⇒⇒ sarcomas, melanoma, andsarcomas, melanoma, and
cancers of the brain and nasal cavities.cancers of the brain and nasal cavities.
Autosomal dominant with highAutosomal dominant with high
penetrance.penetrance.

4. PathogenesisPathogenesis::
• Mutational inactivation ofMutational inactivation of both allelesboth alleles ofof
the retinoblastoma (RB1) gene.the retinoblastoma (RB1) gene.
• On chromosome 13q14.On chromosome 13q14.
• Encodes a nuclear protein that acts as aEncodes a nuclear protein that acts as a
tumor suppressor and cell cycle regulator;tumor suppressor and cell cycle regulator;
checkpoint between G1 & S-phase.checkpoint between G1 & S-phase.
• Normal individual inherits two copies ofNormal individual inherits two copies of
this gene one from each parent.this gene one from each parent.

5. A "two-hit" modelA "two-hit" model
Sporadic retinoblastoma:Sporadic retinoblastoma:
 First hit occurs after conception inFirst hit occurs after conception in
utero or in early childhood in retinalutero or in early childhood in retinal
cells.cells.
 All cells in body are not affected asAll cells in body are not affected as
germ cells are notgerm cells are not involvedinvolved..
 Second somatic mutation results inSecond somatic mutation results in
loss of other normal allele.loss of other normal allele.

6. Hereditary retinoblastomaHereditary retinoblastoma
 Child starts with heterozygous allelesChild starts with heterozygous alleles
(RB/RB+).(RB/RB+).
 Only one mutation is required toOnly one mutation is required to
produce disease.produce disease.
 First hit occurs in utero in germ cellsFirst hit occurs in utero in germ cells
before conception or is inherited frombefore conception or is inherited from
a parent.a parent.
 All cells of body affected.All cells of body affected.
 Second hit occurs in any retinal cell.Second hit occurs in any retinal cell.

7. Natural history & PrognosisNatural history & Prognosis::
If untreated:If untreated:
 Retinoblastoma grows to fill the eye (Retinoblastoma grows to fill the eye (within 6within 6
monthsmonths) and destroys the internal) and destroys the internal
architecture of the globe.architecture of the globe.
 Metastatic spread usually begins after sixMetastatic spread usually begins after six
months. =>months. => BM, bone, cx LNs, liverBM, bone, cx LNs, liver
 Death occurs within a matter of yearsDeath occurs within a matter of years

9.  The 5-year OS rate for children with retinoblastoma inThe 5-year OS rate for children with retinoblastoma in
the United States is 93 %.the United States is 93 %.
 A child who remains recurrence free for 5 years afterA child who remains recurrence free for 5 years after
diagnosis is considered cured.diagnosis is considered cured.
 5-year DFS for Intraocular RB >90%.5-year DFS for Intraocular RB >90%.
(extraocular <10%)(extraocular <10%)
 1-year survival rate for patients with hematogenous1-year survival rate for patients with hematogenous
metastases are approximately 50 %.metastases are approximately 50 %.

10.  The risk of aThe risk of a second malignancysecond malignancy is 40 % at 50≃is 40 % at 50≃
years after the original treatment in patients withyears after the original treatment in patients with
hereditaryhereditary retinoblastoma.retinoblastoma.
 This risk is markedly increased in those who wereThis risk is markedly increased in those who were
treated with radiation therapy when they weretreated with radiation therapy when they were
younger than one year of age.younger than one year of age.
 Child with RB who receive carboplatin are at riskChild with RB who receive carboplatin are at risk
for hearing loss and require long-term audiometricfor hearing loss and require long-term audiometric
follow-up.follow-up.
 The preservation of vision is better if the tumors areThe preservation of vision is better if the tumors are
small and do not involve the fovea.small and do not involve the fovea.

11.  Eye preservations rates range among series fromEye preservations rates range among series from
~60 to 90% when using EBRT and depend on~60 to 90% when using EBRT and depend on
extent of disease.extent of disease.
 Group E patients have eye preservation rates ofGroup E patients have eye preservation rates of
only 2%.only 2%.
 Visual preservation rates range among series fromVisual preservation rates range among series from
~65 to 100% for Groups I–III but are lower for~65 to 100% for Groups I–III but are lower for
Groups IV–V.Groups IV–V.
 Median survival of trilateral RB was 9 months.Median survival of trilateral RB was 9 months.

