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135
Trilateral Retinoblastoma
Is the Location of the Intracranial Tumor Important?
Arnold C. Paulino,
M.D.
Department of Radiotherapy, Cardinal Bernardin
Cancer Center and Ronald McDonald Children’s
Hospital, Loyola University Medical Center, Maywood, Illinois.
Address for reprints: Arnold C. Paulino, M.D., Division of Radiation Oncology, The University of
Iowa Hospitals and Clinics, 200 Hawkins Drive,
Room W189-Z, Iowa City, IA 52242.
Received June 15, 1998; revision received October
19, 1998; accepted December 10, 1998.
© 1999 American Cancer Society
BACKGROUND. Trilateral retinoblastoma refers to bilateral retinoblastoma associated with an intracranial primitive neuroectodermal tumor in the pineal or suprasellar region. The purpose of this study was to review patient and tumor characteristics and treatment outcome in patients with trilateral retinoblastoma and to
determine whether there is a difference in presentation or outcome according to
the location of the intracranial tumor.
METHODS. A MEDLINE search of all English language articles pertaining to trilateral retinoblastoma published between 1977–1997 was performed. A total of 94
different cases were identified and analyzed.
RESULTS. The gender was male in 39 patients (41.5%), female in 50 patients
(53.2%), and unknown in 5 patients (5.3%). Family history for retinoblastoma
was positive in 44 patients (46.8%), negative in 39 patients (41.5%), and unknown in 11 patients (11.7%). The median age at the time of diagnosis of
retinoblastoma was 6 months. The median time interval to the development of
an intracranial tumor from the time of diagnosis of retinoblastoma was 21
months. In 78 patients (83.0%) the intracranial tumor was in the pineal region
and in 16 patients (17.0%) it was in the suprasellar region. The median time
interval from the time of diagnosis of retinoblastoma to the development of a
pineal region tumor was 24 months whereas the median time interval for the
development of a suprasellar region tumor was 1 month. At 6 months after the
diagnosis of intraocular tumors, 6 of 61 children with pineal region tumors and
10 of 14 patients with suprasellar region tumors had developed intracranial
disease (P 5 0.005). Unilateral intraocular retinoblastoma associated with intracranial tumor was more likely to occur in patients with suprasellar region
tumors than pineal region tumors (P , 0.015). The median survival after the
diagnosis of an intracranial tumor was 6 months regardless of the location of
the intracranial tumor. For patients who received no treatment for the intracranial tumor the median survival was 1 month whereas it was 8 months for
those who received treatment. Children who were asymptomatic at the time of
diagnosis of the intracranial tumor had a better overall survival than those who
were symptomatic (P 5 0.002).
CONCLUSIONS. The prognosis of children who develop trilateral retinoblastoma is
dismal with current treatment strategies. Tumors of the suprasellar region present
earlier than tumors of the pineal region after the diagnosis of intraocular tumors.
Because patients who were asymptomatic at the time of diagnosis of intracranial
disease had a better overall survival than those who were symptomatic, screening
for intracranial tumors may be a valuable strategy in the management of patients
with bilateral and/or hereditary retinoblastoma. [See editorial on pages 3–5, this
issue.] Cancer 1999;86:135– 41. © 1999 American Cancer Society.
KEYWORDS: trilateral retinoblastoma, intracranial tumor, childhood cancer, radiotherapy, chemotherapy, screening.
136
CANCER July 1, 1999 / Volume 86 / Number 1
T
he trilateral retinoblastoma syndrome is a rare
condition that traditionally refers to bilateral retinoblastoma in association with an ectopic intracranial
tumor indistinguishable histologically from the intraocular tumors. The association first was described
in detail by Jakobiec et al. in 19771 and the term
“trilateral retinoblastoma” was popularized in 1980 by
Bader et al.2 When Bader et al. described their initial
ten cases with trilateral retinoblastoma, the intracranial tumors identified were located in the pineal gland
region.2 Since that time, multiple reports have identified a location in the suprasellar region associated
with bilateral retinoblastoma. The purpose of this
study was to determine whether there is a difference
in presentation or outcome in relation to the location
of the intracranial tumor in children with trilateral
retinoblastoma. An additional aim of the study was to
provide patient and tumor characteristics, pattern of
failure analysis, and treatment outcome in patients
with this unusual entity.
