Early delivery of retinoblastoma children 1

Impact of early delivery of children with familial retinoblastoma after prenatal

RB1 mutation identification for familial cases of retinoblastoma

Sameh E. Soliman, MD; Helen Dimaras, PhD; Vikas Khetan, MB, BS; Elise Héon, MD, FRCSC;

Helen S. L. Chan, MB, BS, FRCSC; Brenda L. Gallie, MD, FRCSC

Corresponding Author: Dr Brenda Gallie at the Department of Ophthalmology and Vision

Sciences, the Hospital for Sick Children, 525 University Avenue, 8th floor, Toronto, ON M5G 2L3,

Canada, or at brenda@gallie.ca

Authors’ Affiliations:

Departments of Ophthalmology & Vision Sciences, (Soliman, Dimaras, Héon , Gallie) and

Division of Hematology/Oncology, Pediatrics (Chan), Hospital for Sick Children, Toronto,

Canada; Division of Visual Sciences, Toronto Western Research Institute, Toronto, Canada

(Héon , Gallie); Ophthalmology Department, Faculty of Medicine, Alexandria University, Egypt

(Soliman); Sankara Nethralya Hospital, Chennai, India (Khetan); Departments of Pediatrics

(Chan), Molecular Genetics (Gallie), Medical Biophysics (Gallie) and Ophthalmology & Vision

Sciences (Dimaras, Héon, Gallie), and the Division of Clinical Public Health (Dimaras) University

of Toronto, Toronto, Ontario, Canada.

Early delivery of retinoblastoma children 2

Author contributions:

All authors had full access to all the data in the study and take responsibility for the integrity of

the data and the accuracy of the data analysis.

Study concept and design: Soliman, Dimaras, Gallie, Khetan

Acquisition, analysis, or interpretation of data: Soliman, Dimaras, Khetan, Gallie

Drafting of the manuscript: Soliman, Dimaras, Khetan, Gallie

Critical revision of the manuscript for important intellectual content: Dimaras, Gallie, Chan,

Héon

Statistical analysis: Soliman, Dimaras, Gallie

Study supervision: Chan, Héon, Gallie

Financial Support: None

Conflict of Interest: No conflicting relationship exists for any author

Running head: Early delivery of familial retinoblastoma

Word count: 3262 /3000 words

Numbers of figures and tables: 3 figures and 2 tables

Key Words: prenatal retinoblastoma, retinoblastoma gene mutation, RB1, molecular testing,

late pre-term delivery, near-term delivery, amniocentesis

Early delivery of retinoblastoma children 3

Abstract (348/350)

IMPORTANCE: Familial retinoblastoma can be predicted by prenatal RB1 mutation detection. Early

delivery following prenatal detection for treatment of smaller tumors may achieve better outcomes with

minimal therapy.

OBJECTIVE: To compare overall outcomes and intensity of treatment for children with familial

retinoblastoma diagnosed postnatally or by obstetrical ultrasound, and those diagnosed by prenatal RB1

mutation identification and delivered preterm.

DESIGN: A retrospective, observational study.

SETTING: This study was conducted at The Hospital for Sick Children (SickKids), a retinoblastoma referral

center in Toronto, Canada.

PARTICIPANTS: All children born between 1 June 1996 and 1 June 2014 with familial retinoblastoma

who were cared for at SickKids.

EXPOSURE(S): Cohort 1 consisted of infants where were spontaneously delivered and had postnatal

RB1 testing. Cohort 2 consisted of infants who were identified by amniocentesis to carry the affected

relative’s known RB1 mutant allele and had planned early term or late preterm delivery (36-37 weeks

gestation). All children received treatment for eye tumors.

MAIN OUTCOME MEASURES: Primary study outcome measurements were gestational age, age at first

tumor, eye classification, treatments given, visual outcome, number of anesthetics, pregnancy or

delivery complications and estimated treatment burden.

