Historic Review of

Retinoblastoma
DANIEL M. ALBERT, MD

Abstract: Retinoblastoma was first described as a specific entity by James

Wardrop in 1809, with enucleation as his suggested treatment. Histologic stud-
ies including those of Flexner and Verhoeff and subsequent electron micros-
copy have given insights into its pathogenesis. The establishment of cell lines of
retinoblastoma, the "nude" mouse model, and other animal models have con-
tributed additional information. Classic genetic and epidemiologic studies
have led to a broad and intense interest in the tumor despite its relative infre-
quency. Attempts now in progress to identify and characterize the oncogene
for retinoblastoma may prove to be the most exciting part of the history of
retinoblastoma. [Key words: medical history, retinoblastoma.] Ophthalmology
94:654-662, 1987

With the cloning of the "retinoblastoma gene," we

have entered into a new and exciting chapter of the
study of retinoblastoma. It is a story that began nearly
400 years ago in a dissecting chamber in Leiden, the
Netherlands. Subsequently, many of the great names in
ophthalmic history were involved in the study of this
tumor. There are several key threads to the history: the
clinical recognition of retinoblastoma, the development
of effective treatment for the tumor, the microscopic
study ofthis neoplasm, the understanding of the molec-
ular biology of its growth, knowledge of the genetics of
its occurrence, and the isolation of the retinoblastoma
gene.
Henry E. Sigerist wrote: "If our work is not to be
haphazard but to follow a well-laid plan, we need the
guidance of history, and it is not by accident that all
great medical leaders were fully aware of the value of
historical studies."! In unfolding the history of progress
in recognizing and treating this tumor, we can see that
the successive generations of inquiring physicians at-
tempting to understand and solve the problems they
faced were indeed acutely aware of what their predeces-
sors had observed and concluded. From the lessons
learned in the study of retinoblastoma, we stand on the
threshold of gaining profound insights into the specific
genetic alterations required to transform normal cells
into cancer cells.
From the Howe Laboratory of Ophthalmology, Massachusetts Eye and
Ear Infirmary, Boston.
Reprint requests to Daniel M. Albert, MD, Howe Laboratory of Ophthal-
mology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Bos-
ton, MA 02114-3002.
THE CLINICAL RECOGNITION OF
RETINOBLASTOMA
Petrus Pawius of Amsterdam is credited with giving
the first description in the literature of a tumor resem-
bling retinoblastoma.F' Pawius was a noted anatomist
in the Netherlands who became Professor of Anatomy
at Leiden. His report, republished by Bartolini in 1657,4
describes a 3-year-old child with a large fungating tumor
of the left eye. The malignancy invaded the orbit, the
temporal region, and spread into the cranium, a picture
strongly suggestive of untreated retinoblastoma. The
tumor was described to be "filled with a substance simi-
lar to brain tissue mixed with thick blood and like
crushed stone."
For the next 150 years, few if any convincing cases of
retinoblastoma can be found in the literature. Then, in
1767, an article was published in Medical Observations
and Inquires [sic] entitled, "The Case ofa Diseased Eye
Communicated to Mr. William Hunter by Mr. Hayes,
Surgeon."? Hayes described a bilateral tumor in a 3-
year-old girl. In his description Hayes states, "The eye
seemed to have lost its deep black appearance. . . and
acquired a more clear bright look, something resembling
a eat's eye in the dark." Dunphy' believes this to be the
first description of the so-called "amaurotic eat's eye,"
although other historians attribute the term to Georg
Joseph Beer of Vienna who emphasized it as a diagnos-
tic sign." Hayes found the vitreous of the right eye re-
placed by a "white curdy substance," and expressed the
belief that the cancer arose from the vitreous body.
In 1805, William Hey, Senior Surgeon at the General

654
 ALBERT
Fig 1. James Wardrop.
