Histopathologic prognostic factors in neuroblastic tumors: definition of subtypes of ganglioneuroblastoma and an age-linked classification of neuroblastomas

Screening for neuroblastoma in France: methodological aspects and preliminary observations

A pilot study of neuroblastoma mass screening was initiated in January 1990 in the Rhône French district. The expected number of births per year is 26,000. The study is designed for a 5-year period with three major goals: 1) measurement of the compliance rate of a voluntary test at 4 months of age; 2) evaluation of the technical value of high-pressure liquid chromatography (HPLC) as a screening method; and 3) detailed biological characterization of all detected tumors. 61,551 children were screened between May 1, 1990 and December 31, 1993. Participation was 69% in 1990, 81.5% in 1991, and over 83% in 1992. HPLC was a satisfactory assay method. The number of clinical examinations required for positive tests as defined in the protocol is 1 per 3,621 tests. The false positive rate is 1 per 3,583 tests. Eight neuroblastomas were discovered by-screening (one stage I, three stage II, one stage III, three stage IVs). All are alive and well but were good prognosis cases according to the main prognostic factors. Five patients were discovered before screening (so called Halo effect): one stage I, one stage III, three stage IVs. One died of disease and four are alive in complete remission after treatment. Two patients were false negative (one stage III with N-myc amplification, one stage IV with bad prognosis features) and three cases of neuroblastoma were missed because of noncompliance with the screening program. This pilot study concludes on the feasibility of a mass screening program in France. The estimated cumulative incidence of neuroblastoma at 3 years is 1 per 4,375 living births and overdiagnosis is probable. All the detected cases were of good prognosis and the false negative ones were poor prognosis cases.

Familial neuroblastoma: a three-generation pedigree and a further association with Hirschsprung disease

Like the other embryonal cancers of childhood, neuroblastoma occasionally occurs within families. We now provide an update on a nuclear family in which seven individuals are affected with neuroblastoma, inherited in an autosomal dominant fashion over three generations. In addition, two of these individuals are also affected with Hirschsprung disease. This family may lend insight into the molecular pathogenesis of familial neuroblastoma.

Clinical relevance of TRKA expression on neuroblastoma: comparison with N-MYC amplification and CD44 expression

TRKA expression was evaluated on 122 untreated neuroblastomas by immunohistochemistry using an antibody with predetermined specificity. This procedure is simple and reliable for protein detection at cellular level in a routine clinical setting. Fourteen tumours were classified as benign ganglioneuroma with a restricted expression of TRKA on ganglion cells; these patients were excluded from the following analysis. A total of 108 tumours were classified as neuroblastoma or ganglioneuroblastoma; 74 expressed TRKA protein, which strongly correlated with low stage, absence of N-MYC amplification, age (<1 year), CD44 expression and favourable clinical outcome. In a univariate analysis including tumour stage, age, histology, N-MYC amplification, CD44 and TRKA expression, all parameters had significant prognostic value. The absence of TRKA expression on CD44-positive or N-MYC non-amplified tumours permits the characterization of a subgroup of patients with intermediate prognosis. However, in a multivariate analysis taking into consideration the prognostic factors mentioned above, CD44 and tumour stage were the only independent prognostic factors for the prediction of patients' event-free survival.

Spatial association of apoptosis-related gene expression and cellular death in clinical neuroblastoma

Several unique features of neuroblastoma (NB), including the capacity for spontaneous regression and maturation to benign pathology, suggest that genes that regulate cellular proliferation, survival and differentiation may be involved in directing clinical tumour aggressiveness. The in situ expression of Bcl-2, Rb, p21, p53 and Bax proteins, as well as the proliferation marker proliferating cell nuclear antigen (PCNA) were examined immunocytochemically in a selection of 38 stage- and outcome-identified NB tumours. Apoptotic cells were identified morphologically and by a DNA fragmentation labelling technique (TUNEL). Although the tumour cell density of Bcl-2, p53, Bax, PCNA and TUNEL positivity correlated with patient survival, a spatially organized expression pattern was further recognized in stroma-poor differentiating tumours. Immature tumour cells adjacent to thin fibrovascular stroma are proliferating, as evidenced by PCNA positivity, and often express Bcl-2. At increasing distance from this fibrovascular stroma, intermediately differentiated tumour cells express Rb, while with more advanced differentiation, proliferation ceases and Bcl-2 immunoreactivity is lost. The most differentiated tumour cells, which often express p53, and occasionally p21 and Bax, lie adjacent to TUNEL-positive, morphologically apoptotic cells. This spatial organization in favourable outcome NB tumours suggests that physiological regulation of differentiation and apoptosis may be involved in tumour regression.