13. Poor prognostic factorsPoor prognostic factors::
 Optic nerveOptic nerve,, choroidal or orbital invasion ⇒choroidal or orbital invasion ⇒
risk of metastatic disease.risk of metastatic disease.
 Delay in diagnosis of more thanDelay in diagnosis of more than six monthssix months..
 intraocular surgeryintraocular surgery ⇒⇒ vitreous seeding andvitreous seeding and
extraocular spread.extraocular spread.
 Cataract.Cataract.
 EBRTxEBRTx ⇒⇒ secondary cancers; particularly insecondary cancers; particularly in
patients with the heritable form of RB.patients with the heritable form of RB.

14.  Risk factors for extension into the optic N:Risk factors for extension into the optic N:
• Exophytic growth pattern.Exophytic growth pattern.
• Elevated intraocular pressure.Elevated intraocular pressure.
• Tumor thickness ≥15 mm.Tumor thickness ≥15 mm.
 Risk factors for extension into the choroid:Risk factors for extension into the choroid:
• Elevated I.O. pressure.Elevated I.O. pressure.
• Iris neovascularization.Iris neovascularization.

15. DiagnosisDiagnosis::
The diagnosis of retinoblastoma can usuallyThe diagnosis of retinoblastoma can usually
be made during a dilated indirectbe made during a dilated indirect
ophthalmoscopic examinationophthalmoscopic examination that isthat is
performed under anesthesia;performed under anesthesia;
the characteristic findingthe characteristic finding
is a chalky, white-grayis a chalky, white-gray
retinal mass withretinal mass with
a soft, friable consistencya soft, friable consistency

16. • Leukocoria (60%) Strabismus (20%) Secondary glaucoma
Anterior segment invasion •Orbital inflammat. • Orbital invasion
Presentations of retinoblastoma

17. Pattern of growthPattern of growth::

18. To confirm the diagnosisTo confirm the diagnosis::
 Ocular U/S:Ocular U/S:
• Demonstrates a mass more echogenic than theDemonstrates a mass more echogenic than the
vitreous on B mode.vitreous on B mode.
• Highly reflective intrinsicHighly reflective intrinsic
echoes of fine calcificationsechoes of fine calcifications
on A mode.on A mode.
• Accuracy 80 %.Accuracy 80 %.
 computed tomography:computed tomography:
• may demonstrate a solidmay demonstrate a solid
intraocular tumor withintraocular tumor with
characteristic intratumoralcharacteristic intratumoral
calcifications.calcifications.

19.  Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)::
• tumor size.tumor size.
• optic nerve involvement.optic nerve involvement.
• the presence of an associated intracranialthe presence of an associated intracranial
lesionlesion→→ Tri-lateral RB.Tri-lateral RB.
• preferred in children younger than one year ofpreferred in children younger than one year of
ageage →→ avoid cancer risk that increase with CTavoid cancer risk that increase with CT

20. C T MRIC T MRI

21.  FNACFNAC from tumor should be avoidedfrom tumor should be avoided =>=>
increase risk of vitreous seeding.increase risk of vitreous seeding.
 if there is clear evidence of tumor outsideif there is clear evidence of tumor outside
the eye, the fullthe eye, the full metastatic evaluationmetastatic evaluation
should be done:should be done:
• bone marrow examination (aspiration andbone marrow examination (aspiration and
biopsy).biopsy).
• lumbar puncture.lumbar puncture.
• bone scan.bone scan.

22. Differential diagnosis of leukocoria
Congenital cataract
Unilateral or bilateral Unilateral
Inflammatory cyclitic
membrane
Persistent hyperplastic
primary vitreous
Unilateral or bilateral
Coats disease
Unilateral Unilateral
Advanced retinopathy
of prematurity
Posterior pole toxocara
granuloma
Always bilateral but
may be asymmetrical

23. stagingstaging
 The most commonly used system is theThe most commonly used system is the Reese-Reese-
Ellsworth systemEllsworth system, which predicts the chance of, which predicts the chance of
visual preservation well, but not survival.visual preservation well, but not survival.
 TheThe Abramson-Grabowski systemAbramson-Grabowski system addresses bothaddresses both
intraocular and extraocular Rb.intraocular and extraocular Rb.
 TheThe International Classifcation (“ABCDE”) systemInternational Classifcation (“ABCDE”) system
for intraocular Rbfor intraocular Rb is under modifcation and is usedis under modifcation and is used
in recent clinical protocols.in recent clinical protocols.
 TheThe AJCC TNM systemAJCC TNM system..

24. The International Classifcation system for intraocular RbThe International Classifcation system for intraocular Rb
From COG Protocol ARET0331 (with permission): Trial of systemic neoadjuvant chemotherapy for Group BFrom COG Protocol ARET0331 (with permission): Trial of systemic neoadjuvant chemotherapy for Group B
Intraocular Retinoblastoma: A Phase III Limited Institution Study. Available atIntraocular Retinoblastoma: A Phase III Limited Institution Study. Available at
https://members.childrensoncologygroup.org/Prot/ARET0331/ARET0331DOC.pdf.https://members.childrensoncologygroup.org/Prot/ARET0331/ARET0331DOC.pdf.