Infirmary at Leeds, England, coined the term fungus
haematodes to describe an extremely vascular fungating
tumor which he encountered a number of times, often
on the limbs or the breast. He wrote, "This disease not
infrequently affects the globe of the eye, causing an en-
largement of it with the destruction of its internal orga-
nization. If the eye is not extirpated the sclerotic bursts
at the last, a bloody, sanious [sic] matter is discharged
and the patient sinks under the complaint." This term
fungus haematodes continued to be applied to retino-
blastoma for many years. Dollfus and Auvert, in their
report on glioma ofthe retina," cite a total of 40 different
names given to the tumor!
It was in 1809 that James Wardrop (Fig 1), a brilliant
and colorful Scottish surgeon who practiced for many
years in London, described retinoblastoma as an entity.
His principal contributions regarding retinoblastoma
were in his text, On Fungus H aematodes or Soft
Cancers In the preface, Wardrop cited the major point
of his book: "In the following observations it has been
my great object to point out the anatomical structure of
the fungus haematodes, and fix precise limits to the im-
port of the name, to bring under one general view a
considerable number of facts, the greater part of which
RETINOBLASTOMA
are to be found insulated and not arranged in the works
of different authors-and also to describe the disease in
particular organs where it has not been hitherto known
to exist."
Wardrop brought together the random, isolated facts
and observations of earlier authors and in light of his
own experience was able to demonstrate that there were
disparate tumors and not a single disease. He concluded
that because the ocular form of this disease so often
involved children, it must be distinct from the more
general classification of "soft cancer." Wardrop's metic-
ulous dissection of some of these eyes led him to the
conclusion that the ocular form seen in children arose in
most instances from the retina. His drawings and clini-
cal descriptions accurately reflect the clinical course of
the disease. Wardrop also demonstrated the extension of
the tumor to the optic nerves and brain and described
metastases to different parts of the body.
With Helmholtz's introduction of the ophthalmo-
scope in 1851,9 it became possible to make a more accu-
rate study of early cases. Fungating lesions growing
through corneal perforations, proptosis resulting from
orbital invasion, buphthalmos, optic nerve invasion,
and direct spread to the brain or leptomeninges were no
longer the usual presenting signs in Europe and North
America. In addition, as increasing numbers of surgical
specimens from surviving patients were studied histo-
pathologically, clinicohistologic correlations were estab-
lished. The manner of intraocular and extraocular ex-
tension, patterns of metastasis and recurrence, ocular
complications, and associated malignancies gradually
became recognized.
The first cases of spontaneous regression of retinoblas-
toma were described by DeKleijn lO and Knieper.!'
Knapp in Germany, LeGrange in France, Francois in
Belgium, Reese, Ellsworth, Abramson, and Kitchen in
the United States, and Stallard, Bedford, and Hunger-
ford in England are among the many names in modern
times which deserve mention with regard to our knowl-
edge of the clinical course of this tumor.
Zimmerman points out that until the 1970s, "Vir-
tually every new malignancy that arose in a survivor of
treatment for retinoblastoma met the criteria for a diag-
nosis of radiation-induced neoplasia . . . "12 The occur-
rence of second cancers arising outside the field of radia-
tion was pointed out by Jensen and Miller,13 and
Abramson et at. 14 Appreciation of the occurrence of ec-
topic retinoblastomas in the pineal body or in a parasel-
lar region ("trilateral retinoblastoma") stemmed from
reports of Jakobiec et al" and Bader et al."
THE TREATMENT OF RETINOBLASTOMA
In addition to being the first to describe retinoblas-
toma as a distinct entity, James Wardrop reached the
radical (and for many years controversial) decision that
early enucleation of the involved eye might save the life
of the patient. 8 He stated this in spite of the fact that, in
all cases in which he had removed the eye, the disease
655
 OPHTHALMOLOGY JUNE 1987 VOLUME 94 NUMBER 6

returned and the patient died. He was nevertheless

aware in those days before the invention ofthe ophthal-
moscope that he was dealing with advanced cases. War-
drop stated specifically: "But as we know of no instance
of the operation being performed at a very early period
of the disease or in any case where the optic nerve was
found in a healthy state, there is still room to hope for
success under such circumstances. It is an experiment,
at all events, which still merits trials ; and were I in any
case to be assured of the existence of the disease in the
early stage, I would have no hesitation in urging the
performance of the operation. Past experience proves
the impropriety of attempting any operation, when the
disease has advanced so far that the posterior chamber is
filled with the diseased growth. The operation at this
period has in many instances, alleviated the patient's
sufferings, but I have no hesitation in saying that it has
also in many cases hastened the patient's death."