RESULTS: Of Cohort 1 (n=9) infants, 67% (6/9) already had vision-threatening tumors at birth. Of Cohort

2 (n=12) infants, 9 were electively induced at 36-38 weeks gestation and 3 were born spontaneously

preterm; 25% (3/12) had vision-threatening tumors at birth. Both Cohorts eventually developed tumors

Early delivery of retinoblastoma children 4

in both eyes. Acceptable vision (better than 0.1) was achieved for 78% of Cohort 1 compared to

100% of Cohort 2 (p<0.017). At first eye tumor diagnosis, 11% of Cohort 1 had both eyes Group A

(smallest and least vision-threatening tumors) compared to 67% of Cohort 2 (p<0.01). Eye salvage

(defined as avoidance of enucleation and external beam irradiation) was achieved in 33% of Cohort 1

compared to 97% of Cohort 2 (p<0.002). There were no complications related to preterm delivery.

CONCLUSIONS AND RELEVANCE: Prenatal molecular diagnosis with late preterm/near-term delivery

resulted in more eyes with no detectable retinoblastoma tumors at birth, and better vision outcomes

with less invasive therapy. Prenatal molecular diagnosis facilitates anticipatory planning for both child

and family.

Something that will come up it that over your study period the Rx have evolved, what is the current

age of cohort 1 vs cohort 2 with SD. That would be important for full disclosure

Early delivery of retinoblastoma children 5

Introduction

Retinoblastoma, the most common primary ocular malignancy in children, is commonly initiated when

both alleles of the RB1 tumor suppressor gene are inactivated in a precursor retinal cell, and progresses

when mutations in other specific genes occur.1,2 Both alleles may be lost only in the somatic cell from

which the tumor arises, however, in about 50% of children, a germline mutation predisposes to the

development of multiple retinal tumors during childhood, and other cancers later in life. Ten percent of

patients display a family history of disease, inheriting a family-specific mutation from a parent.1,3

Children with RB1 germline alleles mutation may already have retinoblastoma tumor(s) at birth, .

They which are often develop in the posterior pole of the eye where they threaten vision.4-8 Preservation

of vision with treatment of these small tumors is can be often difficult, because focal laser treatment in

proximity to thenear the optic nerve and macula may compromise vision. Most of these children are

bilaterally affected, with either simultaneous or sequential detection of tumors.4,7 Later developing tumors

tend to be located peripherally.7,9 Low penetrance mutations (10% of families)3 and mosiaicism result in

fewer tumors and more unilaterally affected childrenunilateral phenotype.10 The timing of first tumors

after birth has not yet been studied.

It is recommended that infants with a family history of retinoblastoma be screened examined as soon

as possible after birth and repeatedly for the first few years of life, including under anaesthesia for tumor

detection and management., . aiming The purpose of this is to achieve anat early diagnosis, when tumors

are small and treatable with less invasive therapies for salvage of the eye and vision.6,7,11

Full term birth is generally defined as live birth occurring between 38 and 40 weeks gestation.

Preterm birth is defined as live birth occurring before completion of 37 weeks gestation; . The American

College of Obstetrics and Gynecology has suggested the description of ‘early term’ be ascribed to Infants

infants born after completion of 37 and but before 39 weeks gestation are considered early term.12,13so

then was is late term The main concern with late preterm or early term delivery is its potential reported

Early delivery of retinoblastoma children 6

effect on neurological and cognitive development and later school performance of children with a wide

range of indications for early delivery.,14-16 For children with high risk of cancer and visual dysfunction

from large macular tumors risking blindness17 exceed such risks of early delivery. but visual dysfunction

from a large macular tumor may risk similar neurocognitive defects due to blindness17, although this has

not been studied.

We now present the first report of outcomes of prenatal genetic screening testing and late preterm or

early term delivery for treatment of retinoblastoma for children demonstrated to carry the RB1 mutant

allele of a parent. We show that prenatal molecular diagnosis and late preterm or early term delivery for

children carrying a germline RB1 mutant allele resulted in earlier detection and treatment of small tumors,

lower treatment morbidity, better tumor control, and visual outcome, compared to children born

spontaneously without genetic diagnosis.