26. TreatmentTreatment
Goals of treatment:Goals of treatment:
 Save life.Save life.
 Preserve vision or salvage eyePreserve vision or salvage eye
(i.e. avoid enucleation).(i.e. avoid enucleation).
 Minimize any complications or side effects ofMinimize any complications or side effects of
therapy.therapy.

27. Treatment options:Treatment options:
 Enucleation & Exenteration.Enucleation & Exenteration.
 EBRTx.EBRTx.
 Local therapies:Local therapies:
• Plaque RTx.Plaque RTx.
• Laser photocoagulation.Laser photocoagulation.
• Cryotherapy.Cryotherapy.
• Thermotherapy.Thermotherapy.
 Chemoreduction:Chemoreduction:
• I.V.I.V.
• Subcojunctival.Subcojunctival.
 Chemotherapy.Chemotherapy.

28. Traditional Treatment:Traditional Treatment:
 Unilat. RBUnilat. RB ⇒⇒Enucleation F.U till school age.⇒Enucleation F.U till school age.⇒
 Bilat. RBBilat. RB ⇒⇒ Enucleation for more advanced side &Enucleation for more advanced side &
EBRTx for less adv side.EBRTx for less adv side.
 Metas. RBMetas. RB Ctx.⇒ Ctx.⇒

29. Recent Treatment of Retinoblastoma
1. Small tumours
• Laser photocoagulation
• Transpupillary thermotherapy
• Cryotherapy
2. Medium tumours
• Brachytherapy
• Chemotherapy
• External beam radiotherapy
3. Large tumours
• Chemotherapy followed by local treatment
• Enucleation
4. Extraocular extension
• External beam radiotherapy
5. Metastatic disease
• Chemotherapy

31. EnucleationEnucleation
 Involves removal of the eye leaving behindInvolves removal of the eye leaving behind
lids and extraocular muscles but removinglids and extraocular muscles but removing
the longest possible segment (10 to 15mm)the longest possible segment (10 to 15mm)
of optic nerve in continuity with the globe.of optic nerve in continuity with the globe.
 Care should be taken to avoid perforation ofCare should be taken to avoid perforation of
the globe to prevent seeding.the globe to prevent seeding.

33. Indications of Enucleation:Indications of Enucleation:
• Large tumors (Large tumors ( >50 % of globe volume>50 % of globe volume) with no) with no
visual potential.visual potential.
• Tumors that extend into the optic nerve.Tumors that extend into the optic nerve.
• Blind or painful eyes.Blind or painful eyes.
• Group E tumors that have failed previous "globe-Group E tumors that have failed previous "globe-
conserving" approaches.conserving" approaches.
• Group D tumors. (Group D tumors. (significant vitr seed, subretin infiltsignificant vitr seed, subretin infilt.).)
• Secondary glaucoma.Secondary glaucoma.
• Vitreous seeding.Vitreous seeding.
• Anterior chamber invasion.Anterior chamber invasion.
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Hurwitz RL, Shields CL, Shields JA, et al.. Retinoblastoma. In: Principles and Practice of
Pediatric Oncology, 6th ed, Pizzo PA, Poplack DG (Eds), Lippincott Williams & Wilkins,
Philadelphia 2011. p.809.

34. Adjuvant chemo after enucleation:Adjuvant chemo after enucleation:
considered in patients withconsidered in patients with high-risk featureshigh-risk features::
• iris, ciliary body infiltrationiris, ciliary body infiltration
• massive choroidal or scleral infiltration,massive choroidal or scleral infiltration,
• invasion of the optic nerve posterior to the laminainvasion of the optic nerve posterior to the lamina
cribrosacribrosa..
Adjuvant EBRTxAdjuvant EBRTx should be considered inshould be considered in
extrascleral extension.extrascleral extension.

35. ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
‫ــــــــــــــــــــــــــــــــــــــــ‬Orphanet Journal of Rare Diseases 2006, 1:31

36. Post-enucleation follow-up:Post-enucleation follow-up:
 Child must be monitored closely for orbital relapseChild must be monitored closely for orbital relapse
in thein the two yearstwo years after surgery. (after surgery. (All recurrences areAll recurrences are
diagnosed within 24 months of enucleationdiagnosed within 24 months of enucleation).).
 the incidence of orbital recurrence afterthe incidence of orbital recurrence after
enucleation is 4.2%.enucleation is 4.2%.
 The majority of patients (85 %) with orbitalThe majority of patients (85 %) with orbital
recurrence also developed metastatic disease.recurrence also developed metastatic disease.
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Kim JW, Kathpalia V, Dunkel IJ, et al. Orbital recurrence of retinoblastoma following
enucleation. Br J Ophthalmol 2009; 93:463.

