Insulin-like growth factor II-mediated proliferation of human neuroblastoma

Neuroblastoma is an embryonal tumor that typically arises in cells of the developing adrenal medulla. IGF-II mRNA is expressed at high levels in the adrenal cortex before birth but it is not detectable until after birth in the adrenal medulla. Neuroblastoma cell lines corresponding to early adrenal medullary precursors did not express IGF-II, although all three cell lines we tested were growth stimulated by IGF-II. Cell lines corresponding to more mature adrenal medullary cells expressed IGF-II, and one, SK-N-AS, grows by an IGF-II autocrine mechanism (J. Clin. Invest. 84:829-839) El-Badry, Romanus, Helman, Cooper, Rechler, and Israel. 1989. An examination of human neuroblastoma tumor tissues for IGF-II gene expression using in situ hybridization histochemistry revealed that IGF-II is expressed by tumor cells in only 5 of 21 neuroblastomas, but is detectable in cells of nonmalignant tissues including adrenal cortical cells, stromal fibroblasts, and eosinophils in all 21 tumors. These findings indicate that IGF-II may function as an autocrine growth factor for some neuroblastomas and as a paracrine growth factor for others. They suggest that the growth regulatory pathways utilized by neuroblastoma mimic those used in the precursor cell type from which individual tumors arise.

Late effects of treatment for Wilms' tumor. A report from the National Wilms' Tumor Study Group

The National Wilms' Tumor Study (NWTS) was initiated in 1969. One of its objectives was to modulate treatments according to risk factors to minimize the number and severity of treatment-related short-term and long-term iatrogenic complications. The NWTS has therefore incorporated a Long Term Follow-up Study (LTFS) within its framework to monitor late effects. The LTFS is confined to relapse-free survivors alive 5 years or longer after initial surgery, and data are collected using specifically designed forms. A total of 787 patients registered on NWTS-1 or NWTS-2 (1969 to 1979) were eligible, of whom 680 (86%) were available for analysis regarding musculoskeletal, cardiovascular, and neuropsychologic status, and the presence of benign and malignant tumors. Patients with early-stage disease who were treated with radiation had scoliosis reported, along with other musculoskeletal abnormalities (32 versus 2), nearly seven times as often as did the members of the cohort population who did not undergo radiation (35 of 57 versus 5 of 53, respectively). The difference in cardiovascular problems recorded in survivors who did and did not receive Adriamycin (Adria Laboratories, Columbus, OH) (2.4 versus 1.1 per 100-person years at risk) had borderline statistical significance (P = 0.06). No excess in neuropsychologic events was reported for those given the neurotoxin vincristine. When considering patients with disease of all stages, all 5 second malignant tumors occurred in the 623 patients who underwent radiation (RT patients); benign tumors were also more frequent in RT patients than in those patients who did not undergo radiation (41 of 486 or 8% versus 4 of 194 or 2%). Continuing study of this unique body of patients is needed, especially for those given Adriamycin, because of the known long interval needed for latent cardiomyopathy to become clinically manifest in some patients.

Validation of two methods of long-term epidemiological follow-up

Two methods of long-term epidemiological follow-up were compared by using each to study the survival of 1622 myocardial infarction patients registered by the Belfast MONICA Project. Length of follow-up ranged between 3 and 5 years during which time 277 deaths were recorded. A computer-based method for linking MONICA Project registration records with the Registrar General's death certification data identified 273 of the 277 deaths. Follow-up supplied by the Northern Ireland Central Services Agency through the flagging of patients in their master patient index identified 271 deaths; four of the six deaths which were missed occurred before computerisation of the index was complete. The study illustrates the value of computer-based linkage with death certification data and of flagging in the Central Services Agency master patient index.