Screening for neuroblastoma in late infancy by use of EIA (enzyme-linked immunoassay) method: 115000 screened infants in Austria

The aim of this study was to investigate the feasibility of a neuroblastoma screening programme for children in late infancy, based on collaboration of general paediatricians and practitioners in Austria, using the technique of enzyme-linked immunoassay (EIA) for biochemical analyses. Analysis of catecholamine metabolites in spot urine samples by EIA with high performance liquid chromatography as a backup was undertaken. Austrian infants (median age 8.7 months) were screened. Overall compliance was 30%. The EIA method had a high rate (6.7%) of false-positive results. 28 infants were admitted to hospital. In 15 cases, neuroblastoma was found (four stage 1, five stage 2B, six stage 3). The EIA method can be used for neuroblastoma screening, but requires a backup analytical technique in order to avoid unnecessary hospital admissions. The stage distribution and biological features of neuroblastomas diagnosed by screening at a later age are different from those detected by earlier screening. Screening in late infancy might be of more benefit than early screening.

Gastric ganglioneuroblastoma: a rare finding in an infant with multifocal ganglioneuroblastoma

PURPOSE

This report describes a female infant with stage 4 multifocal ganglioneuroblastoma with gastric involvement.

PATIENT

The patient had a right cervical tumor, a left posterior mediastinal tumor, bilateral adrenal tumors, and bony and bone marrow metastases. The tumor cells were diploid and lacked N-myc gene amplification. The gastric involvement, which did not produce clinical symptoms, was only detected by meticulous exploration during laparotomy.

RESULTS

Our patient achieved only a partial response to alternating cycles of cyclophosphamide, vincristine, and adriamycin; and etoposide and cisplatin. She currently has stable, unresectable disease with elevated catecholamines.

CONCLUSIONS

Multifocal ganglioneuroblastomas may arise from either neuroblastic rests or aberrant deposits of neuroblasts. The latter mechanism may have accounted for our patient's gastric tumor. Patients with multifocal ganglioneuroblastomas warrant meticulous radiographic and surgical evaluation to completely document the full extent of disease, and to ensure appropriate staging and therapy.

Stage IVS neuroblastoma: a clinical, histological, and biological analysis of 45 cases

This study reports clinicopathologic and biological analysis of 45 stage IVS neuroblastomas (IVS-NBs). All IVS-NB cases had small or undetectable primary tumors associated with disease involving the liver, skin, or bone marrow. Their ages at diagnosis ranged from 1 day to 12 months, with a median age of 4 months. The primary sites were adrenal in 34 cases, retroperitoneum in two, mediastinum in one, and unknown in eight; the liver was involved in 24 of 31 cases, the bone marrow in 11 of 27, and the skin in 4 of 29. According to the histopathological evaluation (Shimada classification), 43 IVS-NB tumors had a favorable histology, and 2 cases showed an unfavorable histology. Three patients died of progressive disease and six of indirect tumor death. Among these three deceased cases with tumor progression, two cases showed unfavorable histology, and one case had amplified N-myc (20 copies). These data suggest that most IVS-NB can be described as a tumor presenting characteristic dissemination pattern in the younger age group, having a favorable histology and showing an excellent outcome of the patients. However, poor prognosis group in stage IVS does exist, and this group could be detected histopathologically and biologically.

Localization of Tc-99m MDP in neuroblastoma metastases to the liver and lung

Localization of skeletal tracer in a neuroblastoma primary is common but localization in extraskeletal metastatic sites has not received recognition. Tc-99m MDP concentration in hepatic or pulmonary metastases was noted in three of ten patients with such metastases. Lesion size appears to be important for demonstrating these metastases with Tc-99m MDP. This was particularly true for hepatic metastases, which were identified only when they were 5 cm or greater in diameter.

Role of ploidy, chromosome 1p, and Schwann cells in the maturation of neuroblastoma

BACKGROUND

Neuroblastoma is a heterogeneous disease, with manifestations ranging from spontaneous regression to lethal spread. Sometimes the tumor spontaneously differentiates toward a benign ganglioneuroma (maturing neuroblastoma). The prognosis is frequently related to ploidy, deletions in the short arm of chromosome 1, and amplifications of the N-myc oncogene. Maturing neuroblastomas consist of both neuronal cells and Schwann cells. We investigated the genetic composition of both cell types in maturing neuroblastomas, to determine the relation between genetic abnormalities and maturation.

METHODS

We studied 20 maturing and mature neuroblastomas by in situ hybridization to count the chromosomes and evaluate possible deletions in the short arm of chromosome 1 in neuronal and Schwann cells. The DNA content of the cells was measured by flow cytometry.

RESULTS

Neuroblastic and ganglionic cells showed aberrations in the number of chromosomes. In situ hybridization and flow cytometry demonstrated near-trip-loidy in 18 of 19 tumors and pentaploidy in the remaining tumor. The Schwann cells in all 20 neuroblastomas contained normal numbers of chromosomes. In 18 tumors studied, there were no chromosome 1 deletions in either type of cell.

CONCLUSIONS

The Schwann cells in maturing neuroblastomas differ genetically from the neuronal cells. The normal number of chromosomes in Schwann cells and the abnormal number in neuroblastic ganglionic cells suggests that Schwann cells are a reactive population of normal cells that invade the neuroblastoma. Near-trip-loidy of neuroblastoma cells and intact chromosome 1 are presumably genetic prerequisites for spontaneous organoid maturation, because we found no diploidy or chromosome 1 depletions in the neuronal cells of spontaneously maturing neuroblastomas.