37. Orbital implants:Orbital implants:
 Historically not used due toHistorically not used due to
potential interference withpotential interference with
palpation of the socket andpalpation of the socket and
clinical detection of orbitalclinical detection of orbital
recurrence.recurrence.
 However CT/MR allow detailedHowever CT/MR allow detailed
orbital analysis despite anorbital analysis despite an
implant.implant.
 Orbital implant (typically hydroxyapatite) is placed at theOrbital implant (typically hydroxyapatite) is placed at the
time of enucleation.time of enucleation.
 After the overlying conjunctiva has healed (approximatelyAfter the overlying conjunctiva has healed (approximately
3 months), a prosthesis can be fitted by an ocularist.3 months), a prosthesis can be fitted by an ocularist.

38. External beam RTExternal beam RT::
It is currentlyIt is currently rarely utilizedrarely utilized
may be considered for:may be considered for:
• Large bilateral tumors.Large bilateral tumors.
• Vitreous seeding.Vitreous seeding.
• Thick tumors near the optic nerve or fovea inThick tumors near the optic nerve or fovea in
the eye with visual potential.the eye with visual potential.
• Multiple tumors that are too large forMultiple tumors that are too large for
cryotherapy or laser photocoagulation.cryotherapy or laser photocoagulation.
• Recurrent dis.Recurrent dis.
• Progression on chemoreduction.Progression on chemoreduction.

39. Complications of EBRTx:Complications of EBRTx:
• Second cancers, particularly in patients withSecond cancers, particularly in patients with
hereditary RB.hereditary RB.
• Damage to the retina, optic nerve, lacrimalDamage to the retina, optic nerve, lacrimal
gland, lens and loss of eyelashes.gland, lens and loss of eyelashes.
• Midface hypoplasia.Midface hypoplasia.
The risk of tumor recurrence following EBRTxThe risk of tumor recurrence following EBRTx
is 7 % within 40 months.is 7 % within 40 months.
‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Fletcher O, Easton D, Anderson K, et al. Lifetime risks of common cancers among
retinoblastoma survivors. J Natl Cancer Inst 2004; 96:357.
Singh AD, Garway-Heath D, Love S, et al. Relationship of regression pattern to recurrence in
retinoblastoma. Br J Ophthalmol 1993; 77:12.

40. Target volume:Target volume: entire retina upto ora serrata andentire retina upto ora serrata and
atleast 1 cm of Optic N.atleast 1 cm of Optic N.
Dose:Dose:
 Definitive R/ 45-50.4 Gy; (1.8 Gy/Fx.)⇒Definitive R/ 45-50.4 Gy; (1.8 Gy/Fx.)⇒
 Post-opr R/ micro residual: 45 Gy.⇒Post-opr R/ micro residual: 45 Gy.⇒
⇒⇒ macro residual: 50.4 Gy.macro residual: 50.4 Gy.
 Child < 1y definitive: 45 Gy.⇒Child < 1y definitive: 45 Gy.⇒
⇒⇒ post-opr: 39.6 Gy.post-opr: 39.6 Gy.

41. Technique:Technique:
Classic single temporalClassic single temporal
portal 3×4 cm, anteriorportal 3×4 cm, anterior
border at lateral bonyborder at lateral bony
canthus with posteriorcanthus with posterior
151500
tilt (D-shaped field).tilt (D-shaped field).
Other plan:Other plan:
Anterolateral differentiallyAnterolateral differentially
weighted beams withweighted beams with
anterior lens shield.anterior lens shield.

43. Recent techniques:Recent techniques:
3D-CRTx, IMRT, Proton:3D-CRTx, IMRT, Proton:
• Four non coFour non co--planar fieldsplanar fields
• All anterior oblique fieldAll anterior oblique field::
(sup,inf, med, lat(sup,inf, med, lat..((
• Less orbital hypoplasiaLess orbital hypoplasia..
• Minimize dose to opposite eye,Minimize dose to opposite eye,
optic chiasma, postoptic chiasma, post.. PituitaryPituitary
and upper cervical spineand upper cervical spine..
• More homogenous doseMore homogenous dose
distributiondistribution..
• Less vitreal recurrenceLess vitreal recurrence..