METHODS
A MEDLINE search of all English language articles
between 1970 –1997 pertaining to trilateral retinoblastoma was performed and identified a total of 125
cases.1,3-42 Table 1 lists the authors, institutions, and
the number of cases described in each study. Overlap
of case reports occurred in some patients2– 4,12–13,
16 –17,19 –23,25–26,28,30 –31,33,35–37,39 – 40,42
and after correction for repetition of cases a total of 94 different children with trilateral retinoblastoma was identified.
Special attention was paid to characteristics of the
host and tumor, treatment, patterns of failure, and
outcome; family history of retinoblastoma also was
examined. An attempt was made to contact the first
authors of the articles when important information
regarding the patient and tumor characteristics was
lacking.
The Fisher exact test was employed to determine
whether there was a difference in the time interval
from the time of the diagnosis of retinoblastoma to the
occurrence of an intracranial tumor between children
who developed tumors of the pineal and suprasellar
regions. Likewise the same test was used to determine
whether unilateral intraocular retinoblastomas with
germline mutations were more likely to be associated
with the suprasellar region than pineal tumors. Survival estimates of children who were symptomatic and
asymptomatic were calculated using the Kaplan–
Meier method43; the log rank test was employed to
compare survival curves of patients who were symptomatic and asymptomatic at the time of diagnosis for
intracranial disease.
RESULTS
Patient and Tumor Characteristics
Gender was male in 39 patients (41.5%), female in 50
patients (53.2%), and unknown in 5 patients (5.3%). A
family history of retinoblastoma was found to be positive in 44 patients (46.8%), negative in 39 patients
(41.5%), and unknown in 11 (11.7%). The median age
at the time of diagnosis of an intraocular tumor was 6
months.
Eighty-five patients had bilateral retinoblastoma
associated with an intracranial tumor. Nine of the 85
children with bilateral retinoblastoma who subsequently developed an intracranial primitive neuroectodermal tumor (PNET) had asynchronous intraocular
tumors. Laterality of initial ocular involvement was
known in eight of nine asynchronous patients; four
had initial right eye involvement and four had initial
left eye involvement.
Seven children with trilateral retinoblastoma who
were reported in the literature had a unilateral retinoblastoma with germline mutation associated with an
intracranial tumor. In two patients, the unilateral intraocular tumor was diagnosed at the same time as the
intracranial tumor; for the remaining five patients, the
time interval from the diagnosis of the eye tumor to
the development of the brain tumor ranged from 4 –30
months (median, 12 months). Of the seven patients
with unilateral retinoblastoma and an associated intracranial malignancy, four had right intraocular tumors and three had left intraocular tumors; four children had tumors of the suprasellar region and three
children had tumors of the pineal region. A unilateral
intraocular tumor associated with an intracranial
PNET was more likely to be found in the suprasellar
region than in the pineal region (4 of 16 patients vs. 3
of 78 patients; P 5 0.015).
Two patients had intracranial tumors (one in the
suprasellar region and the other in the pineal region)
in the absence of intraocular disease. Both patients
had a sibling with bilateral retinoblastoma; one sibling
had a tumor in the pineal region in addition to bilateral intraocular tumors.
Intracranial Tumor
Intracranial tumor location was known in all patients.
Seventy-eight children (83.0%) had tumor of the pineal region and 16 (17.0%) had a PNET of the suprasellar region. The median time interval from the diagnosis of an intraocular tumor to the development of
an intracranial neoplasm for 75 evaluable children
was 21 months. Figure 1 shows the various time intervals for all evaluable patients according to the location
of the intracranial tumor.