Methods

Study Design

Research ethics board approval (REB approval number 1000028725) was obtained from The Hospital

for Sick Children (SickKids) for a retrospective review of medical records of all children with familial

retinoblastoma seen at SickKids, and born between 1 June 1996 and 1 June 2014. Data collected for

children born between 1 June 1996 and 1 June 2014 included: relation to proband; laterality of

retinoblastoma in proband; sex; gestational age at birth; pregnancy, prenatal abdominal ultrasound if

done; delivery or perinatal complications; type of genetic sample tested and result; penetrance of RB1

mutation; age and location of first and all subsequent tumor (s) in each eye; treatments used; number of

anaesthetics; International Intraocular Retinoblastoma Classification18 of each eye (IIRC); Tumor Node

Metastasis (TNM) staging for eyes and child;11 treatment duration; date of last follow-up; and visual

outcome at last follow-up. RB1 mutation testing was performed by Retinoblastoma Solutions before 2013,

and Impact Genetics after (formerly Retinoblastoma Solutions2013), as previously described.19

Early delivery of retinoblastoma children 7

The gestational age at birth for each child was calculated (taking 39 weeks as was considered full

term). Vision threatening tumors were defined as those close to optic nerve or macular (IIRC18 Group B

or worse). Treatments were summarized as focal therapies (Laser laser therapy, cryotherapy and

periocular subtenon’s injection of chemotherapy) or systemic therapies (systemic chemotherapy or

stereotactic external beam irradiation). Treatment burden (defined by the impact of treatment course on

general health and development of the child and potential impact on the family) was evaluated based on i)

duration of active treatment (time from diagnosis to last treatment), ii) use of systemic chemotherapy or

radiation, iii) number of examinations under anesthesia (EUAs), and iv) occurrence of extraocular

disease (Figure 1). Treatment success was defined as avoidance of enucleation or external beam

irradiation or extraocular disease. Acceptable visual outcome was defined as visual acuity better than 0.1

decimal (20/200). Legal blindness is defined as visual acuity worse than 0.1.

StatisticsData analysis

Basic descriptive statistics were used for comparisons between patients who diagnosed postnatal (Cohort

1) and those provided prenatal testing and planned preterm delivery (Cohort 2). These (included Student

T-Test, Chi Square Test (when all cell frequencies weare more than 5), Fisher Exact Test (when any cell

frequency wais less than 5), Mann Whitney Test and Mood’s Median Test) were used for statistical

comparisons between patients who diagnosed postnatal (Cohort 1) and those provided prenatal testing and

planned preterm delivery (Cohort 2). Correlations and Kaplan-Meyer Survival Graphs were plotted using

Microsoft Excel 2007.

Results

Patient Demographics

Twenty-one children with familial retinoblastoma were reviewed (11 males, 10 females) and eligible for

this study (Supplementary Table 1, Figure 1). Diagnosis for Cohort 1 (9 children) was by observation of

prenatal retinoblastoma tumor (child #9) or postnatal tumor (child #8) or postnatal testing for the parental

Early delivery of retinoblastoma children 8

RB1 mutation: 6 were delivered full term and 3 late preterm because of pregnancy-induced hypertension

(child #7), fetal ultrasound evidence of retinoblastoma20 (child #9) or spontaneous delivery (child #8). The

12 children (57%) in Cohort 2 were prenatally diagnosed to carry their family’s RB1 mutation and

planned for late preterm or early term delivery: 3 were spontaneously premature (children #10, 13, 15;

28-37 weeks gestation) and 9 were referred to a high-risk pregnancy unit for elective late preterm or early

term delivery (36-38 weeks gestation).

Molecular diagnosis

All study subjects were offspring of retinoblastoma probands. Nineteen probands were bilaterally, and 2

were unilaterally affected (mother #8, father #19). The familial RB1 mutations were previously detected

except for the unilaterally affected parent of #8, who had not been tested; because she was unilaterally

affected, and she believedunderstood that her children had nowere at no increased risk since she was

unilaterally affectedfor retinoblastoma. Cohort 1 children were (#1-9) tested postnatally for their family’s

RB1 mutation by blood; Cohort 2 children (#10-21) were tested prenatally by amniocentesis at 16-33

weeks gestation.