Massive apoptosis detected by in situ DNA nick end labeling in neuroblastoma

To seek evidence that tumor regression in neuroblastoma might result from massive apoptosis, we investigated tumor cell death in 39 neuroblastomas. Characteristic histologic features of apoptosis, condensed nuclear fragments and eosinophilic cytoplasm, were observed in all specimens. A ladder of DNA fragments induced by apoptosis was demonstrated by means of DNA agarose gel electrophoresis in 18 of the 19 tumors examined. In situ DNA nick end labeling (TUNEL) stained the nuclei with DNA fragmentation in 16 of 39 neuroblastomas. The TUNEL -positive cells were distributed in a scattered fashion in 10 tumors. In the remaining six tumors, they were densely located around nonviable areas of calcifications, where karyorrhectic or pyknotic cells were frequently observed. Five of six patients with such tumors were under 12 months of age, but there was no significant difference between the two groups in the patient age, origin of the primary lesion, or tumor stage. Biological features, including histology. DNA ploidy, and N-myc amplification, were not significantly different . Double fluorescent staining for bcl-2 oncoprotein and TUNEL showed that bcl-2 oncoprotein was expressed in the cytoplasm of tumor cells that were negative for TUNEL staining. This accumulated evidence suggests that massive apoptosis of tumor cells occurs in some neuroblastomas and may be related to tumor regression, whereas inhibition of apoptosis by bcl-2 oncoprotein expression might be associated with the tumorigenesis of neuroblastomas, as reported in our previous study.

Long-term survival in refractory recurrent neuroblastoma

BACKGROUND

Patients older than age 1 year with metastatic neuroblastoma have poor survival. A patient with a unique history of metastatic neuroblastoma by virtue of disseminated nodal disease with multiple relapses and a 14-year survival is presented.

METHODS

A case history of a 24-year-old man who was diagnosed at age 9 years with Evans stage IV neuroblastoma with multiple recurrences is reviewed. A review of the literature was undertaken to uncover similar patients with advanced stage disease and an absence of hematogenous metastasis.

RESULTS

Eleven patients older than age 1 year, in addition to the case presented, have been reported in the literature with stage IV disease without extralymphatic metastasis. These patients have a survival of 50% at 5 years as compared with 15% in historical controls. Long-term survival with recurrent disease has not previously been noted in this population. Other favorable prognostic factors including favorable histology, and a single N-myc oncogene copy were documented in the present case.

CONCLUSION

A tendency toward improved survival is seen in patients with nonhematogeneous stage IV neuroblastoma. It is unknown whether long-term survival with residual disease, as observed in the present case, is seen in other patients with stage IV disease without extralymphatic metastasis. Prospective analysis of other patients with stage IV neuroblastoma without extralymphatic metastasis is required to confirm these observations.

Modified histologic grading of neuroblastomas by replacement of mitotic rate with mitosis karyorrhexis index. A clinicopathologic study of 223 cases from the Pediatric Oncology Group

BACKGROUND

Histologic grading (HG) of neuroblastomas (NB) of prognostic significance is based on the presence of absence of calcification and low mitotic rate ( < or = 10/10 high power fields). Mitosis karyorrhexis Index (MKI) is the main feature used for prognostic categorization in Shimada classification and can be determined more readily than mitotic rate (MR). The purpose of this study is to test whether MKI can be used instead of MR for histologic grading.

METHODS

Low and intermediate MKI were lumped together as low MKI. We replaced MR with the modified MKI categories. Histologic grades for 223 NBs registered with the Pediatric Oncology Group protocols 8104 and 8441, were defined ad follows: HG 1 = calcification + low MKI, HG 2 = calcification or low MKI, HG 3 = high MKI and absence of calcification. Shimada classification was also determined for comparison or modified HGs with favorable histology (FH) and unfavorable histology (UH), HGs were linked with age: low risk (LR) = HG 1 in all age groups + HG 2 in patients age younger than 1 year; high risk (HR) = HG 2 in patients age 1 year of older + HG 3 in all age groups.

RESULTS

Statistically significant differences in 5-year survival were seen in the NBs of different modified HG (1: 92.7%, 2: 74.9%, and 3: 18.2%) and risk groups (LR 93.0% and HR 47.9%) (P < 0.0001 and P = 0.0001, respectively).

CONCLUSIONS

Pathologists may readily adapt to the modified HG described here. Advantages of modified HGs include: (1) familiarity and reproducibility of MKI; (2) no need for linkage with age; and (3) a combination of features used in original HGs and Shimada classification.

The effect of complete excision on stage III neuroblastoma: a report of the European Neuroblastoma Study Group

Current opinion is divided about the value of excisional surgery in Evans stage III neuroblastoma.

AIMS

To evaluate and correlate the survival of patients with stage III neuroblastoma with the effectiveness of the surgical excision, as assessed by (1) the surgeon (resection data) at the time of operation and (2) the pathologist (excision data).

