Parental age in sporadic hereditary retinoblastoma.

Of 104 children with sporadic hereditary retinoblastoma born between 1945 and 1970, we studied the age of their parents at the birth and compared this age with the mean age of parents at the birth of their children during the same period in The Netherlands. The mean age of fathers at the birth of their children with sporadic hereditary retinoblastoma (33.7 years) was significantly higher than the mean age of fathers at the birth of their children in the general population (32.5 years) (P less than .05, one sided). Similarly, the mean age of mothers at the birth of their children with sporadic hereditary retinoblastoma (31.2 years) was significantly higher than the mean age of mothers at the birth of their children in the general population (29.5 years) (P less than .05, one sided). We further analyzed this parental age factor by measuring the relative risk of age groups and comparing the incidence of sporadic hereditary retinoblastoma in the various parental age groups with the incidence of sporadic hereditary retinoblastoma in the total population. Mothers 35 years of age or older had a relative risk of 1.7 to have a child with sporadic hereditary retinoblastoma compared with mothers in the population in general (P = .006, one sided). Similarly, fathers 50 years of age or older had a relative risk of 5.0 to have a child with sporadic hereditary retinoblastoma compared with fathers in the population in general (P = .04, one sided). No parental age effect was found in children with nonhereditary retinoblastoma. We conclude that a high paternal and a high maternal age are significant risk factors for sporadic hereditary retinoblastoma.

Oncogenesis by mutations in anti-oncogenes: a view.

Oncogenesis is the result of accumulation of specific gene mutations. Two classes of specific cancer mutations are distinguished: namely those affecting anti-oncogenes and those in which oncogenes are involved. Anti-oncogenes are thought to regulate normal growth by encoding proteins that inhibit the expression of the oncogenes. This is in line with the observation that tumor cells are often homozygous for a defect in an anti-oncogene, as this will allow the expression of an oncogene. In this paper we attempt to calculate the number of anti-oncogenes involved in the genesis of a malignant tumour cell. These calculations were initially performed using a simplified model for oncogenesis and later applied to more complicated situations. These calculations indicate that usually four mutations in anti-oncogenes are required for oncogenesis in adults. This is in contradiction to the well-known 2-hit model of oncogenesis of Knudson which predicts about 10(9) times more de novo arising tumour cells than are observed in reality. Oncogenesis is only observed in proliferating cells. Cell proliferation and growth kinetics in various organs differ greatly. Therefore the time of oncogenesis and tumour manifestation also varies in the different organs. In organs that develop in early life (e.g. retina and neurons of the brain) mitotic activity ceases soon after birth. Consequently neural and retinal tumours emerge only early in life. In contrast, the main development of the female breast occurs after puberty, and the earliest breast tumours will become apparent in young adults. The four recessive mutations in anti-oncogenes required for oncogenesis imply that probably recessive mutations are involved in two loci. It is clear that an inherited mutation in an anti-oncogene at a particular locus causes different tumour types depending on the various organs in which the tumours arise. Comparison of (a) results of calculations about the number of malignant neuroendocrine tumour cells that arise in a pancreatic islet of a patient with inherited MEN1-syndrome with (b) the pathological anatomy of such a patient, suggests that a cell with two or three oncogenic mutations has a growth advantage over normal cells. This leads to cell proliferation in a premalignant lesion until the set of four oncogenic mutations is complete. The clinically premalignant lesions have a maximal mean diameter of about 0.4 cm when the first true malignant tumour cell develops, and the pathologist will probably note malignancy when the lesion has the size of 1-2 cm.(ABSTRACT TRUNCATED AT 400 WORDS)

Hereditary cancer and its clinical implications: a view.

In hereditary cancers the responsible inherited cancer genes are defective (mutated) anti-oncogenes (tumour suppressor genes). This inherited mutation is present in all cells of the organism, and only leads to cancer if in a somatic cell a complete set of specific cancer mutations is accumulated. Since one defective anti-oncogene has been inherited, only three additional somatic cancer mutations are required, according to our previously published view (Anticancer Res 10:1990). The number of de novo arising tumour cells in such a person is thus multiplied by a factor equal to the reverse of the mutant frequency, that is about 10(4)-10(5). This can be observed e.g. in retinoblastoma. Mutations occur in proliferating cells only. Consequently cancer mutations also depend on cell proliferation. If an inherited cancer mutation predisposes to cancer formation in certain organs, then the cancer risk in these organs is enhanced by 10(4)-10(5) times. Tumours in these organs will appear simultaneously if the number of cells and the growth kinetics are similar. This is of course observed in paired organs, like the retina and the female breast. In cancer family syndromes different organs may be affected at the same time. Examples are type I and type II cancer family syndrome and multiple endocrine neoplasia type 1 2a, and 2b. The secondly diagnosed tumours are not caused by metastatic spread. Tumours in two organs will arise at difference times if the number of end cells per organ and the growth kinetics differ. In this case the second tumour is called a second primary malignancy and is not caused by metastatic spread. A good example are the second primary malignancies in hereditary retinoblastoma. The inherited defective anti-oncogene is a recessive gene. This defective inherited gene causes a 10(4)-10(5) fold increase of the normal tumour incidence. This means that nearly always one or more tumours will arise. Evidently, this pattern of inheritance has led to the erroneous conclusion that the genetic abnormality is dominant at the level of the chromosome. The 10(4)-10(5) times enhanced tumour incidence in hereditary cancer is helpful for the clinical recognition of hereditary cancer. That is, hereditary cancer can be recognized not only by family history, but also by early occurrence, the multifocal and bilateral localisation, its occurrence as cancer family syndrome or by second primary malignancies. It is thus recommended to screen patients and families with hereditary cancer for first and second primary tumours. Treatment of patients with hereditary tumours requires extra care to avoid additional cancer mutations.(ABSTRACT TRUNCATED AT 400 WORDS)

Stochastic theory of oncogenesis.