Null RB1 mutations were present in 16 families; 5 had low penetrance RB1 mutations (whole gene

deletion #19; weak splice site mutations #15, 18, 21; and for #5, C712R19). No proband in this study was

mosaic for the RB1 mutation. All study subjects were eventually bilaterally affected. At birth, null RB1

mutations resulted in no tumors (IIRC18 Group 0) in 7/15 (47%) infants and 17/30 (57%) eyes; and low

penetrance mutations resulted in no tumors in 5/5 (100%) infants and 10/10 (100%) eyes (P=0.04* for

patients, P=0.02* for eyes; Fisher’s exact test) (Table 1).

The age at first tumor in either eye was significantly younger for those with null mutations (mean

84, median 39 days), than those with low penetrance mutations (mean 135, median 120 days) (P=0.03*,

Phi=0.38, Mood’s median test). However, the gestational age at first tumor for those with null mutations

(mean 71, median 33 days) tended to be younger but was not significantly different, than for those with

low penetrance mutations (mean 111, median 81 days) (P=0.06, Phi=0.32, Mood’s median test). (Child

Early delivery of retinoblastoma children 9

#8 was excluded from these calculations as the child was first examined at 3 months of age with Group

A/D tumors, so age at first detectable tumor is unknown) (table Table 1c).

Classification of Eyes at Birth

Thirty-three percent (3/9) of Cohort 1 and 75% (9/12) of Cohort 2 were free of visible tumor in either eye

at birth (Table 1a, Figure 1) (P=0.09). We assumed that child #8 had tumor at birth since he had a group

D IIRC18 eye at 3 months of age. Of eyes, 79% (19/24) of Cohort 1 eyes were tumor-free at birth,

compared to 33% (6/18) of Cohort 2 eyes (P=0.026*, Chi Square test), excluding the IIRC18 Group A eye

of child #8, as above (Table 1b). At birth, 39% of eyes (7/18) in Cohort 1 had a visually threatening tumor

(IIRC18 Group B or worse) in contrast to 17% of eyes (4/22) in cohort Cohort 2 (P=0.17, Chi Square test).

All patients eventually developed tumors in both eyes regardless of whether their RB1 mutation was

full or low penetrance. Tumors emerged at a younger age in the macular and peri-macular region (IIRC18

Group B), as previously described21. The median gestational age of diagnosis of 14 IIRC18 B eyes (all

threatening optic nerve and fovea, 6 also >3 mm) was 38 days, tended to be younger than of the 103 days

for 26 IIRC18 A eyes (< 3mm and away from optic nerve and fovea) 18(P=0.32, Phi=-0.19, Mood’s median

test).

Bilateral IIRC18 Group A eyes were present at initial diagnosis (optimal situation for achieving good

vision with minimally invasive therapy) in 2/9 (22%) children in Cohort 1 compared to 8/12 (67%) in

Cohort 2 (P=0.009*, Fisher exact test) (Table 2a). IIRC18 Group A was the initial diagnosis of 9/18 (50%)

eyes in Cohort 1, compared to 15/22 (77%) eyes in Cohort 2 (P=0.33, Table 2a). One eye was an IIRC18 D

eye and presented at age of 3 months (child #8).

Treatment Course

All infants were frequently examined from birth onwards (except child #8 who presented at age 3

months) as per the National Retinoblastoma Strategy Guidelines for Care.11 If there were no tumors at

birth, each child was examined awake every week for 1 month, every 2 weeks for 2 months. After 3

Early delivery of retinoblastoma children 10

months of age, the children had an examination under general anesthesia (EUA) every 2-4 weeks. If there

was tumor at birth, the children had EUAs every 2-4 weeks until control of tumors was achieved. Cohort

1 patients were treated with focal therapy (all), chemotherapy using vincristine, carboplatin, etoposide

and cyclosporine (Toronto protocol)22{Chan, 2005 #21688} (4), stereotactic radiation (2), and enucleation

of one eye (5) (Supplementary Table 1, Figure 1). Cohort 2 patients were treated with focal therapy (all);

chemotherapy (5), enucleation of one eye and stereotactic radiation (1) (Figure 1).