A comparison of four staging systems for localized and regional neuroblastoma: a report from the Childrens Cancer Study Group

Four major staging systems have been used to estimate the prognosis for children with local and regional neuroblastoma (NBL). Data obtained at diagnosis for 251 neuroblastoma patients from two Childrens Cancer Study Group (CCSG) studies were analyzed according to staging systems of the CCSG, St Jude Children's Research Hospital, the Pediatric Oncology Group (POG), and the Union Internationale Contre le Cancer (UICC) tumor-nodes-metastasis (TNM) system. The most significant variables were found to be age, tumor stage, extent of tumor removal, transgression of the midline by tumor infiltration, and site of primary tumor. Involvement of lymph nodes per se was not a bad prognostic sign unless associated with extension beyond the midline, the latter being the single most important prognostic variable. All four staging systems had value for prognostication and all identified with accuracy the low stage patient (stage I, stage A) who fares well (greater than or equal to 87% survival). The CCSG definition of stages II and III disease discriminated prognostic groups best among the remaining patients, and was able to identify the child with local-regional NBL with poor survival. The estimated 5-year survival rates for children with regional tumor (stage III, IIIA[N]), according to the four systems were 44%, 74%, 74%, and 74% for the CCSG, St Jude, POG, and UICC methods, respectively. We conclude that all four staging systems effectively define good-prognosis patients with localized disease but that the CCSG staging system most accurately identifies patients with regional tumor who have a poor outcome.

The treatment of medulloblastoma. Results of a prospective randomized trial of radiation therapy with and without CCNU, vincristine, and prednisone

In a prospective randomized trial designed to study the effectiveness of adjuvant chemotherapy following standard surgical treatment and radiation therapy, 233 eligible patients with medulloblastoma were treated by members of the Children's Cancer Study Group and the Radiation Therapy Oncology Group. Eligible patients were randomly assigned to receive radiation therapy with or without adjuvant chemotherapy consisting of 1-(2-chloroethyl)-3-cyclohexyl-nitrosourea (CCNU), vincristine, and prednisone. The estimated 5-year event-free survival probability was 59% for patients treated with radiation therapy and chemotherapy and 50% for patients treated with radiation therapy alone, a difference which is not statistically significant. The 5-year survival probability was 65% for both groups. Although the treatment difference was not statistically significant when all patients were combined, in the small number of patients with more extensive tumors, event-free survival was better in the group receiving chemotherapy (48% vs. 0%, p = 0.006). In these latter patients the survival time is also significantly prolonged. Extent of disease (as measured by the M staging criteria described by Chang) and age at diagnosis were significantly associated with outcome; advanced disease and young age had a worse prognosis. The extent of tumor resection was not an independent prognostic factor. It is concluded that chemotherapy does not benefit patients with low-stage medulloblastoma, but may benefit those with more advanced stages of disease.

The development of cell mediated immunity: very young children have strong LAK activity

We were interested in evaluating immune function in very young children with cancer who were treated with gamma-interferon on a sequential basis. Though gamma-interferon was reportedly able to enhance NK activity, and while many tumor cells are susceptible to lysis by these cells, this effector mechanism is not fully developed in very young children. Since LAK cells also have anti-tumor activity and are produced in response to stimulation with Interleukin-2, we investigated whether LAK killing might be more readily demonstrable in very young children. We report that LAK activity in this group did not differ significantly from that of adults. This was also true for a small group of neuroblastoma patients tested. Furthermore, as opposed to NK activity, LAK activity was demonstrable following freezing and thawing of PBL.

Results of treatment of children with recurrent medulloblastoma/primitive neuroectodermal tumors with lomustine, cisplatin, and vincristine

Primitive neuroectodermal tumors/medulloblastoma (PNET/MB) are the most common posterior fossa tumors in childhood. Despite surgery and radiation therapy, 40% to 50% of children with PNET/MB will have recurrent disease. Various chemotherapeutic agents are transiently effective in recurrent PNET/MB, but long-lasting responses are rarely attainable. To increase the rate and duration of response in children with recurrent PNET/MB, the authors treated seven patients (ages 2-18 years; median, 10 years) with lomustine (CCNU) (100 mg/m2), cisplatin (CPDD) (90 mg/m2) and vincristine (VCR) (1.5 mg/m2; maximum, 2 mg) in a 6-week cycle for a maximum of eight cycles. Six of six evaluable patients responded to chemotherapy. Four patients had a complete response; three with complete disappearance of tumor by imaging studies; and one with eradication of extraneural disease for a median of 24 months from relapse (13-29 months). Overall disease-free survival was 18.5 months. All six patients have subsequently died of recurrent tumor. Major toxicities consisted of reversible bone marrow suppression (six of six), high frequency hearing loss (six of six) and decreased renal function (three of six). All patients required dosage modification for toxicity. A regimen of CCNU, VCR, and CPDD is effective therapy in children with relapsed PNET/MB and can produce relatively long-term disease control with good quality of life. Further investigation into the efficacy of this combination as adjuvant chemotherapy in newly diagnosed high-risk PNET/MB is now being performed.

