Figure legends:
Figure 1: Panel A: LDH trend following his first relapse. Normal LDH levels were recorded at his previous annual visits (9/15/16 and 11/13/17). At the time of first relapse (2/5/18), the LDH level was >6000U/L (undiluted) which reached a maxiumum level of 22,331 U/L and subsequently normalized after recovery following his first cycle of chemotherapy using cisplatin, cyclophospamide, vincristine and etoposide.
Panel B: Summary of the timeline of clinical clinical events and medical management.
Panel C: Copy number assessment was done by targeted exome sequencing of matched tumor and normal samples with chromosomal changes at the different stages of relapse compared to the initial tumor. The most notable copy number aberration was uniparental disomy (UPD) of chromosome 13. Germline RB1 mutation in combination with UPD 13 resulted in biallelic inactivation of RB1. On array CGH, there was aneuploidy with additional chromosomal alterations during disease progression.
Panel D: Abnormal FDG uptake on PET/CT scan demonstrating diffuse bony involvement and uptake in liver, left axillary and infraclavicular regions.
Panel E: After one cycle of chemotherapy, demonstrating no abnormal FDG uptake except for minimal left axillary uptake.
Panel F: 3 x 3.2 x 2.5 cm mass lesion in the posteromedial aspect of the right cerebellar hemisphere with associated edema and mass effect
Table 1a: Epigenetic mutations observed at initial diagnosis and relapses with their corresponding PolyPhen-2 score. Tumor sequencing using “OncoSeq” for whole exome sequencing (WES) and transcriptome (RNA seq) sequencing revealed among all three samples (eye, bone marrow, brain metastases), the germline mutation in the RB1 gene (NM_000321.2: c.1961-2A>G) involving chromosome 13, intron 19. The WES did not demonstrate any driver fusions or mutations among the three samples but acquired somatic mutations of uncertain significance.
Table 1b: Summary of the past twenty-five-year experience for relapsed extraocular retinoblastoma at Children’s Hospital of Michigan.