Treatment burden showed no statistical significant difference between Cohort 1 and 2 in any of the

four parameters tested. The median active treatment duration was 458 days (0-2101 days) in Cohort 1,

compared to 447 days (0-971 days) in Cohort 2 (P=1, Mood’s median test). Treatment by focal therapy

alone (avoidance of systemic chemotherapy or EBRT) was possible in 4/9 (44%) of Cohort 1 and 7/12

(58%) of Cohort 2 (P=0.67, Fisher exact test) (Table 2b). The median number of EUAs in cohort 1 is 25

(range 18-81) and for cohort 2 is 29 (range 20-41) EUAs (P=1, Mood’s median test). One child (#6)

(11%) in Cohort 1 showed high risk features in the enucleated eye and still under active treatment. (table

2b).

Outcomes

There were no adverse effects events associated with induced or natural preterm or induced late

preterm or early term birth, . There wereand no pregnancy, delivery or perinatal complications reported

for any of the infants. Follow up (mean, median) was overall 8, 5.6 years; Cohort 1, 8.4, 5.6 years; and

Cohort 2, 7.6, 5.8 years (Supplementary Table 1).

Neither enucleation nor external beam irradiation were required (defined as treatment success) in

44% of Cohort 1 and 92% of Cohort 2 (P=0.046*, Fisher exact test). Kaplan Meier ocular survival for

Cohort 1 was 62% compared to 92% for Cohort 2 (Figure 2). All children from both Cohorts are still

alive; one child from Cohort 1 is still under active treatment.

Early delivery of retinoblastoma children 11

Visual outcomes were acceptable (better than 0.01) for 50% of eyes in Cohort 1 and 92% of eyes in

Cohort 2 (P=0.014*, Fisher exact test). Children were legally blind (visual acuity less than 0.01 (20/200)

using both eyes) in 22% of Cohort 1 and 0% of Cohort 2 (P=0.017*, Fisher exact test). Seventy one

percent of eyes (17/24) of Cohort 2 had final visual acuity better than 0.5 (20/40) compared to 50% (9/18)

of eyes in Cohort 1.

Treatment success (avoidance of enucleation and/or stereotactic radiation) and good vision per eye

was documented 50% (9/18) of Cohort 1 and 88% (21/24) of Cohort 2 (P=0.014*, Fisher exact test)

(Table 2b, Figure 1). A negative correlation was found between gestational age and final visual outcome

(r=-0.03) with better visual outcome in observed for earlier deliveries (Figure 3).

Discussion

In the first study of its kind,This is the first report on the outcome of early delivery of children for

retinoblastoma (true?). we report suggest that prenatal molecular diagnosis of familial retinoblastoma and

elective late-preterm/early term delivery allowed treatment of tumors as they emerged, which

resultedresulting in better ocular and visual outcomes and less severe intenstive medical interventions in

very young children. This data illustrates that for infants with close to 100%high risk of developing

retinoblastoma in both eyes because(RB1+ or familial history) they carry an RB1 mutant allele, the risk of

vision and eye loss despite intensive therapies, outweighs the risks associated with induced late preterm

delivery (Figure 1). Consistent with previous reports,5 67% of children with a germline gene mutation

already had tumors at full term birth, compared to 25% when the germline mutation was detected

prenatally with planned late preterm or early term delivery (Table 2).

It is practical to identify 96% of the germline mutations in bilaterally affected probands and to

identify the >15% of unilateral probands who carry a germline gene mutation.3,10,23 When the proband's

unique mutation is identified, molecular testing of family members can determine who else carries the

mutation and is at risk to develop retinoblastoma. We report 12 infants identified in utero by molecular

Early delivery of retinoblastoma children 12

testing to carry the mutant RB1 allele of a parent. The 50% of tested infants who do not inherit their

family’s mutation require no surveillance., can be born at full term and do not need examinations to detect

tumors, since they are at no greater risk of developing retinoblastoma than the general population.