Trilateral Retinoblastoma/Paulino
137
TABLE 1
Studies Reporting Cases of Trilateral Retinoblastoma
Authors
Year of
publication
Institution
No. of cases
Jakobiec et al.1
Bullitt and Crain3
Judisch and Shivanand4
Bader et al.5
Zimmerman et al.6
Dudgeon and Lee7
Ehlers et al.8
Brownstein et al.9
Michaud et al.10
Tarkkanen et al.11
Johnson et al.12
Kingston et al.13
Stannard et al.14
Whittle et al.15
Lueder et al.16
Malik et al.17
Meadows18
Towbin and Bisset19
Helveston et al.20
Bomanji et al.21
Pesin and Shields22
Shields et al.23
Schwartz et al.24
Holladay et al.25
Lueder et al.26
Mukherjee et al.27
Nelson et al.28
Stolovitch et al.29
Marks et al.30
Scott and Richard31
Blach et al.32
DePotter et al.33
Finelli et al.34
McCormack et al.35
Nunna et al.36
Provenzale et al.37
Amoaku et al.38
Bagley et al.39
Bejjani et al.40
Moll et al.41
Skulski et al.42
1977
1981
1981
1982
1982
1983
1983
1984
1984
1984
1985
1985
1985
1985
1986
1986
1986
1986
1987
1989
1989
1989
1990
1991
1991
1991
1992
1992
1993
1993
1994
1994
1995
1995
1995
1995
1996
1996
1996
1996
1997
George Washington University, Washington, DC
Duke University, Durham, NC
University of Iowa, Iowa City, IA
National Cancer Institute, Bethesda, MD
University of Missouri, Columbia, MO
University of Glasgow, Glasgow, United Kingdom
University of Aarhus, Aarhus, Denmark
McGill University, Montreal, Canada
University of Montreal, Montreal, Canada
University of Helsinki, Helsinki, Finland
Children’s Hospital National Medical Center, Washington, DC
St. Bartholomew’s Hospital, London, United Kingdom
University of Cape Town, Cape Town, South Africa
Royal Alexandria Hospital for Children, Sydney, Australia
University of Iowa, Iowa City, IA
Duke University, Durham, NC
Children’s Hospital of Philadelphia, Philadelphia, PA
University of Cincinnati, Cincinnati, OH
Indiana University, Indianapolis, IN
St. Bartholomew’s Hospital, London, United Kingdom
Wills Eye Hospital, Philadelphia, PA
Wills Eye Hospital, Philadelphia, PA
Medical College of Virginia, Richmond, VA
Indiana University, Indianapolis, IN and University of Cincinnati, Cincinnati, OH
University of Iowa, Iowa City, IA
Diwan Aggarwal Research Center, New Delhi, India
Duke University, Durham, NC
Ichilov Hospital Tel Aviv, Israel
Duke University, Durham, NC
University of Oklahoma, Oklahoma City, OK
Memorial Sloan-Kettering Cancer Center, New York, NY
Wills Eye Hospital, Philadelphia, PA
Case Western University, Cleveland, OH
University of Oklahoma, Oklahoma City, OK
All India Institute, New Delhi, India
Duke University, Durham, NC
West Midlands Regional Children’s Tumour, Research Group, Birmingham, United Kingdom
Wills Eye Hospital, Philadelphia, PA
George Washington University, Washington, DC
Dutch Retinoblastoma Register, Amsterdam, The Netherlands
University of Cincinnati, Cincinnati, OH
2
1
1
14
1
2
1
2
1
1
3
12
1
1
3
2
1
1
1
1
7
1
1
3
4
1
3
1
1
3
6
13
2
1
1
1
5
10
1
7
1
For the 16 patients with suprasellar tumors, 9
patients (56.3%) were female, 6 patients (37.5%) were
male, and the gender was unknown in 1 patient
(6.3%). The median time interval from the diagnosis of
an ocular tumor to the development of an intracranial
tumor was 1 month. In two children, the tumor in the
suprasellar region preceded bilateral intraocular tumors. Six children (37.5%) with tumors of the suprasellar region had a positive family history of retinoblastoma.
For the 78 patients with pineal region tumors,
the gender was female in 41 patients (52.6%),
male in 33 patients (42.3%), and unknown in 4 patients (5.1%). The median time interval from the
diagnosis of an intraocular tumor to the development of a pineal region tumor was 24 months. Thirty-eight children (48.7%) with tumors of the pineal
region had a positive family history of retinoblastoma.
At 6 months after the diagnosis of intraocular
tumors, 6 of 61 evaluable children with tumors of the
pineal region and 10 of 14 children with tumors of the
suprasellar region had developed intracranial disease
(P 5 0.005).
138
CANCER July 1, 1999 / Volume 86 / Number 1
Treatment Outcome and Pattern of Failure
The median survival after a diagnosis of intracranial
tumor for all patients was 6 months. The median
survivals for children with tumors of the pineal region
(range, 0 –96 months) and PNETs of the suprasellar
region (range, 0 –23 months) both were 6 months. The
median survival for children who received no treatment for the intracranial tumor was 1 month whereas
it was 8 months for children who were treated for the
intracranial tumor. Table 2 lists the 6 patients who
survived at least 2 years after the diagnosis of an
intracranial tumor. All six children had a pineal region
tumor. Treatment included chemotherapy in all six
children and craniospinal irradiation (CSRT) was
given to four patients. The type of treatment given for
the intracranial tumor in all patients is shown in Table
3. The most common type of treatment was chemotherapy in combination with radiation therapy (RT)
followed by RT alone. Eighteen patients received
CSRT; 15 of these patients developed disseminated
neuraxis disease despite CSRT. Forty-one of the 75
evaluable patients (54.7%) died with disseminated
neuraxis disease.