Wardrop's contemporaries took a dim view of his
suggested treatment. The most outspoken was George
Guthrie: "In regard to fungus haematodes of the eyeball,
it may be considered a fatal disease; in as much as the
removal of the eye has not , I believe, hitherto succeeded
in arresting its progress when it has been so fully formed
at the bottom of the eye as to show distinctly its na-
ture."? ?
Scarpa," Travers,'? and Lawrence'? all objected vig-
orously to Wardrop's proposed procedure. It should be
borne in mind that before Simpson's discovery of chlo-
roform as the first general anesthetic, enucleation was an
extremely crude and painful operation. William Mac-
kenzie of Glasgow, who in his important Practical
Treatise on the Disease of the Eye 2 1 referred to the
tumor as "spongoid or medullary tumor of the eyeball," Fig 2. Frederich Herman Verhoeff.
described a method to make the operation more bear-
able: a patient was bled until unconscious. The diseased
eyeball was then removed and the patient eventually gartner of Austin, Texas." The patient, a 3Ih-year-old
regained consciousness. child, had a large "glioma" in the right eye and a small
In the absence of enucleation, what treatments were tumor in the left. After 84 treatments with x-ray (total
performed? A review of the writings before 1850 indi- dosage unknown), the right eye became shrunken and
cates that leeches, poultices, purgatives, bland diet, ven- the growth in the left eye "resorbed." Unfortunately,
esection, antimony, iodide preparations, and volatile there was no histologic confirmation of the diagnosis in
vesicants as "counterirritants" were all advised half- this case, and the patient was lost in follow-up." In
heartedly. 1919, Schoenberg" described the use of radiation ther-
After the introduction of chloroforin as a general an- apy in a 2-year-old girl with bilateral retinoblastoma.
esthetic and with the availability of the ophthalmoscope The eye with the larger tumor was enucleated and the
for earlier diagnosis, enucleation became accepted as the less involved eye treated by radium therapy. The tumor
appropriate treatment. Modern enucleation procedures in the latter eye regressed and 3 years after treatment
had been introduced by Bonnet of Paris" and Ferrall of began the child was healthy with good vision. A follow-
Dublin.P Von Graefe recognized the frequent extension up report by Schoenberg'? stated that the patient had
of retinoblastoma into the optic nerve , and made the useful vision to years after the initial therapy and after
important suggestion that as much optic nerve as possi- removal of a cataract. In 1944, however, a "scar tissue
ble be taken at the time of enucleation." He accom- sarcoma" developed over the temporal portal used dur-
plished this by pulling the globe forward with forceps ing the radium therapy and the patient later died of
after cutting the muscles. Improvement in prognosis was metastatic disease."
soon reported: Hirschberg in 186925 had a 5% survival The first well-documented case of bilateral retinoblas-
rate; Wintersteiner in 1897,26 a 17% rate; and Leber in toma to be cured by x-irradiation was reported by Ver-
1916,27 a 57% rate. hoeff (Fig 2) in 1921. 32 The patient was first examined
The first attempt to treat retinoblastoma with x-ray by Verhoeffin the Massachusetts Eye and Ear Infirmary
occurred in 1903 and was carried out by H. L. Hil- in 1917, when he was 17 months of age. He had been

656
 ALBERT
Fig 3. Left . fundus photograph of the first retinoblastoma patient cured
by x-irrad iation, Patient was treated by Dr. Verhoeff from 1918 to
1919 (fundus photograph 1977).
referred by an ophthalmologist in Providence, Rhode
Island, because the pupil of his right eye was white. Ver-
hoeff examined the child on November 22, 1917, and
noticed a shallow anterior chamber, a dilated pupil, and
a moderately increased tactile tension in the right eye.