METHODS

The ENSG (European Neuroblastoma Study Group) database of 202 patients from 29 centres with proven stage III were analysed. The data include all patients with neuroblastoma diagnosed between 1982 and 1992 and their subsequent follow-up.

RESULTS

Patients were grouped according to the extent of resection (100%, 75% to 99%, and < 75%) and the completeness of excision (complete, microscopic residual, macroscopic residual). There were 123 with resection data, a subgroup of 104 with excision data, and 27 with no excision. There was no statistically significant difference (log rank test) in overall survival (p = 0.11) or event-free survival between the resection subgroups, even when the data from patients without resection were included. Complete excision was associated with a highly significant survival advantage, in terms of overall survival (P = .007) and event-free survival (P = .006). This effect is most obvious among patients with the worst prognosis: older children and those with an abdominal tumour.

CONCLUSION

Histological confirmation of complete excision confers a significant survival advantage for patients with stage III neuroblastoma and justifies a painstaking attempt at complete resection.

Survival of patients with neuroblastoma treated with 125-I MIBG

Recurrent or persistent neuroblastoma in stages III and IV is usually fatal despite modern therapies. Metaiodobenzylguanidine labeled with 131-I (131-I MIBG) concentrates in most neuroblastoma and when given in doses that impart therapeutic radiation, has produced remissions in patients with these tumors. However, success with 131-I MIBG has been limited. The physical characteristics of radiation imparted by 125-I MIBG theoretically could overcome some of the limitations that restrain the therapeutic effects of 131-I MIBG in patients with neuroblastoma. Thereby, 125-I MIBG may offer advantages over 131-I MIBG in the treatment of neuroblastoma. Ten children who manifested persistent/recurrent stage III or IV neuroblastoma were given 8.3 to 30.1 GBq or 224 to 814 mCi of 125-I MIBG in a phase I-II trial. Five of the patients had progression-free survivals > 1 year (continuing in three patients), and four of these subjects are surviving 17 to 52 months after treatment with 125-I MIBG. With appropriate doses of 125-I MIBG, life-threatening toxicity can be avoided. Thus, survivals after 125-I MIBG appear to be as long or longer than those historically observed following other treatments for patients similarly afflicted with refractory neuroblastoma.

Mass screening for neuroblastoma: quo vadis? A 9-year experience from the Pediatric Oncology Study Group of the Kyushu area in Japan

Since 1985, a nationwide program of mass screening for neuroblastoma has been available for 6-month-old infants throughout Japan. From 1985 to 1993, the authors studied 285 patients with neuroblastoma among their regional population of 15 million. There was an increase in the total number of patients per year in comparison to the previous 6-year period (1979 to 1984). However, no significant difference was noted in the number of patients older than 1 year or in the incidence of advanced-stage (stages III and IV) unscreened cases. The majority of neuroblastomas in the screened group showed favorable biological factors, even in the advanced stages. However, there was a small group with histologically and/or biologically unfavorable factors; five of 115 had amplified N-myc oncogene, four of 74 showed unfavorable Shimada histological findings, and three of 33 had an unfavorable DNA ploidy pattern. One case from this group with unfavorable factors died of the tumor. 3) Thirty-eight cases were negative at the time of mass screening, but later presented with neuroblastoma. Most of them were diagnosed between 1 and 3 years of age, and 30 of the 38 cases (78.9%) were advanced stage with unfavorable prognostic factors. Thus, the authors conclude that mass screening at 6 months can detect a selected population of infants with neuroblastoma; some of the tumors may represent subclinical masses destined for spontaneous regression. However, some tumors with unfavorable factors have been detected by mass screening before progression and/or dissemination. Infants in this group are considered to benefit most from early diagnosis and treatment.

HMG-CoA reductase mediates the biological effects of retinoic acid on human neuroblastoma cells: lovastatin specifically targets P-glycoprotein-expressing cells

The enzyme 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, involved in de novo cholesterol synthesis and cell-cycle progression, was identified as a potential mediator of the growth inhibitory effects of retinoic acid on human neuroblastoma. Lovastatin, a nonreversible inhibitor of HMG-CoA reductase, induced extensive cytotoxicity that was restricted to drug-resistant P-glycoprotein-expressing neuroblastoma cell lines. This response was potentiated by dibutyryl cyclic AMP but not retinoic acid. Patients with advanced-stage metastatic neuroblastoma often display an acquired chemoresistant phenotype, which may in part be mediated by P-glycoprotein. Our studies support the application or use of HMG-CoA reductase inhibitors as potential therapeutic agents in the treatment of these patients who are refractory to chemotherapy.

In situ detection of DNA fragmentation and expression of bcl-2 in human neuroblastoma: relation to apoptosis and spontaneous regression

Spontaneous regression occurs in some cases of neuroblastoma, especially stage IVS. The incidence of neuroblastoma has been reported to be increasing since the mass screening program was introduced in Japan. This would indicate that the screening is detecting regressing tumors. However, the mechanism of regression is still unknown. To evaluate the hypothesis that the regression might be related to apoptosis, the authors examined apoptosis by in situ end-labeling of fragmented DNA and expression of the apoptosis-suppressing protein bcl-2.

