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Journal of Cancer Epidemiology
Volume 2009, Article ID 301973, 5 pages

Review Article
Retinoblastoma and the Genetic Theory of Cancer:
An Old Paradigm Trying to Survive to the Evidence

Domenico Mastrangelo,1 Theodora Hadjistilianou,2 Sonia De Francesco,2 and Cosimo Loré1
1 Department of Biomedical Sciences, University of Siena, 53100 Siena, Italy
2 Department of Ophthalmology, Ocular Oncology Unit, University of Siena, 53100 Siena, Italy

Correspondence should be addressed to Domenico Mastrangelo, mastrangelo@unisi.it

Received 4 June 2009; Accepted 13 September 2009

Recommended by Peter G. Shields

Retinoblastoma (Rb) is considered to represent the prototype of cancer linked to the sequential loss or inactivation of both alleles
of a so-called “tumor suppressor gene”, the Rb1 gene. The pathogenetic mechanism behind this tumor was first hypothesized
by Knudson in 1971 and further confirmed by others who identified the Rb1 gene whose loss or inactivation was claimed to
be responsible for the disease. However, after about four decades of continuous research in the field of molecular biology, the
evidence behind the role of the Rb1 gene in Rb appears to be seriously flawed in the light of epidemiological, biological, and
clinical evidences. This editorial summarizes the inconsistencies on this subject. Nevertheless, the molecular biology establishment
still adheres to the biased view of the genetic origin of Rb and other cancers, and hardly any alternative explanations are taken into

Copyright © 2009 Domenico Mastrangelo et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

1. Introduction that the disease could be inherited and formulated the so-
called “two-hit theory” in order to explain its pathogenesis.
Retinoblastoma (Rb) is the most common intraocular malig- In reality, no clues about the inheritance of retinoblastoma
nant tumor in childhood, with an incidence of 1 in 15000 could be deducted from such a small sample. In fact, in
live births [1]. It may affect one eye (unilateral Rb) or both his first report on this matter, Knudson referred to earlier,
(bilateral Rb) during the first five years of life. Rare cases smaller series showing that, in retinoblastoma survivors with
have also been reported in young adults [2, 3]. Although bilateral disease, the proportion of affected offspring closely
extensive epidemiologic studies have been done to study approximated 50%, as in dominant (Mendelian) inheritance
this tumor, the results have been more often misinterpreted [6]. From an original, mathematical analysis of the above
at the expense of mutation theory which has prevailed data, Knudson inferred that retinoblastoma is caused by
until recently in spite of the outstanding evidence against two sequential (two hit) mutational events. According to
it [4]. In the present review the authors analyze the most this hypothesis, in the dominantly inherited form of the
relevant epidemiological issues concerning retinoblastoma, disease, one mutation is inherited via the germinal cells
in the light of recent developments highlighting the role of and the second spontaneously occurs in somatic cells of the
aneuploidy and genetic instability [5] in the pathogenesis of retina and other tissues of the body. On the contrary, in the
this eye cancer. nonhereditary form, both mutations occur in the somatic
(retinal) cells. The different timing and cell type involved by
2. Historical Background the two mutations determines the different clinical pheno-
type, with all bilateral and a minority of the unilateral cases
The most important studies to investigate the pathogenesis of being classified as hereditary, and the remaining unilateral
retinoblastoma began with a paper published by Knudson in cases being included in the sporadic group (Table 1). During
1971 [6], when the author, after investigating the age distri- the following forty years of epidemiological, clinical, genetic,
bution and laterality of a cohort of 48 Rb patients, concluded and biological research in this field, with the discovery