The tumor was described as a "vascularized yellowish-
white mass in contact with the posterior surface of the
lens." The left eye appeared to be normal when it was
examined while the patient was under anesthesia 2 days
later. His family history was noncontributory. His two
brothers, 8 and 12 years old, and his 6-year-old sister
had normal eyes. On November 24,1917, the right eye
was enucleated and Dr. William Leibman, the radiolo-
gist at the Massachusetts Eye and Ear Infirmary, admin-
istered "five severe x-ray treatments to the right orbit."
Results of pathologic examination showed that the
tumor occupied 75% of the globe extending from the
optic disc to the posterior surface of the lens and com-
pletely replaced the vitreous body. There was a total
retinal detachment and the anterior chamber was shal-
low. The tumor was described by Verhoeffas a "typical
(so-called) glioma retinae" with abundant "typical ro-
settes." Results of an examination on May 2, 1918,
RETINOBLASTOMA
Fig 3. R ight , fluorescein angiogram of fundus seen in 3 left (fundus
photograph , 1977).
showed that a "white, opaque, elevated mass, irregularly
oval in shape" developed in the left eye just behind the
equator in the lower quadrant with two small, white
satellite spots nearby. The patient was referred to Leib-
man for radiation therapy in his left eye. He received
"suberythema dosage exposure" through the sclera
using a 5-mm aluminum filter "to protect the lens and
anterior part of the eye." The patient underwent similar
treatments once a week for 3 weeks and on five other
occasions between June 6, 1918, and January 17, 1919.
The total amount of radiation given was not known.
By June 8, 1921, Verhoeffnoticed some reduction in
the size and elevation of the tumor. The tumor lost its
opaque, white appearance and a circular depressed area
developed; Verhoeff interpreted it as a "shallow hole" in
the tumor, The two small, white nodules near the tumor
completely disappeared (Fig 3), No cataract developed
after the radiation and the patient's visual acuity, esti-
mated by a picture chart , seemed to be at least 20/30.
The mother was not aware of any visual handicap , The
patient retained good visual acuity without any ocular
complication from 1921 to 1977.33 In 1977, a basal cell
carcinoma developed on the left lower lid. The tumor
657
 OPHTHALMOLOGY JUNE 1987
recurred in February 1980, and in January 1981 a squa-
mous cell carcinoma was excised from the left
lower lid."
Verhoeff made the point that it was probably hopeless
to destroy a large retinoblastoma with irradiation and
that immediate enucleation was to be preferred. How-
ever, if the tumor in the other eye was small, x-ray treat-
ment should be tried. This dictum was generally fol-
lowed for the next half-century.
The pioneering effort to use radioactive isotopes oc-
curred in 1930 when Moore and associates destroyed a
retinoblastoma by implanting a radon seed through a
puncture in the sclera." This work was refined by Stal-
lard who developed special applicators conforming to
the sclera and used cobalt 60. 36 Kupfer, in 1953,37 was
the first ophthalmologist to combine chemotherapy
(using a nitrogen mustard agent intravenously) with ra-
diation therapy. In the 1950s and 1960s, the use of an
analogue of nitrogen mustard (triethylene melamine)
was popularized by Reese" as a radiomimetic agent.
The use of nitrogen mustard and triethylene melamine
have, in more recent years, been largely abandoned. Oc-
casionally, other chemotherapeutic agents, including
cyclophosphamide (Cytoxan), vincristine, doxorubicin
(Adriamycin), and 5-fluorouracil have been used singly
or in combination in advanced cases."
Photocoagulation, laser therapy, and cryotherapy are
increasingly used as both primary and supplemental
treatments, particularly for small retinoblastomas."