Analysis of nerve growth factor receptor expression in human neuroblastoma and neuroepithelioma cell lines

A series of 22 neuroepithelioma and neuroblastoma cell lines were screened for expression of nerve growth factor receptor (NGFR) by flow cytometry, Western blotting, and Northern blotting. All 5 neuroepithelioma cell lines expressed cell surface NGFR, with 30-69% of cells NGFR positive, but the 17 neuroblastoma cell lines tested had a smaller percentage of cell surface NGFR-positive cells (0-21%) and 10 lines were completely lacking cell surface NGFR. SY5Y, a variant line with a neuronal phenotype derived from neuroblastoma line SKNSH, expressed much more NGFR than SHEP, a variant line with an epithelial-like phenotype also derived from SKNSH. By Western blotting, the Mr approximately 69,000 NGFR band was detected for all four neuroepithelioma cell lines tested but was visible for only 8 of 15 neuroblastoma cell lines tested. The band was most intense for neuroepithelioma cell lines SKNMC and TC32. For these two lines, a Mr approximately 56,000 and a Mr approximately 60,000 band were also detected. By Northern blotting, all three neuroepithelioma cell lines tested were positive for the 3.8 kilobase NGFR mRNA, but only 8 of 15 neuroblastoma cell lines were positive. Neuroepithelioma cell line TC32 and neuroblastoma cell line GICAN had the strongest expression of NGFR mRNA. These results demonstrate that NGFR is a biological marker for neuroepithelioma and that NGFR expression is heterogeneous for neuroblastoma cell lines. This series of neural cell lines differing in NGFR expression will be useful for future studies of regulation of NGFR expression and neuronal differentiation.

The effectiveness of chemotherapy for treatment of high grade astrocytoma in children: results of a randomized trial. A report from the Childrens Cancer Study Group

Fifty-eight patients with high-grade astrocytoma were treated by members of the Childrens Cancer Study Group in a prospective randomized trial designed to study the effectiveness of chemotherapy as an adjuvant to standard surgical treatment and radiotherapy. Following surgical therapy, patients were assigned randomly to radiotherapy with or without chemotherapy consisting of chloroethyl-cyclohexyl nitrosourea, vincristine, and prednisone. Treatment with chemotherapy prolonged survival and event-free survival. Five-year event-free survival was 46% for patients in the radiotherapy and chemotherapy group, and 18% for patients in the radiotherapy-alone group. Five-year survival was similarly improved. The differences in outcome due to treatment were statistically significant after correcting for imbalances in important prognostic factors (event-free survival, p = 0.026; survival, p = 0.067). The presence of mitoses or necrosis in the tumor specimen was associated with poorer outcome. Patients whose initial surgery was limited to biopsy, and patients with basal ganglia lesions, also had significantly worse outcome. Chemotherapy administered at the time of recurrence in a small number of patients did not produce any long-term survivors. This study is to our knowledge the only randomized trial to investigate effectiveness of chemotherapy in the treatment of high-grade astrocytoma in children.

Development of coronary prevention strategies by health authorities in the United Kingdom

The United Kingdom has one of the highest coronary heart disease mortality rates in the world. However, over the last decade there has been a growing impetus in coronary prevention. In 1988 the Faculty of Community Medicine carried out a survey of all health authorities in the UK to assess the progress and problems with coronary prevention. This survey received a 92 per cent response rate and shows some interesting findings. The picture at present reveals a growing momentum in the last couple of years with half the health authorities at present claiming to have a programme. The main hindrances reported are lack of funding rather than lack of interest. The development and difficulties with nutrition and smoking policies, and with blood pressure screening are also described. The regional pattern of development of these programmes and policies is complex. Many authorities favour a general health promotion approach rather than a negative, disease oriented one; this conflict in approach requires further debate.

