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Diagnosis, and Treatment of Retinoblastoma

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Diagnosis, and Treatment of Retinoblastoma British3'ournal ofOphthalmology 1993; 77: 805-812 805 PERSPECTIVE Br J Ophthalmol: first published as 10.1136/bjo.77.12.805 on 1 December 1993. Downloaded from Applications ofmonoclonal antibodies in the investigation, diagnosis, and treatment of retinoblastoma John F Tarlton, D L Easty In Europe and North America, retinoblastoma has a reported derived cell lines fused with RB1 competent cells.2' Reversal incidence ranging from 1 in 14 000 to 1 in 36 000 live births'-5 of malignancy has also been reported in cell lines transfected and is the most common ocular malignancy affecting children with functional BR1 gene constructs. Recently, however, and infants. Early diagnosis allows the application of a these results have been challenged by other researchers who number of therapies directed at localised disease, including have found incomplete reversal of malignancy in retino- external beam and plaque radiotherapy, cryotherapy, and blastoma cell lines,22 although such effects may be artefacts photocoagulation, although the principal treatment account- resulting from additional genetic changes having occurred in ing for the high cure rate ofaround 90% is enucleation, which cells adapting to tissue culture environments. The impor- is still carried out in over halfofall cases. The justification for tance of RB1 in malignant transformation has also been such radical therapy is the poor prognosis once the tumour demonstrated by inactivating its product by association with escapes the eye, and the high mortality from metastases.6 virus proteins such as adenovirus EIA,23 SV40 large T In the developing countries ofAfrica and Asia the picture is antigen24 and papillomavirus E7 oncoprotein,2" both by different. The higher reported incidence in many areas,7-" transfection and transgenic manipulations.26 Furthermore, coupled with a lower incidence ofocular malignant melanoma this gene has been implicated in the progression of other in particular racial groups results in retinoblastoma being the cancers, such- as colon and breast carcinomas, and hence its commonest ocular tumour in all age groups. Moreover, late significance as a tumour suppressor extends beyond its role in diagnosis and treatment lead to a correspondingly high rate of the tumorigenesis of retinoblastoma. mortality due to metastatic spread, approaching 100% in Perhaps the greatest recent clinical advance to emerge from some areas.'0 theoretical studies ofretinoblastoma, is in the field ofprenatal Therefore the inability to deal effectively with metastatic and perinatal screening and genetic counselling. The predis- retinoblastoma results in a high mortality in areas where posing gene for retinoblastoma may be identifed using DNA medical care is limited and the extensive use of prophylactic probes recognising restriction fragment length poly- enucleation in developed countries. Despite the efficacy of morphisms (RFLP, variable length fragments of DNA current therapeutic intervention, there remains a need for prepared by sequence dependent endonuclease activity) on http://bjo.bmj.com/ further investigation into improvements in treatment of Southern blot analyses of genomic DNA.'215 This enables metastatic disease. predisposed individuals to be identified in utero, as well as Recent advances in the understanding ofthe cancer process recognising carriers of the aberrant retinoblastoma gene in are due largely to the advent ofmolecular genetics and the use cases of incomplete penetrance. 5 ofmonoclonal antibodies, and perhaps the greatest contribu- Monoclonal antibodies provide highly specific molecular tion ofsuch techniques has been in studies ofretinoblastoma. recognition that can characterise and selectively localise The occasional association of the familial predisposition to tumour cells. To date their greatest contribution has been in on September 30, 2021 by guest. Protected copyright. retinoblastoma with a visible chromosome deletion at elucidating the cellular origin of tumours, by equating 13ql4,'2-'4 and the linkage to the gene coding for esterase- immunohistochemical profiles in neoplastic cells with those D,'3 11 6 confirmed the genetic basis for this disease. Epidemi- of defined cell types in their tissue of origin. Although ological evidence led Knudson to formulate the 'two hit' antibodies are highly specific for their molecular markers, the hypothesis for the tumorigenesis ofretinoblastoma, postulat- apparent lack of antigens expressed uniquely by cancer cells ing that both copies ofthe viable gene must be inactivated by has limited their diagnostic and therapeutic applications. By two independent mutational events (or 'hits').' 