THE HISTOLOGY OF RETINOBLASTOMA
As noted, James Wardrop, in 1809,8 on the basis of
his meticulous dissections of eyes with retinoblastoma,
reached the conclusion that it arose in most instances
from the retina. This conclusion, however, was not ac-
cepted by all the authorities of the day. Travers, at
Moorfields, believed that every tissue of the eye, except
the lens and the cornea, was capable of generating the
tumor.'? Tyrrell, one of Travers' successors at Moor-
fields, was convinced that the tumor originated from the
cornea, reasoning that if it was in the retina it would be
seen in bright light, whereas it was, in fact, best seen in
dim light."
The microscopic studies ofLangenbeck in 18364 1 and
Robin and Nysten of Paris'" definitely demonstrated by
microscopic studies that the tumor arose from the ret-
ina. Attention subsequently focused on what cell in the
retina gave rise to the tumor, a question which continues
to be studied to this day. Robin and Nysten'" believed
the tumor arose from the ganglion cells. Iwanoff'f and
Manfredi 4 4 believed the tumor arose from the nerve
fiber layer.
The great Berlin pathologist, Virchow" was the first
to claim that retinoblastomas were ofglial origin, and he
used the term glioma of the retina to describe these
tumors. However, as the review by Willis46 clearly points
out , this interpretation was presumptive. Stains pur-
658
VOLUME 94 NUMBER 6
ported to demonstrate neuroglial spider cells by means
of the Golgi method were, in fact, not specific, and both
Verhoeff'" and Leber " downplayed their significance.
Verhoeff stated that the Golgi method "is noted for giv-
ing misleading pictures."?" He used Mallory's neuroglial
stain, a more accurate method, but never found glial
fibers in retinoblastoma. He did find such glial differen-
tiation in a medulloepithelioma arising from 'the ciliary
body epithelium. Leber showed that degenerating tumor
cells may mimic glial cells when the Golgi staining
method is used, and he also urged caution about the
interpretation of this supposedly specific staining
method."
Despite this inability to demonstrate a retinoblastoma
with a glial component, Bailey and Cushing never
doubted that retinoblastomas were capable of glial dif-
ferentiation. In their classic 1926 monograph on the
classification of tumors of the glioma group, they di-
vided retinoblastomas into two types: medulloblastomas
and neuro-epitheliomas." The medulloblastomas were
undifferentiated retinoblastomas and, like medulloblas-
tomas of the central nervous system, they were derived
from a pluripotential cell of origin, the medulloblast.
They considered both types of retinoblastoma to have a
potential for glial differentiation.
F1exner of Johns Hopkins was the first to notice ro-
settes within the tumor in 1891.49 F1exner noted a re-
semblance to rods and cones and traced one tumor to
the photoreceptor cell layer. Consequently, he proposed
the name neuroepithelioma. Wintersteiner, 6 years later,
apparently unaware of F1exner's earlier description, re-
described the rosettes, which now bear the name
F1exner-Wintersteiner rosettes , and assumed that the
neoplasm arose from misplaced rods and cones."
A less specific structure described in retinoblastomas
was the Homer Wright rosette in which a spheroid group
of nuclei encloses a delicate cobweb tangle of fibrillary
material. This was first described in sympathicoblas-
tomas and is also characteristic of cerebellar medullo-
blastomas. Other observers, instead of focusing on areas
of differentiation, were impressed that the majority of
cells composing the tumor histologically resemble the
cells ofthe undifferentiated retina ofthe embryo." This
resemblance prompted Verhoeff to give the tumor the
name retinoblastoma which was adopted after lengthy
deliberations as a general term by the American Oph-
thalmological Society in 1926.5 1
With the introduction ofelectron microscopy into the
study of retinoblastomas, the association of this tumor
with photoreceptor elements, endocrine elements, and
glial cells have all been convincingly documented. Tso
and co-workers'<" have demonstrated primitive inner
segments of photoreceptor cells, terminal bars, and cilia
with a 9 + 0 pattern.