8 (50%) were healthy and 8 (50%) affected with Rb 25 U 1 (Table 2). within the familial group. 14 B 1 bution of the disease in the offspring of bilaterally affected 15 B 1 individuals. 7 B 1 8 B 2 1 9 B 1 1 3. and since familial inherited the “first hit” through a mutation in one of the Rb represents the 10% of all Rbs. and this would be in sharp contrast with 28 B 1 the current knowledge according to which bilateral Rb is 29 B 1 “always” hereditary and unilateral Rb is “almost always” 30 U 3 sporadic. 19 B 1 In an attempt to elucidate this issue. We discovered that 23 U 1 in a total of 16 children born to 12 unilaterally affected 24 B 1 patients. which after Knudson shows that the unilateral phenotype accounts for about 1/3 are all to be considered “hereditary”. In this case. it is assumed bilateral (hereditary) Rb. As a familial Rbs share the same pathogenetic mechanism with matter of fact. Familial Rb with Unilateral Phenotype: 33 B 1 Is There Any Explanation? 34 U 1 35 U 1 It was reported by Knudson [6] and confirmed by others [26] that about 10% of all Rb cases do have a “positive 36 U 1 family history”. To be more accurate. run in the family. the family history of the “index” case offers at least one other affected member. half of which Nonhereditary 0 55%–65% 55%–65% resulted affected.. as still believed by some authors [25]. the vast majority of these cases that the events leading to the inactivation of the Rb1 gene should show the bilateral phenotype.2 Journal of Cancer Epidemiology Table 1: Distribution of retinoblastoma by type and laterality [6]. since should not be more than 3% (i. Total 25%–30% 65%–70% 100% Patient’s number Lat. bilateral Rbs. 31 B 2 32 B 1 4. thus allowing Knudson to conclude that bilateral 16 B 1 Rb is inherited through the germ cells. in 4 U 1 2 many other scientific articles and review papers [6–24]. are also assumed to have of all hereditary cases (or about 30%). but they are the only affected members in carrying the unilateral phenotype. Minimum or no 17 U 1 disagreement had been appeared on this account in the 18 B 1 literature during the last four decades. Italy. 20 B 1 spring of unilaterally affected Rb survivors. we have performed an analysis of the distribution of the disease in the off. referred to the 21 U 1 Department of Ophthalmology—Ocular Oncology Unit at 22 U 1 the University of Siena in Siena. Offspring Number of healthy Number of affected 1 B 1 of the Rb1 as the prototype tumor suppressor gene. This generated the widespread conviction that Rb is caused by two 5 B 2 mutational events leading to the loss or inactivation of both 6 B 2 1 alleles of the Rb1 gene. the 2 B 2 1 medical establishment agreed on the pathogenetic “two- 3 B 1 2 hit” theory which was further expanded by Knudson. exactly what happens in bilateral Rb. it comes out that Rbs parent’s germ cells. carrying the unilateral phenotype.e. a meta-analysis of a cohort of 3584 patients . the 30% of the 10%). the original input into the possible 12 U 1 genetic derivation of retinoblastoma was based on limited 13 B 1 evidence showing an apparently dominant Mendelian distri. it would be easily 26 U 1 concluded that the unilateral disease phenotype is inherited 27 B 1 and not sporadic. Unilaterally Hereditary 25%–30% 10%–15% 35%–45% affected survivors generated a total of 16 children. We should therefore be reasoning that. either a parent or another close relative. Table 2: A list of 36 retinoblastoma survivors and their offspring referred to the Ocular Oncology Unit of the Department of Bilateral Unilateral Total Ophthalmology of the University of Siena (Italy). The Weak Foundations of the 10 B 1 “Two-Hit” Theory 11 B 2 As mentioned above. Using the reasoning of Knudson. As a matter of fact. and therefore the first “hit” is transmitted we could make a calculation of the percentage of familial Rbs through the germline. In other words. Table 1 but with one difference. their families.