Survival rates for children who were symptomatic
and those who were asymptomatic at the time of
diagnosis of intracranial disease were compared and
showed a statistically significant survival advantage
for patients with asymptomatic intracranial disease
(Fig. 2) (P 5 0.002).
DISCUSSION
In this review of trilateral retinoblastoma from 1977–
1997, four groups of children were identified with regard to the presentation of intraocular tumors in relation to the intracranial tumor. The most common
presentation found in 76 of 94 children (80.1%) was
the “traditional” definition of trilateral retinoblastoma: synchronous bilateral intraocular tumors observed in association with a PNET of the pineal or
suprasellar region. Bilateral retinoblastoma may be
asynchronous and may be associated with an intracranial tumor. Such was the case in 9 of 94 children
(9.6%). The third group of children included 7 patients
(7.4%) with a unilateral retinoblastoma with a germline mutation and intracranial PNET; this first was
described by Whittle et al.,15 who coined the term
“forme fruste” of trilateral retinoblastoma for this presentation. Our study showed that tumors of the suprasellar region were more likely to be associated with
unilateral intraocular tumors when compared with
tumors of the pineal region. Finally, two children with
germline mutations did not have an intraocular tumor
but had an intracranial PNET; one patient had a sib-
ling with bilateral retinoblastoma and the other had
an identical twin with trilateral retinoblastoma.
The pineal region presentation is more frequent
than the suprasellar region presentation. There appeared to be no difference based on gender or family
history between patients with tumors in the suprasellar region and those with tumors in the pineal region.
Regardless of intracranial location, trilateral retinoblastoma was detected more frequently in girls than
boys. The median time interval from the diagnosis of
an intraocular tumor to the development of an intracranial tumor was 21 months. Suprasellar region tumors presented earlier than pineal region PNETs. It
appears that 89% and 98.7% of all patients with trilateral retinoblastoma developed intracranial disease at
4 years and 7 years, respectively, from the time of the
initial diagnosis of an intraocular tumor. This information is important for physicians who treat children
with bilateral retinoblastoma because screening for
intracranial tumors would be most helpful during the
first 4 years after the diagnosis of an intraocular tumor. A small but significant proportion of children
with bilateral or hereditary retinoblastoma develop
intracranial disease. At the Memorial Sloan-Kettering
Cancer Center, 6% of patients with bilateral retinoblastoma and 10% of patients with a family history of
retinoblastoma developed intracranial PNET.32 Another report from the Wills Eye Hospital showed that
trilateral retinoblastoma occurred in 13 of 440 consecutive children with retinoblastoma (3%).33 Some may
argue that screening for trilateral retinoblastoma may
not be very helpful given the median survival of only 6
months and the small number of patients with bilateral or hereditary retinoblastoma who develop intracranial disease. However, in 1 study trilateral retinoblastoma accounted for 6 of 12 deaths (50%) during
the first 5 years after the diagnosis of retinoblastoma.32
Trilateral retinoblastoma is an underappreciated
cause of mortality in the first 5 years after the diagnosis of bilateral retinoblastoma.
Screening for intracranial disease in children with
bilateral and hereditary retinoblastoma may be beneficial because our study showed that patients who
were asymptomatic at the time of diagnosis of intracranial disease had a better survival compared with
those who were symptomatic. Screening may be performed by the use of magnetic resonance imaging of
the brain. It is not clear how often brain imaging
should be performed except that it should be performed for at least 4 years after the diagnosis of intraocular tumors. In a report from Duke University,
the 2 longest survivors (at 33 months and 96 months,
respectively, after the diagnosis of an intracranial tumor) were diagnosed using routine imaging of the
Trilateral Retinoblastoma/Paulino
139
TABLE 3
Type of Treatment of Intracranial Tumors in the 94 Children with
Trilateral Retinoblastomas
CSRT 1 chemotherapy
CSRT alone
No treatment
Unknown
Chemotherapy alone
CSRT 1 surgery
Chemotherapy 1 surgery
CSRT 1 chemotherapy 1 surgery
Surgery alone
FIGURE 1. Time intervals between the diagnosis of an intraocular tumor and
25
20
16
12
10
6
2
2
1
RT: radiation therapy.
the development of an intracranial neoplasm according to the location of the
intracranial tumor in 75 evaluable children with trilateral retinoblastoma.