MATERIALS AND METHODS

One hundred eighteen neuroblastoma cases were available for examination. Eighty (67.8%) were detected by the mass screening program. Serial sections were cut from paraffin-embedded tumors. A modified TdT-mediated dUTP nick end-labeling (TUNEL) method was performed to detect apoptosis. Immunohistochemical analysis was performed to detect bcl-2 expression.

RESULTS

In cases under 1 year of age or with a favorable clinical stage, the incidence of apoptosis was significantly high. Expression of bcl-2 was associated with N-myc amplification and unfavorable histology (Shimada classification). Tumors in patients under 1 year of age often had areas where cellularity was markedly decreased, and apoptosis was often observed while bcl-2 expression was reduced. In such cases, there was a negative correlation between occurrence of apoptosis and bcl-2 expression. This suggests that apoptosis may be related to spontaneous regression in neuroblastoma.

Pelvic neuroblastoma safety excised using a combination of the abdominal and posterior sagittal routes

The authors report on a patient with pelvic neuroblastoma in whom the tumor was totally resected using a combination of the abdominal and posterior sagittal routes. In the treatment of patients with pelvic neuroblastoma, this approach can provide good exposure and improve the chance of total excision.

Expression of the gene for multidrug-resistance-associated protein and outcome in patients with neuroblastoma

BACKGROUND

Overexpression of the gene for the multidrug-resistance-associated protein (MRP) has been linked with resistance to chemotherapeutic agents (multidrug resistance) in vitro. The expression of MRP by neuroblastoma cells correlates with N-myc oncogene amplification, a well-established prognostic indicator in patients with neuroblastoma.

METHODS

To relate MRP gene expression to established prognostic markers and the clinical outcome of neuroblastoma, we analyzed MRP expression in specimens of primary tumors from 60 patients with neuroblastoma.

RESULTS

Levels of MRP gene expression were significantly higher in tumors with N-myc amplification than in tumors without such amplification (P < 0.001). High levels of MRP expression were strongly associated with reductions in both survival and event-free survival (P < 0.001) in the overall study population and in subgroups of patients without N-myc amplification and patients with localized disease. For the overall study population, the five-year cumulative survival rates in the groups with high and low levels of MRP expression were 57 percent (95 percent confidence interval, 37 to 78 percent) and 94 percent (95 percent confidence interval, 86 to 100 percent), respectively. In contrast, expression of the MDR1 multi-drug-resistance gene was not predictive of survival or event-free survival. After adjustment by multivariate analysis for the effects of N-myc amplification and other prognostic indicators, high levels of MRP expression retained significant prognostic value for poor survival (relative hazard, 14.9; P = 0.01) and poor event-free survival (relative hazard, 9.7; P = 0.004), whereas N-myc amplification had no prognostic value.

CONCLUSIONS

High levels of MRP gene expression in patients with neuroblastoma correlate strongly with poor outcome. The findings suggest that expression of this multidrug-resistance gene accounts for the association between N-myc amplification and reduced survival.

Allelic loss of chromosome 1p as a predictor of unfavorable outcome in patients with neuroblastoma

BACKGROUND

Neuroblastoma is a childhood tumor derived from cells of the neural crest, with a widely variable outcome. Differences in the behavior and prognosis of the tumor suggest that neuroblastoma can be divided into several biologic subgroups. We evaluated the most frequent genetic abnormalities in neuroblastoma to determine their prognostic value.

METHODS

We used Southern blot analysis to study the allelic loss of chromosomes 1p, 4p, 11q, and 14q, the duplication of chromosome 17q, and the amplification of the N-myc oncogene in 89 neuroblastomas. We also determined the nuclear DNA content of the tumor cells.

RESULTS

Allelic loss of chromosome 1p, N-myc amplification, and extra copies of chromosome 17q were significantly associated with unfavorable outcome. In a multivariate analysis, loss of chromosome 1p was the most powerful prognostic factor. It provided strong prognostic information when it was included in multivariate models containing the prognostic factors of age and stage or serum ferritin level and stage. Among the patients with stage I, II, or IVS disease, the mean (+/- SD) three-year event-free survival was 100 percent in those without allelic loss of chromosome 1p and 34 +/- 15 percent in those with such loss; the rates of three-year event-free survival among the patients with stage III and stage IV disease were 53 +/- 10 percent and 0 percent, respectively.

CONCLUSIONS

The loss of chromosome 1p is a strong prognostic factor in patients with neuroblastoma, independently of age and stage. It reliably identifies patients at high risk in stages I, II, and IVS, which are otherwise clinically favorable. More intensive therapy may be considered in these patients. Patients in stages III and IV with allelic loss of chromosome 1p have a very poor outlook, whereas those without such loss are at moderate risk.