Coronary risk factor prevalence in a high incidence area: results from the Belfast MONICA Project

Northern Ireland remains at the top of the world mortality league for ischaemic heart disease. The Province is providing a centre for the World Health Organisation's MONICA Project. Registration of coronary heart disease events began in 1983 and the first of three population surveys took place in 1983-4. A total of 2,361 men and women aged 25-64 years was screened. Subjects were shorter and heavier than their fellow citizens in Great Britain. The estimated mean cholesterol levels in the 25-64-year-old population (5.80 mmol/l in males and 5.85 mmol/l in females) were similar to those reported from Great Britain. Although mean systolic blood pressures were lower, mild diastolic hypertension was considerably more common; cigarette smoking levels were similar. The results were consistent with those expected for an area with a high coronary heart disease mortality, with more than 80% of subjects being at increased risk in terms of the three major factors (cigarette smoking, hypertension and raised cholesterol). Public concern about coronary heart disease has grown and recently the Department of Health and Social Services (NI) has launched a 10-year prevention programme which will primarily employ a population approach.

Discharge from a coronary care unit: psychological factors

Anxiety is commonly experienced by patients following myocardial infarction. The role of anxiety in the recovery/rehabilitation process is not well understood, but anxiety is thought to be one of the factors determining outcome. It is important, therefore, to understand the possible effects on anxiety of changing discharge policies in coronary care units. Anxiety was assessed in a sample of MI patients, with good or poor prognoses, assigned to either early or late discharge from a coronary care unit. Although the overall level of anxiety of the total sample was not unduly high, it was clear that there was a subgroup of individuals, high in trait anxiety and with a poor prognosis, for whom early discharge was contra-indicated. Irrespective of prognosis, it was clear that early discharge did not produce a uniform response, indicating the need to differentiate between patients when determining the optimal date for discharge.

International criteria for diagnosis, staging, and response to treatment in patients with neuroblastoma

Neuroblastoma is one of the most common tumors in childhood. However, it often has been difficult to compare clinical and laboratory studies of this disease due to a lack of uniform criteria for diagnosis, staging, and response. An international group of conferees addressed each of these issues and reached a consensus. Specific criteria for making a diagnosis of neuroblastoma are defined. A new neuroblastoma staging system is proposed that takes into account the most important elements of current but incompatible systems. Finally, criteria for response to treatment are standardized. The criteria proposed herein represent an international consensus of essentially every major pediatric oncology group or organization in the United States, Europe, and Japan. The staging system should be referred to as the International Neuroblastoma Staging System, and the response criteria as the International Neuroblastoma Response Criteria. Implementation of these criteria will greatly facilitate the comparison of clinical and laboratory studies by different groups and countries. Furthermore, these criteria should serve as a foundation on which future modifications or improvements can be based.

The Northern Ireland Cancer Registry

The Northern Ireland Cancer Registry was evaluated using a 5% sample of all cancers diagnosed histologically in 1983 as the standard for comparison. The overall registration rate was low. Two years following histological diagnosis only 63% of the cancers were registered and 19% of these were notified solely by the Registrar General's office. In a subgroup of patients who were known to have died by the time of the study, only 49% of the cancers were registered while the patient was alive. A further 30% of cases were registered only after death and 21% of cases went unregistered. There was no significant variation in registrations by area, by hospital or by age group. There was a considerable variation in registration rate by disease group. A low level of awareness among hospital doctors about the Northern Ireland Cancer Registry was postulated as a reason for the low levels of registrations received. This was investigated through a postal questionnaire. A response rate of 51% was achieved after two postings. Both the response rate and level of knowledge varied by grade and specialty of the doctor. Only 43% of responders knew of the existence of the cancer registry and only 2% registered patients more often than once a year. Possible methods for improving the system are discussed.

Efficacy of adjuvant chemotherapy for patients with poor-risk medulloblastoma: a preliminary report