Sang and Albert" demonstrated neurosecretory gran-
ules resembling those found in amacrine cells which
take up and metabolize neurotransmitters normally
found in healthy retina tissue. In 1970, Tso et al 53 de-
scribed and illustrated by electron microscopy "a high
degree of maturation with evidence of photoreceptor
 ALBERT
differentiation by individual tumor cells and small bou-
quet-like clusters of benign-appearing tumor cells
(fleurettes)."
Electron microscopic evidence of glial differentiation
in retinoblastomas was first presented by Popoff and
Ellsworth." Ts0 56 has described an area ofglial differen-
tiation in a retinoblastoma. The glial-like tumor cells
were separate from the undifferentiated retinoblastoma
cells and were located away from the detached retina.
Lane and Klintwortlr" used an immunoperoxidase
technique to demonstrate glial elements within other
cases of retinoblastoma. Craft and co-workers" reported
a case in which cells resembling glial cells were inter-
mixed with more typical cuboidal retinoblastoma cells.
These cells had electron microscopic features typical of
glial cells and stained positively for glial fibrillary acidic
protein and immunohistochemical studies.
The horizons in retinoblastoma research have been
considerably widened by the development of tissue cul-
ture cell lines for retinoblastoma'Y" and the immuno-
deficient nude mouse model for human retinoblas-
toma." The most dramatic demonstration of the multi-
potential nature of the retinoblastoma cell has been the
studies of Kyritsis and associates'<" in which, by ma-
nipulating the tissue culture environment of the cells,
they could induce differentiation along neuronal lines,
glial lines, and even pigment epithelium. The isolation
of retinoblastoma-derived growth factor (ROOF) has
also given important insight into the control of growth
of these tumor cells."
Since early in this century there have been reports of
complete spontaneous necrosis of retinoblastomas lead-
ing to regression and a "cure." Among the earliest such
cases were those reported by Kleijn,1O Knieper, II Lin-
denfeld," and Meller. 66 Typically, these involve blind,
phthisical eyes; the specific pathogenetic mechanism re-
mains unclear. A vascular mechanism (e.g., the tumor
outgrowing its blood supply or occlusion of vessels) and
immunologic mechanism (circulating antibodies as
demonstrated by Char et al)67 have been proposed.
In addition, spontaneous regression has been de-
scribed as occurring in small, often calcified tumors seen
in eyes retaining useful vision. Gallie and co-workers"
have proposed these as small, benign variants of retino-
blastoma termed retinomas and have suggested criteria
for distinguishing retinomas from genuine regressed ret-
inoblastoma. These have also been described by Margo
et al in 1983 as retinocytomas." These are intriguing
lesions and an understanding of their differentiation
may have important implications with regard to the suc-
cessful treatment of malignant tumors.
THE GENETICS OF RETINOBLASTOMA
The role of heredity in retinoblastoma was not appre-
ciated until the 19th century because the disease was
ill-defined and there were no survivors. In 1821, 12
years after Wardrop's description of retinoblastoma as a
distinct entity, Lerche?" described a family in which four
RETINOBLASTOMA
of seven children were affected (interestingly, only 1 bi-
laterally). Subsequently, Sichel of Paris" and Wilson in
England'" described sibships in which most or all of the
children had the disease. Von Graefe's" observation in
1868 that different family lines descended from a com-
mon ancestor (i.e., collateral lines) could have the dis-
ease, raised the suspicion that retinoblastoma might be a
truly inherited disease if a survivor produced offspring.
DeGouveia in Brazil reported the first case of a retino-
blastoma survivor having an affected offspring in the
Brazilian literature in 1886.73 This case was not appre-
ciated, however, for many years.
As late as 1905, Parsons?" stated: "there is no case on
record of a child from whom a gliomatous eye has been
removed, growing up and having children with glioma."
The report that convincingly refuted Parson's conten-
tion was by C. N. Ridley in the 1904 Royal London
Ophthalmological Hospital Reports ofa patient who had
one eye removed for glioma. The child survived and
eventually had a son who also had one eye removed for
glioma. In addition, the sister of the first patient, though
unaffected herself, had two children dying ofthe tumor.