It is generally agreed that most malignancies, particularly those that arise "spontaneously", are caused by randomly occurring mutations at specific sites of the genome. Hence oncogenesis of these spontaneous tumors can be described by stochastic mathematical models. In this paper we offer a mathematical approach to oncogenesis. A stochastic model was developed to calculate the number of mutations required for malignant transformation. This model demonstrates that the two hit model, as originally proposed by Knudson for retinoblastoma in children, is not tenable for tumors in adults. Our results show that malignant transformation is more likely to be due to a specific set of four mutations. This stochastic model is compatible with most current views on oncogenesis and most phenomena in oncology.

Early diagnosis of bilateral retinoblastoma reduces death and blindness.

The influence of early diagnosis on sight and survival was studied in 130 patients with bilateral retinoblastoma. Nineteen patients died of this condition. Statistical analysis predicted that 12 of these 19 early deaths could have been prevented if doctors' delay had been less than 1 week. Consequently, a reduction of 65% in mortality is possible. Similarly, statistical analysis also predicted that the number of patients with resulting blindness could be reduced by 40%. Central registration and monitoring of retinoblastoma families would greatly improve early diagnosis.

Non-ocular cancer in patients with hereditary retinoblastoma and their relatives.

In The Netherlands, retinoblastoma patients have been registered in the Utrecht national retinoblastoma registry since 1862. This register is virtually complete from 1945 onwards. We describe a unique epidemiological survey of the occurrence of non-ocular cancer in all patients registered during the period 1945-1970. The occurrence of non-ocular cancer in relatives of patients with hereditary retinoblastoma is also reported. One hundred and forty-one patients with hereditary retinoblastoma were studied for non-ocular second primary cancer. Nineteen patients died of retinoblastoma. The median follow-up of the surviving 122 patients was 25 years. Seventeen of these patients developed a second primary cancer, most frequently soft-tissue sarcoma. The cumulative incidence of non-ocular cancer was 19% at the age of 35, i.e., a 14-fold increase as compared to the general population. Twelve patients with hereditary retinoblastoma died of non-ocular cancer whereas none of 252 patients with non-hereditary retinoblastoma died of non-ocular cancer. Furthermore, among the parents of our hereditary retinoblastoma patients, 24 (born before 1945) had also been affected by retinoblastoma or had affected sibs. In the parents, 4 tumors occurred, of which 2 were rhabdomyosarcomas and 2 were urinary bladder cancers. Both types of non-ocular cancer were also encountered among the 122 patients with hereditary retinoblastoma. In 103 fathers and 103 mothers of patients with hereditary retinoblastoma who did not have retinoblastoma themselves, there was no previous family history of retinoblastoma. The fathers had a relative risk of 8.3 for pancreatic cancer compared to the general population. There was no significant increase in the number of non-ocular tumors in 332 sibs of patients with hereditary retinoblastoma.

Pathogenesis of Burkitt's lymphoma in children.

The reason that the classical African type of Burkitt's lymphoma often occurs in children is still not well understood. Several data published during the last months have, however shed some light on this phenomenon.

Non-ocular cancer in hereditary retinoblastoma survivors and relatives.

An epidemiological survey has been carried out to establish the incidence of second malignant neoplasms in hereditary retinoblastoma survivors in The Netherlands and the relative risk of cancer in non-affected relatives. The cumulative incidence of second neoplasms was 19% at the age of 35 years. Fathers, unaffected by retinoblastoma, were at risk for pancreatic cancer, the relative risk being 8.3.

Carcinogenesis revisited.

The importance of mutations in carcinogenesis is still unclear. Assuming that mutations of the genetic material are central to this problem, the number needed to give rise to a cancer cell must be established. A one-mutation theory is unsatisfactory for a number of reasons. A four-mutation model fits better and can be calculated in humans assuming that the observed endogenous tumors in 2% of the population equals the frequency of spontaneous carcinogenesis, accepting a mean mutation rate of 2 X 10(-5) mutations per gene per generation, and a production of about 7 X 10(15) cells during our whole lifetime. This model is also consistent with the observed peak incidence of cancer in children, with the hereditary aspects of some pediatric tumors, and with the usually nonhereditary mechanisms of cancer in adults.

A new model for oncogenesis. From tumour immunology to a mathematical approach of oncogenesis.

Around 1970 it was assumed that tumour cells are due to a single specific oncogenic mutation. This implied that daily many thousands of tumour cells would arise de novo and that most of these tumour cells were killed by immune surveillance or natural resistance mechanisms. Recent findings on immune surveillance and natural resistance implicate that tumour cells do not arise frequently, however. Given the fact that mutations occur at a frequency of about 2 X 20(-5) mutants per gene per generation, we calculated that transformation to a tumour cell probably requires 4 oncogenic mutations if a single tumour cell would arise de novo during lifetime. This four-mutation model of oncogenesis can explain many oncological data like the observed peak incidence of cancer in children, the hereditary aspects of some pediatric tumours and the usually non-hereditary cancer in adults, the occurrence of second tumours in children, and the data on the monoclonal and polyclonal origin of tumours.