45. Treatment results with EBRTx:Treatment results with EBRTx:
 Preservation of the eye with control of the diseasePreservation of the eye with control of the disease
using EBRTx is in the range of 58–88%using EBRTx is in the range of 58–88%..
 95% rate of preservation of The eye in R-E groups95% rate of preservation of The eye in R-E groups
I–III.I–III.
 50% local control rate in R-E groups IV and V50% local control rate in R-E groups IV and V
disease.disease.
‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Murali C, Particia C, Evelyn A. Retinoblastoma: Review of Current Management. The Oncologist
2007;12:1237–1246

46. Radioactive plaquesRadioactive plaques::
 II125125
brachytherapy.brachytherapy.
 The radiation dose is approximately 40 to 45 GyThe radiation dose is approximately 40 to 45 Gy
delivered to the tumor apex.delivered to the tumor apex.
 As a primary treatment, it can control approximatelyAs a primary treatment, it can control approximately
90 % of tumors90 % of tumors
 The tumor must be <15 mm in diameter and <10 mmThe tumor must be <15 mm in diameter and <10 mm
thickness.thickness.
‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Shields CL, Shields JA, Cater J, et al. Plaque radiotherapy for retinoblastoma: long-term tumor
control and treatment complications in 208 tumors. Ophthalmology 2001; 108:2116.

47.  Plaques are contraindicated if RT needs to bePlaques are contraindicated if RT needs to be
delivered to multiple tumor foci in each eye.delivered to multiple tumor foci in each eye.
 The amount of RT delivered to the optic nerve andThe amount of RT delivered to the optic nerve and
fovea must be carefully considered, particularly iffovea must be carefully considered, particularly if
there is potential for preserved vision.there is potential for preserved vision.
 Placement of plaques can be technically difficultPlacement of plaques can be technically difficult
and requires a second surgical procedure forand requires a second surgical procedure for
removal.removal.
 Often preferred to external beam RT delivers⇒Often preferred to external beam RT delivers⇒
less radiation to bone and adjacent soft tissue ⇒less radiation to bone and adjacent soft tissue ⇒
reduced risk of second tumors.reduced risk of second tumors.

48.  Ruthenium-106Ruthenium-106 (Ru(Ru106106
) is an alternative:) is an alternative:
• For small tumors (thickness less than 6 mm)For small tumors (thickness less than 6 mm)
• reduces the radiation dose to the uninvolved retina,reduces the radiation dose to the uninvolved retina,
lens, and optic nerve, thus decreasing radiation-inducedlens, and optic nerve, thus decreasing radiation-induced
vision loss.vision loss.
 Children managed with brachytherapy should beChildren managed with brachytherapy should be
monitored for the evelopment of radiationmonitored for the evelopment of radiation
retinopathy and optic neuropathy.retinopathy and optic neuropathy.
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Schueler AO, Flühs D, Anastassiou G, et al. Beta-ray brachytherapy with 106Ru plaques
for retinoblastoma. Int J Radiat Oncol Biol Phys 2006; 65:1212.

49.  Curved applicator to fit the eye with suture holes for fixing.Curved applicator to fit the eye with suture holes for fixing.
 Left in place for 3 to 7 days to deliver 40 Gy to tumor apexLeft in place for 3 to 7 days to deliver 40 Gy to tumor apex
and 10 to 200 Gy to tumor base.and 10 to 200 Gy to tumor base.

50. Treatment results with plaque RTx:Treatment results with plaque RTx:
 Tumor recurrence 6.3% within 9.7 ms.Tumor recurrence 6.3% within 9.7 ms.
 Radiation retinopathy at 2 ys: 19%.⇒Radiation retinopathy at 2 ys: 19%.⇒
⇒⇒ at 5 ys: 22%.at 5 ys: 22%.
 Opt neuropathy at 5 ys 21%.⇒Opt neuropathy at 5 ys 21%.⇒
 Cataract at 5 ys 17.4%.⇒Cataract at 5 ys 17.4%.⇒
 In cases of recurrent or residual retinoblastoma inIn cases of recurrent or residual retinoblastoma in
which the only other option was enucleation.which the only other option was enucleation.
Tumor control and globe salvage were achieved inTumor control and globe salvage were achieved in
89% of cases with plaque irradiation during a89% of cases with plaque irradiation during a
mean follow-up of 52 months.mean follow-up of 52 months.
‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Shields JA, Shields CL, DePotter P, et al. Plaque radiotherapy for residual or recurrent
retinoblastoma in 91 cases. J Pediatr Ophthamol Strab 1994;31:242-5.