Without molecular information, repeated retinal examination is recommended for all first degree

relatives until age 7 years, the first 3 years under general anesthesia.11 Multiple studies now suggest

deleterious effects of multiple general anesthetics in early infancy on the neurocognitive development of

the child.24-26 Such repeated clinical screening also imposes psychological and financial burden on the

children and families. Identification by early molecular RB1 testing of the children who are not at risk and

require no clinical intervention cost significantly less than direct costs than clinical screening for

tumors.19,27

Optimal treatment for retinoblastoma includes combined therapeutic modalities to optimize vision

and minimize treatment morbidity, while achieving tumor control. However, retinoblastoma treatment in

the first 3 months of life is a challenge since these young children may not have sufficient renal function

for full dose systemic therapies. Good treatment options at this age are limited to focal therapy (laser and

cryotherapy) and periocular chemotherapy.28

The earliest tumors commonly involve the macular or paramacular region, threatening loss of central

vision, while tumors that develop later are usually peripheral, where they have less visual impact.5,28-31 In

our study, the risk of a vision threatening tumor dropped from 39% to 17% by prenatal mutation detection

and planned earlier delivery (Table/Figure #). Macular and paramacular tumors are difficult to manage by

laser therapy or application of a radioactive plaque, since these threaten the optic nerve and central vision.

Systemic chemotherapy effectively shrinks tumors such that focal therapy can be applied with minimal

visual damage. In our study, child #9 (Cohort 1) had a tumor at 36 weeks gestation large enough for

detection by obstetrical ultrasound, which showed drug-resistant tumor following reduced-dose

chemotherapy as a newborn,20 ultimately requiring enucleation of that eye. Systemic chemotherapy in

neonates is difficult due to the unknowns of immature liver and kidney function to metabolize the drugs,

Early delivery of retinoblastoma children 13

increasing the potential of severe adverse effects. The conventional recommendation is to either reduce

chemotherapy dosages by 50%, particularly for infants in the first three months of life,32 or administer a

single agent carboplatin chemotherapy;.28 but However, the partial doses carry risk to select forof

selecting for multidrug resistance in the tumor cells, making later recurrences difficult to treat.33-35

Periocular topotecan for treatment of small-volume retinoblastoma36 may increase the effectiveness of

focal therapy without facilitating resistance.

Imhof et al7 in the Netherlands screened 135 children at risk of familial retinoblastoma 1-2 weeks

after birth without molecular diagnosis and discovered 17 cases of familial retinoblastomaretinoblastoma

cases (13% of screened children at risk). Of these, 70% had retinoblastoma in at least one eye at first

examination and 41% of eyes had vision threatening macular tumors; 41% of patients (7/17) had eye

salvage failure (defined by radiation or enucleation) and one case metastasized. Of eyes 74% (27/34) had

good visual acuity (defined by vision >20/100). These results are similar to our Cohort 1, who also

hadwere also diagnosed postnatally diagnosisbut with additional molecular confirmation of disease risk.

In comparison, Cohort 2 with prenatal diagnosis and planned early delivery showed less fewer vision

threatening tumors (17%), fewer less treatment failures (8%) and better visual outcome (88%).

Early screening of at-risk infants with positive family history as soon as possible after birth is the

internationally accepted model convention for retinoblastoma (whether intensive screening is utilized or

not).7,37 In our series, amniocentesis (to collect sample for genetic testing) was performed in the second

half of pregnancy, where risks of miscarriage are low (0.1-1.4%).38,39 HerWee we propose the prenatal

screening for the known RB1 mutation of the proband, by amniocentesis in the second half of pregnancy

where risks of miscarriage are minimal (0.1-1.4%).38,39 show that For for infants confirmed to have carry

their family’s RB1 mutation, we show that planned late preterm or /early term delivery (at 36-38 weeks of

gestation) resulted in smaller tumors with less macular involvement and better visual outcome. There

wasWe did not observe a no difference between our two Cohorts in treatment burden between our two

Early delivery of retinoblastoma children 14

Cohorts, likely because as we didn't change the treatment course did not differ; however, by early

delivery but and thus earlier treatment appeared to changed treatment patient outcomes.

