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Clinical audit of retinoblastoma management: a retrospective single-institution study

      Abstract

      Objective

      The primary aim of this study was to identify the frequency of death, metastasis, enucleation, and use of external beam radiation therapy (EBRT) among retinoblastoma patients. The secondary aim was to determine whether any events were associated with suboptimal clinical management to identify areas for clinical care improvement.

      Methods

      Patients diagnosed with retinoblastoma between January 1, 2000, and December 31, 2015, at The Hospital for Sick Children were included. Medical records of eligible patients underwent a comprehensive 2-part review. First, a chart review collected diagnostic details, treatment course, and occurrence of 4 events: death, metastasis, use of EBRT, and enucleation. Next, events were reviewed in detail, and a multidisciplinary committee reached consensus on cases managed suboptimally.

      Results

      The study included 209 patients (292 eyes). There were 8 deaths, 11 metastases, 177 enucleations (143 primary, 34 secondary), and 8 uses of EBRT. Thirteen patients were reviewed by the multidisciplinary committee, which confirmed that 5 of these patients had events associated with suboptimal clinical management. Three patients developed metastases leading to death (misdiagnosis and mismanagement of trilateral retinoblastoma [1], parental refusal of enucleation [1], and inaccurate histopathology after primary enucleation [1]). One patient developed extraocular extension related to scleral invasion following aggressive focal therapy. One patient underwent secondary enucleation for a Group B eye related to mismanagement of a treatment complication.

      Discussion

      Deaths, metastases, and enucleations with documented instances of suboptimal care highlighted a need to enhance medical team and patient communication, histopathology interpretation, laser treatment guidelines, and trilateral retinoblastoma management. Routine clinical audit of retinoblastoma management can identify areas for clinical practice change.

      Résumé

      Objectif

      Notre étude avait pour objectif principal d'identifier la fréquence des décès, de l'apparition de métastases, des énucléations et du recours à la radiothérapie externe (EBRT) dans le rétinoblastome. Notre objectif secondaire visait à identifier des événements associés à une prise en charge clinique sous-optimale afin de cerner des zones d'amélioration des soins cliniques.

      Méthodes

      L’étude regroupait des patients qui ont reçu un diagnostic de rétinoblastome entre le 1er janvier 2000 et le 31 décembre 2015 à l'Hôpital pour enfants malades (SickKids) de Toronto, en Ontario. Les dossiers médicaux des patients admissibles ont fait l'objet d'un examen exhaustif en 2 parties. On a commencé par extraire les détails liés au diagnostic, au traitement et à la survenue de 4 événements: décès, métastases, recours à l'EBRT et énucléation. Par la suite, après avoir examiné chaque événement en détail, un comité multidisciplinaire est parvenu à un consensus sur les cas dont la prise en charge n'avait pas été optimale.

      Résultats

      L’étude regroupait 209 patients (292 yeux). On a répertorié 8 décès, 11 métastases, 177 énucléations (143 primaires et 34 secondaires) et 8 recours à l'EBRT. Le comité multidisciplinaire a passé en revue le dossier de 13 patients et a confirmé que 5 de ces patients avaient subi des événements découlant d'une prise en charge clinique sous-optimale. Ainsi, 3 patients ont présenté des métastases qui ont mené à leur décès (diagnostic erroné et mauvaise prise en charge d'un rétinoblastome trilatéral [1], refus de l’énucléation par un parent [1] et résultats erronés de l'examen histopathologique après l’énucléation primaire [1]). Par ailleurs, 1 patient a présenté une extension extraoculaire associée à un envahissement scléral à la suite d'un traitement focal énergique; et 1 patient a dû subir une énucléation secondaire de l’œil dont la tumeur était classée Groupe B en raison de la prise en charge inappropriée d'une complication thérapeutique.

      Discussion

      Les décès, l'apparition de métastases et les énucléations s'accompagnant de données probantes qui mettent en relief une prise en charge sous-optimale soulignent le besoin d'améliorer la communication entre l’équipe de soins et les patients, l'interprétation des résultats de l'examen histopathologique, les lignes directrices du traitement au laser et la prise en charge du rétinoblastome trilatéral. La vérification clinique régulière de la prise en charge du rétinoblastome permettra de faire ressortir les aspects de la pratique clinique qui peuvent bénéficier d'une amélioration.
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