51. Cryotherapy and laserCryotherapy and laser
photocoagulationphotocoagulation::
 Can be used to treat smaller tumors (<6 mm inCan be used to treat smaller tumors (<6 mm in
diameter and <3 mm thick).diameter and <3 mm thick).
 Tumor usually regresses within six weeks.Tumor usually regresses within six weeks.
 Complications of these methods include transientComplications of these methods include transient
serous retinal detachment, visually significantserous retinal detachment, visually significant
retinal vascular occlusion, retinal traction, andretinal vascular occlusion, retinal traction, and
preretinal fibrosis.preretinal fibrosis.

52. Cryotherapy:Cryotherapy:
• Under GA, pencil like probe is placedUnder GA, pencil like probe is placed
precisely on the sclera directly behind theprecisely on the sclera directly behind the
intraocular focus of RB.intraocular focus of RB.
• Rapid freezing forms intracellular crystalsRapid freezing forms intracellular crystals
which ruptures tumor cells and causeswhich ruptures tumor cells and causes
vascular occlusion.vascular occlusion.
• 1 or 2 sessions at 1 month interval are1 or 2 sessions at 1 month interval are
required.required.

53. laser photocoagulationlaser photocoagulation::
• Argon/Diode laser/Xenon arc.Argon/Diode laser/Xenon arc.
• Light is focused through dilated pupil under GALight is focused through dilated pupil under GA
and vessels are coagulated which results inand vessels are coagulated which results in
involution of tumor.involution of tumor.
• Most tumors require 2 to 3 sessions to be cured.Most tumors require 2 to 3 sessions to be cured.
• Contraindications:Contraindications:
 Tumor located at or near macula or pupillary areTumor located at or near macula or pupillary are
 Mushroom shaped tumorsMushroom shaped tumors
 Tumors arising from a vitreous base.Tumors arising from a vitreous base.

54. ChemotherapyChemotherapy::
 Retinoblastoma is a chemo-sensitive malignancy.Retinoblastoma is a chemo-sensitive malignancy.
 The most active agents areThe most active agents are carboplatincarboplatin andand vincristinevincristine
with or withoutwith or without etoposideetoposide..
 Indications:Indications:
• Vision salvage and delay or avoidance of radiotherapy inVision salvage and delay or avoidance of radiotherapy in
patients withpatients with bilateral diseasebilateral disease..
• Tumor shrinkage in patients with unilateral disease, goodTumor shrinkage in patients with unilateral disease, good
vision, and a tumor that isvision, and a tumor that is too large for isolated local therapytoo large for isolated local therapy
• MetastaticMetastatic disease.disease.
• Risk factors identifiedRisk factors identified after enucleationafter enucleation (ie, massive choroid(ie, massive choroid
invasion or postlaminar involvement of the optic nerve).invasion or postlaminar involvement of the optic nerve).

55. ChemoreductionChemoreduction
 Most retinoblastomas are large at the time ofMost retinoblastomas are large at the time of
presentation, so chemoreduction is often used topresentation, so chemoreduction is often used to
reduce tumor volume enhances the success of⇒reduce tumor volume enhances the success of⇒
local therapies.local therapies.
 As initial treatment of retinoblastoma improves⇒As initial treatment of retinoblastoma improves⇒
the ocular salvage rate.the ocular salvage rate.
 Most common chemoreduction regimen containsMost common chemoreduction regimen contains
carboplatincarboplatin,, vincristinevincristine, and, and etoposideetoposide, given, given
approximately every 4 weeks.approximately every 4 weeks.

56.  Numerous studies have been published that ShowNumerous studies have been published that Show
that chemotherapy is very effective in globethat chemotherapy is very effective in globe
salvage; (salvage; (eliminating the need for EBRTx/enucleationeliminating the need for EBRTx/enucleation) in R-E) in R-E
group I–IV eyes success rate: 85% of treated⇒group I–IV eyes success rate: 85% of treated⇒
patients by 5 years.patients by 5 years.
 while proving to be significantly less successful inwhile proving to be significantly less successful in
more advanced disease Approximately 40% of⇒more advanced disease Approximately 40% of⇒
group C and 70% of group D eyes failed systemicgroup C and 70% of group D eyes failed systemic
chemotherapy alone.chemotherapy alone.
‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
• Shields CL, Mashayekhi A, Demirci H et al. Practical approach to management of
retinoblastoma. Arch Ophthalmol 2004;122:729–735.
• Shields CL, De Potter P, Himelstein BP et al. Chemoreduction in the initial management of
intraocular retinoblastoma. Arch Ophthalmol 1996; 114:1330–1338.