Recent studies have demonstrated that preoperative and postoperative factors can broadly stratify patients with medulloblastoma/primitive neuroectodermal tumors (MB/PNET) into risk groups. For children with factors that suggest poor outcome after treatment with surgery and radiotherapy, the addition of chemotherapy can improve survival. Since 1983, 26 children with poor-risk posterior fossa MB/PNET have been treated at our institution with craniospinal radiation therapy and adjuvant chemotherapy. Chemotherapy consisted of vincristine during radiotherapy and eight 6-week cycles of vincristine, cis-platinum, and 1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea (CCNU). Twenty-five of 26 patients (96%) who have been entered on this protocol remain alive and free of disease at a median of 24 months from diagnosis (range 6 to 50 months). Twenty patients have completed all therapy and are at a median of 32 months from initial diagnosis with no evidence of disease. These patients were compared to a group of children with similar prognostic features treated at our institution between 1975 and 1983. Actuarial disease-free survival was statistically significantly better for protocol patients than for historical control subjects (p less than 0.002). This difference was most marked in patients who had received radiation therapy alone (p less than 0.0003). Actuarial 2-year disease-free survival was 96% for patients on protocol as compared to 59% for historical control patients who had been treated with radiotherapy alone. The chemotherapy given in this protocol was well tolerated. The results of this study, although preliminary, suggest that adjuvant chemotherapy is at least transiently effective in improving the rate of disease-free survival for children with poor-risk MB/PNET.

Basic and acidic isoferritins in the sera of patients with neuroblastoma

Serum ferritin frequently is elevated in patients with neuroblastoma. Isoferritins extracted from neuroblastoma tumors and cells in culture show a wide range from basic (rich in L subunit) to acidic (rich in H subunit) isoferritins. Total ferritin is a combination of basic and acidic isoferritins. Forty-four serum samples from 25 patients with neuroblastoma were measured for basic and acidic isoferritin levels by radioimmunoassay using antibodies to liver (basic) ferritin and HeLa (acidic) ferritin. Normal ranges for basic and acidic serum ferritins were 7 to 142 ng/ml (median, 30 ng/ml) and 0 to 12 ng/ml (median, 3.4), respectively. Basic ferritins in the 44 neuroblastoma sera ranged from 0 to 1460 ng/ml, and acidic ferritins, 0 to 40 ng/ml. Sera with high levels of acidic ferritins always had increased basic ferritins. Thus, acidic/basic ferritin ratios were nearly constant, less than 0.3 in all sera. There was a significant linear correlation between basic and acidic isoferritins (r = 0.833). These results suggest that neuroblastoma tumors produce both basic and acidic isoferritins and release them into circulation. However, there is no acidic ferritinemia not accompanied by basic ferritinemia. Therefore, the commercial assay for basic isoferritin currently seems sufficient for clinical prognostic purposes.

Fatal ischaemic heart disease in Belfast: a comparison of two community surveys

Data from two community surveys in Belfast were used to compare all deaths attributed to ischaemic heart disease during two one-year periods (1965/66 and 1981/82). There was an increase in mortality in men of all ages from 3.3 to 4.4 per 1,000 population (33%) and in women from 1.6 to 3.1 per 1,000 population (94%). Only in men aged less than 70 years was the mortality rate unchanged (2.2 per 1,000 population). The proportion of deaths in persons whose fatal attack began outside the hospital was virtually unchanged (65% in 1965/66 compared with 69% in 1981/82). Survival time was markedly decreased in the later survey, as were delay times in initiating medical care. The increase in mortality probably is due to an increase in the incidence of acute myocardial infarction. The introduction of mobile coronary care in Belfast in 1965 seems to have had equal effects in reducing mortality inside and outside hospital.

Results of the treatment of children with recurrent gliomas with lomustine and vincristine

Gliomas comprise over 50% of all childhood brain tumors. Treatment of recurrent childhood gliomas has been disappointing and the effectiveness of therapy has been difficult to judge because of the variable natural history of the disease. Information gathered recently has suggested that treatment with [1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea)] (CCNU) and vincristine (VCR) after radiotherapy is effective in prolonging survival in children with newly diagnosed anaplastic gliomas. The authors have used these same drugs--CCNU (100 mg/m2) and VCR (1.5 mg/m2 up to a maximum dose of 2 mg)--in 6-week cycles for a maximum of eight cycles in children with recurrent gliomas. To date, 15 patients have been treated; five patients had malignant gliomas and ten low-grade gliomas. Three children showed improvement, five had stable disease, and seven had progressive disease. Of the five patients with malignant gliomas, four progressed within two cycles of treatment and one had stable disease for 7 months on treatment and then relapsed. Seven of ten children with low-grade gliomas benefitted from treatment and six remain in continuous remission a median of 16 months after initiation of therapy. Three of these children are off all therapy 21, 30, and 30 months after treatment, respectively. Therapy was well tolerated and toxicity consisted primarily of reversible bone marrow suppression. The authors conclude that CCNU and VCR chemotherapy is effective in children with recurrent low-grade gliomas and can result in relatively long-term disease stabilization. In limited experience of the authors, it is not of benefit in children with recurrent anaplastic lesions.