A concern with late preterm or early term delivery is its reported effect on neurological and

cognitive development and later school performance,.14-16 but One could argue that the visual dysfunction

from a larger macular tumor common in retinoblastoma patients is equally concerning, as it can cause

similar neurocognitive defects due to blindness,17 though thisdespite has never not studied in a

comparative manner. Moreover, tAlso, thesehe results from studies reporting on preterm and early term

babies may also be difficult to generalize, as they tend to included many children with complex reasons

for the early delivery, . In contrast, retinoblastoma children are otherwise healthy normal babies, save

forwhile the only morbidity for RB1 carrier infants is the eye tumor growing in their eye. Early term

delivery requires an interactive team of neonatologist, ophthalmologist and oncologist to reach the best

timing for better outcome.40 We show that safe preterm delivery resulted in lower tumor burden at birth

(Cohort 2) that was significantly easier to treat than in Cohort 1 (Figure 2, Table 2). Safe late preterm and

early term delivery resulted in more infants born tumor-free, facilitating frequent surveillance to detect

tumors as they emerged, enabling focal therapy of small tumors with minimal damage to vision (Figures

1, 2).

Counseling on reproductive risks is important for families affected by retinoblastoma including

unilateral probands. In developed countries, where current therapies result in extremely low mortality,

most retinoblastoma patients will survive to have children. Prenatal diagnosis also enables pre-

implantation genetics (to ensure an unaffected child) and informs parents who wish to terminate an

affected pregnancy.41 There have been two prior reports indicating pre-natal molecular testing for

retinoblastoma; in one, the fetus sibling of a proband was found not to carry the sibling’s mutation,42 and

in the other, 2 of 5 tested fetuses of a mosaic proband were born without the parental mutation.43 We are

first to report that elective safe late-preterm delivery of prenatally diagnosed infants with familial

retinoblastoma results in improved outcomes. It is our experience that often retinoblastoma survivors and

Early delivery of retinoblastoma children 15

their relatives with full understanding of the underlying risks, are interested in early diagnosis to optimize

options for therapy in affected babies rather than termination of pregnancy. We also surmise that since

germline mutations predispose to future, second cancers in affected individuals, perhaps it is worth

investigating the role of cord blood banking infants that are prenatally molecularly diagnosed with

retinoblastoma, as a potential stem cell source in later anti-cancer therapy. We conclude that the infants

with familial retinoblastoma likely to develop vision-threatening macular tumors, have an improved

chance of good visual outcome with decreased treatment associated morbidity with prenatal molecular

diagnosis and safe, late-preterm delivery.

Acknowledgements

Early delivery of retinoblastoma children 16

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Early delivery of retinoblastoma children 18

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Early delivery of retinoblastoma children 19

Table 1: Occurrence of tumors at birth according to the type of RB1 mutation (Null vs Low penetrance mutation) in the whole

child (table 1a), eyes (table 1b) and prevalence of IIRC group A eyes at first retinoblastoma tumor (table 1c).

Table 1a Table 1b Table 1cChildren with tumors at

birth n=Eyes with tumors at birth

n=Children with A/A eyes at

as first tumors n=

(child #8 included) (excluding IIRC A eye of

child #8 first examined at age 3 months)

(child #8 included)

YES

NO total

% NO

YES

NO total

% NO

YES

NO total % NO

Null RB1 mutation 9 7 16 44% 14 17 31 55% 6 9 15 60%Cohort 1 5 2 7 9 6 15 1 6 7Cohort 2 3 5 8 5 11 16 5 3 8

Low penetrance RB1 mutation 0 5 5 100

% 0 10 10 100% 3 2 5 40%

Cohort 1 0 1 1 0 2 2 0 1 1Cohort 2 0 4 4 0 8 8 3 1 4

Total N=21 children

N=41 eyes

N=21 childre

nFisher’s Exact Test P=0.04* P=0.02* P=0.61

Early delivery of retinoblastoma children 20

Early delivery of retinoblastoma children 21

Early delivery of retinoblastoma children 22

Table 2: Outcome parameters for both groups per eye (table 2a) and per child (table 2b) and their level of significance.