Thus, in this family there was both direct and collateral
inheritance.
During the 20th century with an accumulating num-
ber of retinoblastoma survivors and their offspring avail-
able, more scientific studies were undertaken concern-
ing the pattern of heredity. Ofthe studies in the first half
of the 20th century, Reese" considered those by Bene-
diet," Weller,76 Griffith and Sorsby," Rados" and
Falls79 to be the most important. It was concluded that
sporadic cases occur either as a somatic mutation or as a
new germinal mutation. The somatic mutation was rec-
ognized to be the more common and not transmitted.
Tumors arising as a germinal mutation were stated to be
transmitted as an irregular dominant trait with incom-
plete penetrance. It also became evident that a somatic
mutation was associated with unilateral cases and soli-
tary tumors and was seen at a later age. In contrast, the
germinal mutation was usually bilateral, associated with
multiple tumors, and diagnosed at an earlier age.
This explanation was unsatisfactory, however, in two
respects: (1) the explanation of the incomplete pene-
trance was vague, and (2) it was difficult to know if the
abnormal gene was present or not in a phenotypically
normal offspring sibling or parent of an affected individ-
ual. There were also discrepancies and disagreements
regarding the unusually high mutation rate occurring in
spontaneously affected individuals.
In 1971, Knudson'? provided strong evidence to sup-
port a two-hit model for the causation of retinoblas-
toma, hypothesizing that all retinoblastomas arise as a
result of two mutational events. Patients with the non-
hereditary form are thought to undergo both mutations
in the same postzygotic somatic cell which give rise to
single unilateral tumors. Patients with the hereditary
form mayor may not have a known history or a detect-
able chromosomal abnormality. Hereditary patients are
thought to undergo a first germinal (prezygotic) muta-
tion, which would thus be present in all resulting so-
659
 OPHTHALMOLOGY JUNE 1987
matic cells, and, subsequently, a second somatic (post-
zygotic) event. Using his Poisson distribution analysis of
clinical data, Knudson was able to predict the incidence
of gene carriers with bilateral multiple tumors, single
unilateral tumors, and no-expressed tumor. Thus, his
theory provides a rational explanation to account for
both the similarities and the differences between herit-
able and nonheritable retinoblastomas.
In 1962, Stallard reported on cytologic investigations
of a female infant with no family history of a retinoblas-
toma in whom the tumor cells and fibroblasts from
conjunctiva and epidermis showed abnormal karyo-
types in all mitoses. At that time, it was difficult to
distinguish between chromosomes 13, 14, and 15, and
Stallard's associate, Penrose, believed the patient to have
a deletion of the long arm of the number 15 chromo-
some." Stallard speculated that the deletion may have
"unmasked a latent genic potentiality situated on the
homologous intact No. 15 chromosome." Additional
patients with the D-deletion syndrome were subse-
quently reported. With refined techniques, including
autorad iography and quinacrine fluorescence analysis of
the DNA d-r Giemsa pattern , the involved area on the D
group chromosome on affected patients has consistently
been the long arm of chromosome 13. Yunis and Ram-
say82 and others observed that in these children, who
typically have various somatic and mental developmen-
tal abnormalities, there is an occurrence of retinoblas-
tom a associated with the deletion including the q 14
band. However, when the q 14 band is not included in
the deleted segment, retinoblastoma does not occur. Al-
though Dryja and co-workers" found this deletion in
fewer than 5%of retinoblastoma patients, it nevertheless
directed attention to the 13q14 band as the possible
locus for the retinoblastoma gene. Sparkes and asso-
ciates'" have demonstrated that the human esterase D
locus also maps at band 13q14. Normal enzyme activi-
ties were found in patients with retinoblastoma and
normal chromosomes as well as in control; all patients
with retinoblastoma and 13q14 deletion had low ester-
ase 0 levels in either erythrocytes or fibroblasts. Such
findings have proven useful in genetic counseling and
prenatal diagnosis.