I-131 metaiodobenzylguanidine: diagnostic use in neuroblastoma patients in relapse

Metaiodobenzylguanidine (MIBG) has been used for the detection and treatment of neuroectodermal tumors, including neuroblastoma. We report our experience with 131I-MIBG used diagnostically in neuroblastoma patients with relapse. Thirty-eight studies were performed in 26 patients. There were 24 children (range 3 months-14 years) and two adults. While the study was found to be both sensitive and specific for the presence of disease, there are instances of discordance. False-negative studies were found with a markedly anaplastic tumor and with two mature ganglioneuromas. A bone lesion was negative with 131I-MIBG, but positive on bone scan. A biopsy confirmed the presence of neuroblastoma. Caution should be exercised when scanning pretreated patients, and perhaps with newly diagnosed patients as well.

Selecting initial therapy for pediatric genitourinary cancers

A few decades ago, there were few choices in the initial management of children with genitourinary tumors. Radical surgical removal was the only line of attack that promised any chance of survival. Improvement in the results of multimodal therapy in the last 15 years have radically altered the outlook for these children, hence the choice of therapy. As with other childhood cancers, the choice of therapy is based on risk-benefit evaluations of the roles of surgery, irradiation, and chemotherapy, since all three modalities have their associated morbidities. Current emphases are on preservation of function without compromising cure. The large cooperative clinical trials have emphasized this aspect of pediatric oncology. They have demonstrated, for example, that radiation therapy can be omitted from primary management of early stage Wilms' tumor patients who are given adequate adjuvant chemotherapy as can both radiation therapy and ablative surgery in certain cases of early stage rhabdomyosarcoma. Routine retroperitoneal node dissections have been shown to be of dubious diagnostic or therapeutic value in boys with testicular cancers. The need for bilateral oophorectomy in girls with dysgerminoma can similarly be questioned. Choices of initial therapy, therefore, are not static. They are becoming wider with each advance in multimodal therapy. Clinicians must keep abreast of the results of clinical trials so they can offer their patients the combination of treatments that will preserve function, and produce the smallest number of late complications without jeopardizing survival chances.

Prognostic factor in neuroblastoma

Known prognostic factors in neuroblastoma were analyzed in 124 children to determine which were independent and which were most useful in predicting outcome. The following factors were analyzed: age, sex, stage of disease, serum neuron-specific enolase (NSE), serum ferritin, E-rosette inhibition, urinary catecholamines, and histologic type according to the criteria of Shimada. Estimates of survival were calculated using the method of Kaplan and Meier. The overall survival for 124 patients was 60% at 2 years. There were significant differences in survival by pathology, age, NSE, ferritin, vanilmandelic acid (VMA): homovanillic acid (HVA) ratio, and stage. There was a strong association among NSE, age, stage, and ferritin. Using the recursive partitioning approach, it was possible to subdivide patients into three groups (based on diagnostic values of ferritin, age, and stage) with a good, intermediate, and poor prognosis and estimated 2-year survival of 100%, 62%, and 19%, respectively. Further analysis could not be done because of small numbers in the subgroups, but the results suggest that combinations of age, stage, serum ferritin, and histologic type may be able to define two populations: favorable with 80% + 2-year survival and unfavorable with less than 20%.

Radionuclide therapy of neural crest tumors

The potential concentration of I 131-Meta-iodo-benzylguanidine (MIBG) in pheochromocytoma, and the successful application in diagnosis and therapy of pheochromocytoma, has led to its use in therapy in other tumours derived from the neural crest. In neuroblastoma, the concentration of MIBG is as reliable as it is in pheochromocytoma. 18 patients with a neuroblastoma were treated, leading to two complete remissions, seven partial remissions, two no change, and two progressive disease; one patient was lost for follow-up. Six adults were treated, three with a carcinoid, two malignant pheochromocytoma and one medullary thyroid carcinoma. Although follow-up is still short, preliminary results of therapeutic use of I 131-MIBG indicate that this treatment modality may be effective.