Table 2a: Outcome parameters per eyeCohort 1

(n=18)

Cohort 2

(n=24) P value

No % No %

Tumor(s) at birth 10 0.56 5 21% 0.027*

Treatment success 11 0.61 22 92% 0.025*Ocular salvage

13 0.72 23 96% 0.07

Visual Outcome 0.014*

Acceptable vision (better than 0.1) 9 50% 21 88%

Poor Vision 9 50% 3 12%

Table 2b: Outcome parameters per childCohort 1

(n=9)

Cohort 2

(n=12) P value

No % No %

Tumor(s) at birth 6 67% 3 25% 0.087

IIRC AA at first tumor 1 11% 8 67% 0.009*

Treatment burden 0.67Focal therapy only

4 44% 7 58%

Early delivery of retinoblastoma children 23

Systemic chemotherapy 5 56% 5 42%

Treatment success 3 33% 11 92% 0.002*

Ocular salvage 4 44% 11 92% 0.046*

Visual Outcome 0.017*

Acceptable vision (better than 0.1) 7 78% 12 100%

Legal Blindness 2 22% 0 0%

Early delivery of retinoblastoma children 24

Early delivery of retinoblastoma children 25

Figure 1: Schematic representation of each child in Cohort 1 (postnatal RB1 detection) and Cohort 2

(prenatal RB1 detection) from delivery until time of first tumor, IIRC at first tumor per eye, treatment

burden (focal, systemic chemotherapy, or radiation treatment). Number of EUAs, visual acuity at last

follow up and follow up duration.

I suggest you put all VA in black , if there are no reason for bolding, do not bold some only or bold all, I

would ljustify the VA to the left

Gestational Age

20/20; 20/25

28 29 30 31 32 33 34 35 36 37 38 39 40 1 2 3 4 5 6 7 8 9 10

20/20; 20/200

3 20/20; E

1 20/20; 20/20

8

20/20; 20/25

20/30; 20/60

20/600; 20/60

9

10

E; 20/30

4 E(OS) 20/20, E

11

20/15; 20/10

20/50; 20/20

13

20/20; 20/25

15

Coho

rt 1

Coho

rt 2

5.6

18

7.1

18

14.8 5.2

12.8

9.5

8.8

4.3

6.4

FU (y)

Spontaneous birth Induced birth Birth to first tumor

monthsweeks

E(OS)

20/25; 20/25

17

3.2

6 NPL; 20/25 2.7

VA (OD, OS)

2 20/200* 3.7

5

IIRC (OD, OS)A, AC, B

A, BA, BA, B

B, A7 A, B 20/30; 20/30 2.8

(OS)

D, A

B, B

E; 20/20E(OD) 2.4

(OU) E(OD) E; 20/400 15.5

12

14

16

1819

20

21

A, A 15.5

B, AB, B

(OU) E(OD) 4.9B, B

A, A

A, A

A, A

B, B

A, A

20/25; 20/100

B, B 20/125; 20/25

A, A 2.3

EUAs25

41

24

22

21 33

36

30

30

24

31

20

30

43

18

81

41

28

21

23

22 20/20; 20/25 3.8 A, A

E(OD)

E

Focal Therapy Chemotherapy

Radiotherapy Enucleation

Early delivery of retinoblastoma children 26

Early delivery of retinoblastoma children 27

Figure 2: Kaplan Meyer curves of eye salvage without radiation showing a significant treatment success

in Cohort 2 versus Cohort 1.

.

Good point from Helen, explain “0” and percentage of what? Children without irradiation?

Perc

enta

ge

Time in months

Early delivery of retinoblastoma children 28

Figure 3: Correlation between visual acuity at last follow up (decimal) and gestational age at delivery in

weeks showing a negative correlation.

26 28 30 32 34 36 38 400

0.5

1

1.5

2

f(x) = − 0.0284788135593221 x + 1.66274293785311R² = 0.0313248065403926

Gestational age (weeks)

Visu

al A

cuity

(dec

imal

)