Disseminated neuroblastoma in the nude rat. A xenograft model of human malignancy

BACKGROUND

The overall survival of children with neuroblastoma remains less than 30% due to disease dissemination at the time of diagnosis. An animal model of neuroblastoma, with characteristics similar to those observed clinically in children, would be beneficial to investigations into the diverse biology of this tumor. The purpose of this study was (1) to develop a model of disseminated neuroblastoma in the nude rat by intracardiac injection of neuroblastoma cells derived from cell lines with different N-myc copy numbers; (2) to investigate the effect of age on tumor growth and dissemination; and (3) to assess progression of disease radiologically and correlate with autopsy findings.

METHODS

Nude rats (n = 38), 5-13 weeks of age, underwent intracardiac injection of the human neuroblastoma cell lines IMR-32 with amplified N-myc oncogene and SKNSH with 1 N-myc copy. The animals were observed for at least six weeks for the development of tumor. Twelve rodents injected with IMR-32 cells underwent imaging studies including magnetic resonance imaging (MRI), skeletal radiographs, and indium-111(IN-111)-diethylenetriamine penta-acetic acid-D-Phe1-octreotide scintigraphy. Autopsies with standardized microscopic examinations were performed on all animals.

RESULTS

Most of the nude rats (95%) developed neuroblastoma following intracardiac injection of neoplastic cells. Disseminated tumor was evident in 66% of animals. Anatomic sites of neuroblastoma growth were similar to those observed clinically in children, including adrenal glands, paraspinal ganglia, bone, bone marrow, and skin, but no tumor was identified in the liver. Disseminated disease occurred in more animals injected with IMR-32 (78% of animals) than with SKNSH cells (34% of animals) (P < 0.05). Tumor spread appeared to be age dependent; only rodents 5-8 weeks old at the time of injection developed disseminated disease when compared with animals 9 weeks of age or older (P < 0.0001). Radioreceptor scintigraphy demonstrated only pericardial tumor; MRI identified pericardial, adrenal gland, and subcutaneous neoplasms; only skeletal radiographs detected neuroblastoma in cortical bone.

CONCLUSIONS

(1) Following intracardiac injection of human neuroblastoma cell lines into nude rats, a xenograft model of disseminated disease develops that closely parallels the malignant process in children. (2) Tumor dissemination is associated with the cell line that demonstrates N-myc amplification and with young age of the recipient at the time of injection. (3) Tumor growth and dissemination may be assessed radiologically. (4) This model of human malignancy may offer an opportunity to investigate the pathophysiologic mechanisms underlying tumor development and dissemination in advanced stage neuroblastoma.

Comparison of calbindin D-28k and S-100 protein B in neuroblastoma as determined by enzyme immunoassay

Levels of two calcium-building proteins, calbindin D-28k (calbindin-D) and S-100 protein B (S-100b), were measured by immunoassay in solid tumors obtained surgically from pediatric patients. Mean concentrations of calbindin-D and S-100b in 73 neuroblastomas (23 ganglioneuroblastomas and 50 neuroblastomas) were 10- or 25-fold higher, respectively, than those in other types of solid tumors in pediatric patients (n = 15). The mean tumor concentration of calbindin-D in patients with neuroblastoma (n = 73) was 25.1 ng/mg (range 0.20 to 317.0 ng/mg soluble protein, SE = 6.26); that of S-100b was 278.3 ng/mg (range 0.93 to 2521 ng/mg soluble protein, SE = 71.7). The mean concentration of calbindin-D (4.4 ng/mg soluble protein) was significantly (P < 0.05) lower in stage IV, the most advanced stage. The mean concentration of S-100b (74.0 ng/mg soluble protein) was lower in patients with undifferentiated neuroblastomas (P < 0.01). Tumor levels of the two calcium-binding proteins were not correlated in patients with neuroblastoma, but each was strongly correlated with outcome in patients with neuroblastoma. The evidence suggests that measurements of the calcium-binding proteins calbindin-D and S-100b would be useful for evaluating the prognosis of patients with neuroblastoma.

3,4-dihydroxyphenylalanine (DOPA) metabolism in screening-detected and non-screening-detected neuroblastoma

To investigate the possible clinical application of the hypothesis that insufficient induction of 3,4-dihydroxyphenylalanine decarboxylase (DDC) causes accumulation and secretion of 3,4-dihydroxyphenylalanine (DOPA) in unfavorable neuroblastomas, we measured plasma DOPA in 28 neuroblastoma patients. Abnormally high levels were demonstrated in patients with neuroblastoma, and the levels in patients with clinical manifestations (median, 44,800 pg/ml; range, 17,700 to 220,000 pg/ml; n = 6) were significantly higher than those in patients detected by screening (median, 5825 pg/ml; range 2890 to 33,300 pg/ml; n = 22) (P = 0.0004). The catecholamine secretion profiles of the two groups were different, and it was suggested that the relative deficiency of DDC caused DOPA secretion in patients in the former group, whose prognosis was unfavorable, except in one case. In both groups, serial determination of plasma DOPA was a good monitor of the disease course. The higher plasma DOPA level (>9400 pg/ml) was significantly correlated with the patients' age (>1 year old) (P = 0.019), tumor stage (III, IV) (P = 0.029), and DNA diploidy (P = 0.018). These results are consistent with previous studies that demonstrated plasma DOPA was a useful marker in the diagnosis and follow-up of neuroblastoma. The results also indicate that higher plasma DOPA levels are associated with the unfavorable characteristics of neuroblastoma, which seem to support the hypothesis on DDC deficiency in unfavorable neuroblastoma.