Abramson 626 905 1531 36 150 186 Patient Gender Age at diagnosis Laterality Gunalp 441 195 636 10 24 34 Z. further reinforces ble minutes. F 5m B 5 0 3 9 15 21 27 33 39 45 54 66 84 [28]. S. (Table 3). F 29 m U (23%) (77%) M. isochromosome 6p. M 8m U 45 40 P. M 5m B Matzunaga 403 196 599 11 17 28 V. F 10 m B Tot. The calculation of the mean age at diagnosis reveals a Author uRB bRB Tot. the Rb1 gene locus. therefore. I. and it is due to Not in Favour of the “Two-Hit” Hypothesis a “constitutional” deletion of the long arm of chromosome 13 which involves. bladder the calculation of the “mean” in this sample may lead to unreliable inferences. I. benign of unilateral Rb by age at diagnosis is highly skewed. marker 1p+. present if transmitted through the germ cells of one parent. Five cases. F 5m U 20 Z. F 8m U 35 P. thus reinforcing the belief that the loss or inactivation Unilateral RB of the Rb1 was the only responsible for Rb to develop. F 16 m U Hadjistilianou 227 160 387 11 32 43 D. cancer [35]. Fam. the 13q deletion syndrome must be confirmed by the cytogenetic 5. phenotype. however. As it can be appreciated. F 9m U 15 10 L. but the unilateral disease phenotype is .Journal of Cancer Epidemiology 3 Table 3: A meta-analysis of literature shows that within a total Table 4: 13 cases of 13q deletion syndrome referred to the of 344 familial retinoblastoma. drome and the finding of 13q deletions or monosomy 13 in it follows that all patients affected by 13q deletion syndrome Rb cells in individuals with normal constitutional karyotypes and retinoblastoma belong to the “hereditary” group of seemed to suggest that chromosome 13q could contain a gene Knudson’s and must. in addition to those involving deletion syndrome and retinoblastoma referred to us over the chromosome 13. in the bilateral disease phenotype. B Tot. Of these patients. hepatocellular carci- reported in the diagram. value of 10 months. in the light of the predictions made by the real number of bilateral tumors among the patients the “two hit” hypothesis. 5]. As a matter of fact. and prostate cancer [37]. further investigations on this the assumption that they must belong to the “hereditary” matter stressed the role of 13q deletions in the genesis of Rb group of Knudson’s. in 18% of cases. monosomy 16. reveals that on But the most important consideration to be made about a total of 344 (9. and homogeneously staining regions and dou. Potluri and coworkers observed that the association the “constitutional” deletion of the Rb1 gene can only be of Rb with the constitutional chromosome 13q deletion syn. In Table 4 a series of 13 cases of 13q chromosome abnormalities.5%) familial cases. S. F 5m U 50 Z. R. F. 13q Deletion Syndrome: A Case against and analysis of peripheral blood lymphocytes. 9/13 expressed the unilateral disease phenotype. in 9% of cases). G. A M 12 m U 30 25 Z. Cancers linked with these deletions include chronic lym- of the Department of Ophthalmology of the University of Siena pocytic leukaemia (CLL) [29]. F 9m B Sanders 282 149 431 15 38 53 B. U Fam. are evident in retinoblastoma (additional last four decades is reported. express the bilateral disease responsible for tumor development in retinoblastoma [27]. The mean age at diagnosis 13% of cases. But it Bilateral RB is well known that retinoblastoma is only one among many Figure 1: The distribution of retinoblastoma by laterality in a different tumors associated with deletions of chromosome sample of 387 patients referred to the Ocular Oncology Unit 13. the University of Siena (Italy). which is about 10 months. 83 (24%) show the the association of 13q deletion syndrome and Rb concerns unilateral phenotype. D. are not disorders [30]. malignant mesothelioma [36]. by definition. 83 (23%) showed the unilateral Ocular Oncology Unit of the Department of Ophthalmology of phenotype. the distribution noma (HCC) [32]. affected by this genetic disorder. C. It happens. A. multiple myeloma [31].C. The same pleiomorphism in the phenotypic expression of cancers associated with Rb1 gene mutations [38] is therefore evident in 13q deletion syndrome. M. in this group. Fam. a rather the evident discrepancy existing between the expected and unexplainable figure. only 4 had copies of 1q material in 44% of cases. diagnosed beyond the age of 87 months. Since In 1986. while the remaining 9 were 45% of cases. nasopharyngeal carcinoma [33]. 1979 1605 3584 83 261 344 S. reported by us elsewhere [4. E. M 10 m U F. and therefore. and low-grade malignant lipomatous tumors [34]. chronic myeloproliferative (Italy). that this assumption does Although the authors themselves acknowledged that other not fit the clinical reality. instead of the predicted 3%. in unilaterally affected (Table 4).