57. In a series of patients with group E, at the 2In a series of patients with group E, at the 2
year follow-up:year follow-up:
⇒⇒ ocular salvage in:ocular salvage in:
91%91% treated with chemoreduction + EBRTxtreated with chemoreduction + EBRTx
(median 22Gy).(median 22Gy).
VSVS
53%53% in patients treated with chemoreductionin patients treated with chemoreduction
alone.alone.
‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Shields CL, Ramasubramanian A, Thangappan A, et al. Chemoreduction for group E
retinoblastoma: comparison of chemoreduction alone versus chemoreduction plus low-dose
external radiotherapy in 76 eyes. Ophthalmology 2009; 116:544

58.  Conclusion:Conclusion: chemoreduction is generallychemoreduction is generally
considered for group A, B, and C eyes, and is lessconsidered for group A, B, and C eyes, and is less
effective for group D.effective for group D.
 Following chemoreduction, these groups respondFollowing chemoreduction, these groups respond
well to thermotherapy and rarely require externalwell to thermotherapy and rarely require external
beam RT or enucleation.beam RT or enucleation.
 Some reports suggest chemotherapy maySome reports suggest chemotherapy may
predispose to the development of secondary acutepredispose to the development of secondary acute
myeloid leukemia later in life.myeloid leukemia later in life.

59. Local ChemotherapyLocal Chemotherapy
 Injection ofInjection of carboplatincarboplatin
into the sub-Tenon’s spaceinto the sub-Tenon’s space
has shown some limitedhas shown some limited
success as a primarysuccess as a primary
therapy, and longer follow-therapy, and longer follow-
up suggests a high failureup suggests a high failure
rate.rate.
 It is currently consideredIt is currently considered
for possible use as a “boost”for possible use as a “boost”
with chemoreduction forwith chemoreduction for
groups C, D, and E tumorsgroups C, D, and E tumors
(controversial).(controversial).

60. Intra-arterial chemotherapy:Intra-arterial chemotherapy:
in a very recent prospective study To determine whetherin a very recent prospective study To determine whether
intraintra--arterial chemotherapy is safe and effective in advancedarterial chemotherapy is safe and effective in advanced
intraocular RB.intraocular RB.
 78 patients with were treated.78 patients with were treated.
 Catheterization of the ophthalmic artery and injection ofCatheterization of the ophthalmic artery and injection of
chemotherapy, usuallychemotherapy, usually melphalanmelphalan ((with or without topotecanwith or without topotecan(.(.
 End-points:End-points: eventevent--freefree ((enucleation or radiotherapyenucleation or radiotherapy)) ocular survival,ocular survival,
and ocular and extraocular complicationsand ocular and extraocular complications..
 2-years results:2-years results:
• Ocular eventOcular event--free survival rates were 70%.free survival rates were 70%.
• 81.7%81.7% for eyes that received intrafor eyes that received intra--arterial chemotherapy as primaryarterial chemotherapy as primary
treatment.treatment.
• 58.4%58.4% for eyes that had previous treatment failure with intravenousfor eyes that had previous treatment failure with intravenous
chemotherapy andchemotherapy and//or external beam radiation therapyor external beam radiation therapy..
• There were no permanent extraocular complicationsThere were no permanent extraocular complications..
‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
Gobin YP, Dunkel IJ, Marr BP, et al. Intra-arterial chemotherapy for the management of retinoblastoma: four-year
experience. Arch Ophthalmol 2011; 129:732.

61. Treatment of ExtraocularTreatment of Extraocular
RetinoblastomaRetinoblastoma
 There is no clearly proven effective therapy for theThere is no clearly proven effective therapy for the
treatment of extra-ocular retinoblastoma.treatment of extra-ocular retinoblastoma.
 Clinical trials are now under way to improve theClinical trials are now under way to improve the
overall dismal outcome (survival of approximatelyoverall dismal outcome (survival of approximately
10%) for this group of patients.10%) for this group of patients.
 Those with CNS metastases appear to do worse thanThose with CNS metastases appear to do worse than
those with other forms of extra-ocular disease.those with other forms of extra-ocular disease.

62.  In the past, chemotherapy has included conventionalIn the past, chemotherapy has included conventional
doses of vincristine, cyclophosphamide, anddoses of vincristine, cyclophosphamide, and
doxorubicin, and, although they produce an initialdoxorubicin, and, although they produce an initial
response, relapse is common.response, relapse is common.
 Carboplatin, ifosfamide, and etoposide have shownCarboplatin, ifosfamide, and etoposide have shown
more promisemore promise
 Generally, induction chemotherapy is given for fourGenerally, induction chemotherapy is given for four
cycles and this is followed by high-dosecycles and this is followed by high-dose
chemotherapy followed by stem cell rescue.chemotherapy followed by stem cell rescue.
 Following recovery from stem cell transplantation,Following recovery from stem cell transplantation,
radiotherapy is generally given to sites of initial bulkyradiotherapy is generally given to sites of initial bulky
disease.disease.