As a result of intensive molecular genetic research, the
current findings suggestthat despite the typically normal
karyotype, a chromosomal abnormality resulting from a
submicroscopic deletion or some other alteration is
present in the region of q 14 of one of the two chromo-
somes 13 in heritable retinoblastoma, and this deletion
may be equated with the first-hit of Knudson's two-hit
hypothesis. In nonheritable retinoblastoma, there is a
normal allele at the retinoblastoma locus of both 13
chromosomes , thus requiring the two-hits of Knudson's
hypothesis for the development of retinoblastoma. The
normal allele at the retinoblastoma locus behaves as a
Mendelian dominant and somehow prevents the for-
mation of retinoblastoma. The abnormal, tumor-pre-
disposing mutant allele is recessive. Consequently, the
presence of a pair of normal genes at the retinoblastoma
locus prevents the development of retinoblastoma while
660
VOLUME 94 NUMBER 6
its absence or alteration predisposes to the formation of
retinoblastoma. When a cell becomes homozygous for
the tumor-predisposing mutant allele, that cell under-
goes malignant transformation.
Abramson et al'" demonstrated that patients with
heritable retinoblastoma (i.e., heterozygous at the reti-
noblastoma locus, with one chromosome containing the
tumor-predisposing allele, and the other the normal al-
lele) are highly susceptible to the development of other
nonocular cancers. Such patients are particularly vul-
nerable to the development of sarcomas of bone and
other neoplasms at sites of irradiation used in the treat-
ment of retinoblastoma and may be more sensitive to
chemotherapy and other mutagens as well.
The most dramatic part of the retinoblastoma story is
also the most recent: Friend and co-workers" have iso-
lated a human cDNA sequence which detects a chromo-
somal segment having properties of the retinoblastoma
gene which maps to human chromosomes l3q14. Part
or all of the sequence is deleted in some retinoblastomas
and osteosarcomas.
CONCLUSION
When one reviewschronologically the history of med-
icine and science, it becomes apparent that discoveries
and advances are being made at an exponentially in-
creasing rate. Such is the case in retinoblastoma; we
have seen that the first published case of apparent reti-
noblastoma was in 1597, and then for the next 150 years
only two or three possible cases were described. In 1808,
James Wardrop , the first man to accurately recognize
and describe retinoblastoma, published his essayson the
Morbid Anatomy of the Human Eye. 86 By 1834, there
was great demand for additional copies of his work;
Wardrop reviewed what was known in the field and
republished the earlier edition with the following note:
"Although 26-years have elapsed since the Morbid Anat-
omy of the Human Eye was first published. . . subse-
quent researches in this interesting department of pa-
thology have not contributed any additional facts to
render any alteration in the work desirable."
In 1963, Edwin B. Dunphy delivered to the American
Academy of Ophthalmology and Otolaryngology the
20th Edward Jackson Memorial Lecture entitled, "The
Story of Retinoblastoma.'? This magnificent address
has become a classic in ophthalmic history. When we
examine it today, however, we find that what Dunphy
included as current concepts 25 years ago regarding the
nature , cause, and treatment have now been relegated to
history. At the conclusion of his lecture, Dunphy noted,
"The 4th period (of the history of retinoblastoma)
begins with the 20th century and might be called the
period of therapeutic advance when irradiation and
chemotherapy accomplish such remarkable results. "
Friend et al86 offer perhaps a more current insight into
the direction of future therapy when, in their paper on
cloning the retinoblastoma gene they state, "W~ next
I
I
,
 ALBERT
seek to determine whether some malignant properties of
retinoblastoma. . . cells can be reverted on introduc-
tion of cloned sequences thought to represent the Rb
gene. The isolation of the p4.7R clone should also pro-
vide a powerful diagnostic reagent that will help to de-
termine whether a particular retinoblastoma stems from
an inherited genetic lesion or from a new mutation of
somatic germinal origin. Furthermore, the variable ex-
pression of this gene in different tumors may provide a
new method by which tumors are classified."
The most exciting part of the retinoblastoma story is
yet to come.
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