TABLE 2
Treatment Characteristics of Patients Surviving at Least 2 Years after
the Diagnosis of an Intracranial Tumor
Case no.
Survival
(mos)
Treatment
4
40
41
45
69
78
31
96
33
26
30
28
CSRT 1 CCNU, VCR
CPM, MTX, ARA-C, HYDRO
CSRT 1 CPM, ARA-C, HYDRO
CSRT 1 CPM, MTX, VCR, DOX
Unspecified chemotherapy
CSRT 1 unspecified chemotherapy
CSRT: craniospinal irradiation; CCNU: lomustine; VCR: vincristine; CPM: cyclophosphamide; MTX:
methotrexate; ARA-C: cytosine arabinoside; HYDRO: hydrocortisone; DOX: doxorubicin.
brain prior to the development of symptoms.28 Data
from the Wills Eye Hospital also argue for the screening of children with bilateral retinoblastoma. In a series of 13 patients, children who were asymptomatic
had a significantly longer survival compared with
those who were symptomatic (P 5 0.05).33 DePotter et
al. recommend screening for intracranial tumors in
children with bilateral and/or familial retinoblastoma
until age 4 years.33 This recommendation can be modified further using the results of our analysis, which
showed that 89% of patients will have developed an
intracranial tumor 4 years after the initial diagnosis of
intraocular retinoblastoma.
Treatment for trilateral retinoblastoma resulted in
a median survival of 8 months. There was no difference in survival outcome regardless of whether the
tumor was in the pineal versus the suprasellar region.
Of the 6 children who survived . 2 years after a
diagnosis of intracranial PNET, all received chemotherapy and 4 received CSRT. For the 75 evaluable
children in whom the pattern of failure was reported,
41 (54.7%) had disseminated neuraxis disease. Only 3
FIGURE 2.
Comparison of overall survival rates after a diagnosis of intracranial tumor according to symptomatology. Children who were asymptomatic
for intracranial disease at the time of diagnosis had a better overall survival
than children who were symptomatic at the time of diagnosis (P 5 0.002).
of 18 children who received CSRT achieved control of
tumor dissemination along the neuraxis; 2 of these
children received chemotherapy. Therefore, efforts in
achieving a cure for this tumor should be directed
toward the prevention of tumor dissemination along
the neuraxis. The use of chemotherapy and CSRT appears to be reasonable because this form of treatment
was used in four of six “long-term” survivors. Furthermore, the use of chemotherapy and CSRT resulted in
3-year overall and progression free survival rates of
57% and 45%, respectively, in children with primary
supratentorial PNET treated on a Children’s Cancer
Group protocol.44 In a retrospective study of 36 children at the Hospital for Sick Children in Toronto, all
six survivors with primary PNET of the brain received
CSRT and four received chemotherapy.45
Certainly, there are limitations in this report. First,
this is a 20-year review of patients treated using a
variety of therapeutic approaches. The data gathered
140
CANCER July 1, 1999 / Volume 86 / Number 1
from each case were not all complete because some
articles did not evaluate all the patient, tumor, and
treatment characteristics. Another potential problem
with this study is that we do not know whether the
early detection of intracranial disease in asymptomatic patients produces a lag time bias similar to that
observed in the detection of women with breast carcinoma using mammography.
The median survival of children with trilateral retinoblastoma is dismal regardless of the location of the
intracranial tumor. Pineal region tumors occur more
frequently than suprasellar PNET. Children with tumors of the suprasellar region develop intracranial
disease earlier and are more likely to have intracranial
disease associated with unilateral intraocular retinoblastoma with germline mutations when compared
with children with tumors of the pineal region. In
children with bilateral or hereditary retinoblastoma,
screening for intracranial disease for at least 4 years
may be warranted because patients who are asymptomatic at the time of diagnosis of an intracranial
tumor have been found to have a better overall survival than patients who were symptomatic. Efforts to
control this disease should be directed toward the
prevention of tumor dissemination along the neuraxis,
which is a pattern of failure observed in . 50% of
patients.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
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