63. Recurrent RetinoblastomaRecurrent Retinoblastoma
 The prognosis for a patient with recurrent orThe prognosis for a patient with recurrent or
progressive retinoblastoma depends on the siteprogressive retinoblastoma depends on the site
and extent of the recurrence or progression.and extent of the recurrence or progression.
 Responses as high as 85% have been reportedResponses as high as 85% have been reported
following treatment with etoposide andfollowing treatment with etoposide and
carboplatin.carboplatin.
 If the recurrence or progression of retinoblastomaIf the recurrence or progression of retinoblastoma
is confined to the eye and is small, the prognosisis confined to the eye and is small, the prognosis
for sight and survival may be excellent with localfor sight and survival may be excellent with local
ophthalmic therapy only.ophthalmic therapy only.

64.  If the recurrence or progression is confined to theIf the recurrence or progression is confined to the
eye but is extensive, the prognosis for sight iseye but is extensive, the prognosis for sight is
poor, however the survival remains excellent.poor, however the survival remains excellent.
 If the recurrence or progression is extra-ocular,If the recurrence or progression is extra-ocular,
the prognosis is more guarded and the treatmentthe prognosis is more guarded and the treatment
depends on many factors and individual patientdepends on many factors and individual patient
considerations.considerations.

65. Follow-upFollow-up
 Long-term follow-up is best accomplished by aLong-term follow-up is best accomplished by a
multidisciplinary team.multidisciplinary team.
 Recurrence usually occurs with in 3 years.Recurrence usually occurs with in 3 years.
 The risk period for extraocular spread afterThe risk period for extraocular spread after
successful treatment is generally recognized to besuccessful treatment is generally recognized to be
12 to 18 months.12 to 18 months.
 Long-term survivors should also be followed forLong-term survivors should also be followed for
the development of second malignancies.the development of second malignancies.
 Routine CT or MRI scans and bone scans areRoutine CT or MRI scans and bone scans are
probably not necessary.probably not necessary.

67. Second cancersSecond cancers

68. Genetic counselingGenetic counseling
 Recommended for:Recommended for:
• Patients with family history of RB should undergoPatients with family history of RB should undergo
genetic counselling (blood sample only).genetic counselling (blood sample only).
• Parents having a child with RB (done at the time ofParents having a child with RB (done at the time of
enucleation or during treatment).enucleation or during treatment).
 Clinical Recommendation:Clinical Recommendation: examination at birth & 4examination at birth & 4
monthly thereafter until 4 years of age.monthly thereafter until 4 years of age.
 Sampling:Sampling:
• in sporadic cases:in sporadic cases: tumor tissue & blood requiredtumor tissue & blood required
• in inherited cases:in inherited cases: only blood sample sufficientonly blood sample sufficient

69.  Molecular tests:Molecular tests:
• Direct analysisDirect analysis of the constitutional mutation ofof the constitutional mutation of
RB1 gene, performed on constitutional DNA.RB1 gene, performed on constitutional DNA.
• Indirect analysisIndirect analysis of the allele carrying theof the allele carrying the
mutation.mutation.
• Tumor cell LOH evaluation.Tumor cell LOH evaluation.
 Patients should be informed about the risk ofPatients should be informed about the risk of
transmission and of second primary malignanttransmission and of second primary malignant
tumor development ⇒tumor development ⇒
 20% at 10 years.20% at 10 years.
 50% at 20 years.50% at 20 years.
 90% at 30 years.90% at 30 years.

70. • Risk for offspring of survivors of retinoblastoma:Risk for offspring of survivors of retinoblastoma:
 Bilateral disease:Bilateral disease: The risk of RB arising in theThe risk of RB arising in the
offspring is 45%.offspring is 45%.
 Unilateral disease:Unilateral disease: the risk of RB in offspring is 2.5%.the risk of RB in offspring is 2.5%.
• Risk for siblings of patients with retinoblastoma:Risk for siblings of patients with retinoblastoma:
 In siblings of bilaterally affected children whose parentsIn siblings of bilaterally affected children whose parents
are also affected the risk of retinoblastoma is 45%.are also affected the risk of retinoblastoma is 45%.
 If the sibling is unilaterally affected the and has a FH,If the sibling is unilaterally affected the and has a FH,
risk is 30%.risk is 30%.
 Without a family history the risk is 2% for siblings ofWithout a family history the risk is 2% for siblings of
bilateral cases and 1% for siblings of unilateral casesbilateral cases and 1% for siblings of unilateral cases