pp. 1.. Z. medicine. and F. 3. “Genetics and 823. H. 5.” Genes Chromosomes and Cancer. turn. L.” Cell Death and Differentiation. Munier. Ed. no. Knudson Jr. Knudson Jr. 39]. M.” Proceedings of the National Academy of 150. pp. Knudson Jr. and tion of the available data. K. incorrect. other scientific endeavor. 1995. no. 1979.. G. 1978. “The genetics of childhood cancer. pp. 2004. Medical Genetics.” Histology and Histopathology. 11. Lentini. vol.. 96–102. supplement. pp. vol.” European Journal of Cancer. 1. no. pp. S. pp. 1993. Komeda. 4.” [6] A. pp. no. vol. 1974. G. Zhang. “Hereditary cancers: from discovery to It was not by chance that we had to approach many different intervention. no. “Retinoblastoma epidemiology: does . 42. 3. implications. and T. T. vol.” Cancer. oncogenes. and S. 1888–1891.4 Journal of Cancer Epidemiology unexplainably high. 1980. “A personal sixty-year tour of genetics and [2] C. Knudson Jr. and F. The presumed genetic origin of Rb and cancer genes. D. Knudson Jr. pp..” The New 6. G. pp. “Hereditary cancer. with chemotherapy. G. De Francesco.” The Journal of the American Medical Association. “Genetics and cancer. no.” Cancer Research. pp. [31] P. 6. “Cancer genetics. A. Hadjistilianou. Nishida. Knudson Jr. 228–234. “Persons at high risk of cancer. academic. NY. Journal of Pathology.. Rushlow.” The American standing of disease pathogenesis and etiology. vol. probabilistic model for the incidence of Rb. or other interests. no. 11. supplement. no. R. [4] D. A.. et al. 255.” Cancer. 2007. 301. no. 1977. Knudson Jr. p. A review. Leahey. B. Di Leonardo. Hadjistilianou. In the light of the “two hit” theory. Lentini. Thonney. “Model for the incidence of embryonal can- data summarized above do not have any rationalization. Concluding Remarks England Journal of Medicine. [26] http://www. 4. no. S. “Does the evidence matter in medicine? [28] F.. pp. Mastrangelo. 23. pp. 12. 121. Pescia. 842–851. “Detection of mosaic classification and management of retinoblastoma.” Proceedings of the National Academy the only plausible conclusion is that the assumptions made of Sciences of the United States of America. pp. Döhner. in antioncogenes. The retinoblastoma paradigm. vol. 3.” in and cancer. “Heredity and human cancer. “Ocular tumors. supplement.” Annual Review of Genomics and Human Genetics. [24] A. no. [27] V.. T.org/profiles/retinoblastoma/details and T.” of how an entire body of prominent researchers may fail to Proceedings of the National Academy of Sciences of the United question a flawed pathogenetic hypothesis (i. L. 63. K. Knudson Jr. risk-stratified approach to therapy in chronic lymphocytic [7] A. relies not only on the individual researcher’s skill but 1985. theory). “Continuing challenges in the management of retinoblastoma vol. 10. M.html. no. for the sake of personal.” Human Mutation. 5–7. 5. 69. Karcioglu and T. vol. G. New York. A. 2007. 135–140. 2002. [30] A. [23] A.” American leukemia.. Shields. Shields. 43. vol. 1989. 20.. G. 2009. Ellsworth. pp.. Panani. 2. 1. G. 3. no. Fukuda. “Mutation and cancer in man. pp. vol.. “Hereditary cancer. genesis of Rb [4. USA. 90. G. 1996. 129– of retinoblastoma. no. its relationship with the Rb1 gene represent a clear example [18] A. vol. 4. 18. no. 17. economic.. 79. Opinion in Ophthalmology.” Cancer. in retinoblastoma.” about the role of aneuploidy and genomic instability in the Journal of Cancer Research and Clinical Oncology. no. Orbital Tumors: Diagnosis and Treatment . pp. Meadows. G. no. vol. Case report and review of literature. pp. [14] A. Sciences of the United States of America. T. pp. Zenz. Helson.” Current RB1 mutations in families with retinoblastoma. G. A. T. 111. the [12] A. “Genetics of human cancer.” Cancer. pp. 2004. G. Knudson Jr.” American Journal of appeared in recent ophthalmologic literature [40]. pp. Y. Knudson Jr.geneclinics. 897–909. Clinical Epidemiology is a leading discipline in the under. “Constitutional karyotype cer. no. pp. Potluri. 11. 2007. Piovesan. Knudson Jr. 1520–1529. 663–671. and political environment in which [17] A. 10. 1. 77–84. Knudson Jr. Döhner. [22] A. “Antioncogenes and human cancer. A. 24. pp. 77. vol. 3. G. vol. 10914–10921. Knudson Jr. Knudson Jr. [3] C. 5116–5120. 1596–1603. R. 45. the evidence matter?” European Journal of Cancer.. Knudson Jr. no. Karcioglu. pp. 1–14. Shields and J. The proper analysis of data. vol. cinogenesis. 2501–2505. G. the “two-hit” States of America. 12–25.. [32] N. Gilbert. G. Reid. as any Journal of Medicine. 1–3. Mastrangelo. pp. pp. vol. 1975. however. 3. 58. pp. A.. vol. no.” Best Practice and Research: Clinical Haematology. 1975. 68. 849–862. 1986. 6. G. C. 2006. A. pp. vol. pp. 10. We are still optimistic. no. no. .. 1882–1886. vol. but. “Basic understanding of current [25] D.. 2006. T. 1989. [16] A. 279. phia negative chronic myeloproliferative disorders: clinical [9] A. L. no. because our alternative pathogenetic explanation has finally [21] A. 305–316. and cers: application to Rb.. 30. 1437–1443. Gailloud. vol.” Genetics. vol. 11–12.” International Journal of Can. L. vol. 257–265. 2003. toma. Knudson Jr.” Journal of the National Cancer Institute .. “Cytogenetics and molecular cyto- [10] A. 72. “Cytogenetic and molecular aspects of Philadel- vol. vol. G. 75. also on social. no. G. Knudson Jr. 1. G. “Mutation and childhood cancer: a genetics in multiple myeloma. Hadjistilianou. “Mutation and cancer: statistical study Ophthalmic Paediatrics and Genetics. Knudson Jr. 5. 820– [29] T. 2005. pp. A. 439–453. 2003.. Jotterand-Bellomo.e. Springer. G. References no.” Cancer Letters. 3. 288–291. “Chromosomal abnormalities in human retinoblas- [5] D. scientific journals to have access to the medical community [20] A. 17. 39. 11. no. 1975. National Academy of Sciences of the United States of America. [19] A. L. 2004. De Francesco. 1971. vol. Nishimura. vol. in regard to the role of the Rb1 gene in retinoblastoma are 2453–2457. pp. G. 1979. Ito. “Chromosomal instability and human hepatocar- [11] A. M. “Of sea urchins and worms: development [1] Z. Knudson Jr. 38. Liebisch and H. 606–607. 1022–1026. 122. [8] A. “Hereditary cancer: two hits revisited. “Cancer genetics through a personal retrospectroscope. 241. Nakao. vol.” Retina. it relies on the correct interpreta. Balmer. vol. and vol. “Hereditary cancers disclose a class of the data are analyzed.. 2007. Shields. [15] A. Stilgenbauer. 4. and J. A. Di Leonardo. [13] A.” Proceedings of the vol.