Screening for neuroblastoma in North America. Preliminary results of a pathology review from the Quebec Project

BACKGROUND

The Quebec Neuroblastoma Screening Project was initiated to assess clinical and biologic aspects of neuroblastomas detected by screening infants born in the province of Quebec from May 1, 1989, to April 30, 1994.

METHODS

Infants were screened for preclinical detection of neuroblastoma by determination of catecholamine metabolites, vanillylmandelic acid (VMA), and homovanillic acid (HVA). Patients with tumors discovered through this screening as well as patients in the same birth cohort with clinically detected tumors were referred to Quebec Oncology Centers for further investigation, diagnosis, and treatment. Pathology specimens were submitted to Childrens Hospital Los Angeles for central review. Tumors were histopathologically classified according to the Shimada system.

RESULTS

As of August, 1993, 340,000 infants were screened at 3 weeks and 245,000 of them were retested at 6 months of age. Thirty-one tumors were detected through this screening and removed. Histologic material was available for 27 cases: 14 were detected at 3 weeks of age and 13 at 6 months of age. Twenty-six patients had tumors with favorable histology (FH), and one patient had a Stage I tumor with unfavorable histology (UH). At the time of this writing, all mass screening patients are alive, including one child with relapsed disease. During this period, 48 tumors were detected clinically in the same birth cohort, 40 of which were evaluated histologically. Of these 40 cases, 28 of 29 tumors diagnosed in patients up to age 12 months indicated an FH, whereas 9 of 11 tumors diagnosed in patients older than age 12 months indicated a UH. All patients with FH tumors are alive including a child with relapsed disease. The single patient with UH diagnosed before age 12 months died of disease. Of the nine patients with UH diagnosed after age 12 months, four died of disease, one relapsed, and four are alive (including one treated with bone marrow transplantation) after variable follow-up periods.

CONCLUSIONS

The tumors detected by mass screening, similar to those tumors detected through clinical examination before age 12 months, were predominantly FH with good prognosis. However, those tumors that were missed by screening and were detected clinically after the patient was 12 months of age were predominantly UH, with serious clinical problems. This subgroup of patients not detectable by the current screening system presents an immediate and important clinical challenge that should be addressed in future studies.

Pelvic neuroblastoma--implications for a new favorable subgroup: a Children's Cancer Group experience

BACKGROUND

The survival in neuroblastoma is influenced by patient age, disease stage, tumor site, and several biologic factors. This study was undertaken to determine if primary pelvic lesions are associated with an unusually favorable outcome.

METHODS

Nine hundred eighty-six patients registered on Children's Cancer Group studies from 1980 to 1993 were reviewed, and 41 (4.3%) were found to have pelvic tumors. Survival was analyzed, and correlations among age, stage of disease, surgical resectability, histopathology, serum ferritin, and N-myc oncogene amplification were evaluated.

RESULTS

Age at diagnosis was comparable between patients with pelvic and nonpelvic tumors. Disease distribution was similar, with stages III and IV comprising 78% (32 of 41) of pelvic lesions compared with 73% (692 of 945) for nonpelvic tumors. There was no outcome difference in favorable stages (I, II, and IV-S), with 3-year progression-free survival rates of 88% and 82% for pelvic and nonpelvic sites, respectively. However, in stages III and IV, the 3-year progression-free survival was 70% for pelvic lesions compared with 47% for nonpelvic tumors (p = 0.04). Some favorable biologic factors were more common in children with pelvic lesions.

CONCLUSIONS

The pelvis is an unusual primary site for neuroblastoma but represents a more favorable prognostic subgroup, which is most evident in advanced-stage disease.

Indolent course of advanced neuroblastoma in children older than 6 years at diagnosis

BACKGROUND

An early observation suggests that children older than 6 years of age at diagnosis of neuroblastoma constitute a favorable prognostic group.

METHODS

Kaplan-Meier plots of survival of all such patients diagnosed at the Children's Hospital of Pittsburgh 1975-1992 were compared with curves of concurrently treated patients with Stage IV disease who were 1-6 years of age at diagnosis ("younger patients"). Known prognostic features, including stage and primary site of disease, pattern of metastases, histopathology, MYCN gene amplification, and urinary catecholamine metabolite ratios, were reviewed.