8 An indi- identifying the inadequacies of monoclonal antibodies, vidual with the familial predisposition has inherited one researchers are now devising means ofoptimising their use in inactive gene, such that only one subsequent mutational the clinical situation, and recent advances in recombinant event is necessary, during the susceptible stage ofembryonic technology may help in overcoming many oftheir limitations. development, to cause a retinoblast to become malignant. Retinoblastoma was the first cancer to be identifie7d with a tumour suppressor gene, or anti-oncogene,'" to have this Immunohistochemistry in defining cellular origin gene, RB1, located and cloned, and its protein product, The immunochemical reactivity of tumour samples and cell pl1 0' ', isolated.419 The inheritance is autosomally dominant lines such as Y7927 and WERI RB128 has been investigated in individuals with a single germline mutation due to the high using monoclonal antibodies which recognise markers associ- probability ofa second 'hit' inactivating the single remaining ated with particular tissues and cell types. Such markers viable copy of the gene in one or more of the vulnerable include retinal S antigen,2"3' inter-retinoid binding protein,3' retinoblasts. This malignancy is recessive at the genetic level, opsin,3' 32 and rhodopsin,33 all associated with photoreceptors; as indicated by the frequent loss of heterozygosity in tumour S100 and glial fibrillary acidic protein3""33"37 associated with cells'920 and reversal of the malignant phenotype in tumour glial cells; neuron specific enola'se,'3234 38 tetanus toxin and 806 Tarlton, Easty dopamine B hydroxylase,37 neurofilaments and synapto- evidence from other studies,'3 34 38 indicate that the tumour physin,"39 all characteristic of neuronal cells. From the probably arises from a primitive multipotential neuro- presence ofthese markers, a tumour origin from photorecep- epithelial cell of early embryogenesis, and present in declin- tors, glial, or neuronal cells has been postulated, as well as ing numbers into later stages of development. This would Br J Ophthalmol: first published as 10.1136/bjo.77.12.805 on 1 December 1993. Downloaded from from a primitive common progenitor cell. offer an ever shrinking target for Knudson's second 'hit', and An alternative approach has been to equate antigenic account for the reduction in incidence with advancing age. heterogeneity with cell types, and therefore the differentia- Furthermore, if the second 'hit' is sustained when partial tion potential oftheir common progenitor, the cell oforigin of differentiation has already occurred, this may result in the the tumour. By correlating with the known cell lineage of less malignant form of the disease described as retinocytoma developing embryonic retinal cells, this allows definition of or retinoma.2 the tumour stem cell in terms of normal retinal progenitors The use of histological sections of tumour tissue and (Figs 1, 2, and 3). Results from this work,' and the weight of established retinoblastoma cell lines present some difficulties in interpretation. The tumour may have incorporated non- neoplastic cells such as normal retinal and reactive glial cells,4 and cell lines of retinoblastoma are thought to be modulated extensively in tissue culture. In addition, cell lines may not possess the full differentiation capacity ofthe tumour stem cell, and are therefore not necessarily representative. Immunocytochemistry in differential diagnosis and prognosis There are a number of conditions which simulate retino- blastoma in presentation, including Coats' disease, persistent hyperplastic primary vitreous, and toxocariasis.4' Up to 30% of eyes enucleated for suspected retinoblastoma have been misdiagnosed,42 and yet delayed treatment of the tumour resulting from ambiguous presentation may prove fatal.' Accurate differential diagnosis is therefore essential if appro- o rh -- i1irhrh. Figure 1 Immunohistochemical reactivity profiles ofretinoblastoma, adult, http://bjo.bmj.com/ andfetal retina with respect to seven differentially marking monoclonal antibodies. Tumour may be distinguishedfrom nornal retinal cell types using a panel ofantibodies. NF= nerve fibre, GC=ganglion cell, IP=inner plexiform, IN=inner nuclear, OP=outer plexiform, ON-outer nuclear, PR=photoreceptor, C=choroid.40 Adult retina on September 30, 2021 by guest. Protected copyright. Retino- Nerve Ganglion Inner Inner Outer Outer Photo Figure 3A Retinoblastoma reaction with anti-NCAM, UJt13A; very blastoma fibre cell plex nuclear plex nuclear receptor strong cell membrane expression ofthis adhesion molecule (original 1)1RT97 . + magnification x480). 12) 181.4 4.- 13) BF10 + ,l z. '-I (4) ATHY ++ 1- VW, :.ft (5)FD32 V.' * L (6)FD44 + ......+. C..., - M 1711153 A44 '' I^ T, ,. .S I .: A4 '~ v;li oS.I.IVP- {,s W. 4.I r '44.4 *§t '. '4 ^ x *,s t,/ iw ,~ ....A ., Z .,
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