vol. H. J. pp. A. no. 1–10.” Medical Science Monitor. pp. and Groupe français de cytogénétique oncologique.” Clinica Terapeutica. J.org/cgi-bin/carddisp. et al. . and M.Journal of Cancer Epidemiology 5 [33] J. Zeng. “Clustering of deletions on chromosome 13 in benign and low-malignant lipomatous tumors. Huret. L. vol. and Y. 2002. [40] A. vol. Dahlén. 12.genecards. R. [37] G. “Cytogenetic alterations in prostatic carcinoma. vol. “The retinoblastoma paradigm revis- ited. 2. pp. no. 6. 2000. De Francesco. vol. 103.” Pathologe. 19. 2002. 1. 89. 5. X. [35] C. [39] D. S. pp. “Retinoblastoma: what is new in 2007-2008. Léonard. [38] http://www.” International Journal of Cancer. pp. 151. no. Gasser. Y. 2003. “Molecular genetic progression on nasopharyngeal carcinoma. M.” Ai Zheng. Sauter. no.” Current Opinion in Ophthalmology. vol. Moch. 526–534. Zeng. Abramson. Th.-L. 19. 616–623. “Recent advances in the molec- ular analysis of human malignant mesothelioma. F. Hadjistilianou. C. Mastrangelo.pl?gene=Rb1. H. 6. no. C. Di Leonardo. 2008. Shao. “From cytogenetics to cytogenomics of bladder cancers. 166–173. no. Testa. 231–240. Debiec-Rychter. 1998. Schefler and D. Mihatsch. [34] A. F. pp. 14. Pedeutour.. De Rienzo and J. [36] A. Bubendorf. 21. vol. 433–438. and T.” Bulletin du Cancer. no. Lentini. pp. 63–68. L. 2008. 1. W.

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