RESULTS

Of 17 children diagnosed after the age of 6 years ("older patients"), 13 patients had Evans' Stage IV disease and 4 had Stage III disease. The median survival was 3.24 years (range, 0.63-15.04 years) for the entire cohort and 3.07 years for those children with Stage IV disease. This compared with a median survival of 1.05 years in 34 concurrent younger patients (P < 0.01). In most cases, disease in these older patients was characterized by a short-lived complete or partial remission followed by aggressive recurrent disease that was partially and only transiently chemo- or radiosensitive. Only 3 patients (2 with Stage IV disease) are in continuous complete remission at 3, 5 10/12, and 14 1/2 years from diagnosis. Although poor prognostic factors were common, including the presence of bony metastases (12/17), biopsy material from pretreatment tumor specimens demonstrated a single MYCN gene copy number in all patients and favorable histology in 15 of 16 samples.

CONCLUSION

Older children with neuroblastoma have a more indolent course than do younger patients, a finding that appears to be related to favorable histology and the absence of MYCN amplification. Examination of larger numbers of such patients from cooperative groups should lead to a better understanding of what appears to be a subset of pediatric patients with neuroblastoma who may benefit from specifically tailored treatment protocols.

Demonstration of apoptosis in neuroblastoma and its relationship to tumour regression

The in vivo occurrence of apoptosis in neuroblastomas was investigated. Histologically, a number of tumour cells showed typical apoptotic changes, including cell shrinkage, condensed and fragmented nuclei, eosinophilic cytoplasm, and absence of the inflammatory response. These cells coincided closely with the so-called karyorrhectic cells. An electrophoretic DNA ladder, a functional hallmark of apoptosis, was demonstrated in four of six tumours, and DNA fragmentation was detected in situ by terminal deoxytransferase-mediated nick end-labelling in 26 of 35 tumour specimens (74%). The labelled cell counts ranged from 5 to 62 per 5000 tumour cells (mean +/- SD: 15.0 +/- 14.5). Immunoperoxidase staining revealed that an apoptosis-suppressing protein, bcl-2, was expressed abundantly in advanced-stage tumours, whereas it was absent from karyorrhectic-apoptotic cells. Several tumours with the potential for spontaneous regression were bcl-2-deficient. Immunostaining of the Fas receptor for apoptosis demonstrated that the tumour cells expressed this molecule on their cell surfaces. Our results provide evidence of apoptosis in neuroblastomas and suggest that bcl-2 and the Fas receptor may play a role in its regulatory mechanisms.

Patterns of failure following total body irradiation and bone marrow transplantation with or without a radiotherapy boost for advanced neuroblastoma

PURPOSE

To evaluate the patterns of failure and outcome of patients undergoing high-dose chemotherapy, total body irradiation (TBI), and bone marrow transplantation (BMT) for advanced/relapsed pediatric neuroblastoma, with emphasis on the impact of a radiotherapy boost to primary and metastatic sites.

METHODS AND MATERIALS

Between May 1986 and June 1993, 26 patients with advanced neuroblastoma underwent high-dose chemotherapy and TBI followed by BMT at our institution. The majority of patients were over the age of 2 years (73%) and were Stage IV at diagnosis (81%). Multiple metastatic sites were involved including bone (17), bone marrow (15), distant nodes (11), liver (5), lung (4) and brain (1). Twenty patients (77%) received cyclophosphamide (50 mg/kg x 4 days) and TBI as consolidation therapy. TBI was delivered to a total dose of 12 Gy given in 2 Gy twice daily (b.i.d.) fractions over the 3 days preceding bone marrow infusion. A local radiotherapy boost of 8-24 Gy was given to 13 out of 26 patients (50%) to the primary and/or metastatic sites immediately prior to or following induction chemotherapy according to physician judgement. Sites not amenable to a radiotherapy boost included the bone marrow, diffuse/bilateral lung involvement, and multiple bone metastases (> four sites).

RESULTS

The actuarial overall survival of the 26 patients was 40.4% at 3 and 5 years, with a progression-free survival at 5 years of 38.5%. Six patients died of transplant-related toxicity (23%). The use of cyclophosphamide as high-dose consolidation chemotherapy was significantly better than other multidrug regimens used in terms of overall survival (p < 0.0001) and progression-free survival (p = 0.0004). The presence of liver involvement prior to BMT was a significant adverse prognostic factor by multivariate analysis. Of the 20 patients surviving the transplant, 10 (50%) underwent a local radiotherapy boost. The patterns of failure were as follows: 3 out of 10 "boost" patients failed overall, none in previous (old) sites of disease only, 1 in new sites only, and 2 in old and new sites; 6 out of 10 "no boost" patients failed overall, 4 in old sites only, none in new sites only, and 2 in old and new sites. There was a trend toward improved 5-year progression-free survival in patients surviving the transplant that received a boost (68% vs. 33%, p = 0.24). A failure analysis was also performed for each of the 59 initially involved sites, of which the majority (64%) were amenable to a radiotherapy boost. Overall, there is a trend toward less failure in sites amenable to a radiotherapy boost that were irradiated (1 out of 10) vs. those not irradiated (6 out of 28). Failure in the liver occurred in three out of four of the patients with liver involvement that did not receive boost radiotherapy, whereas all seven patients with distant nodal involvement were controlled without a boost. Long-term sequelae include learning difficulties (2), cataract formation (1), and hearing loss (2). Sequelae attributable to a radiotherapy boost occurred in only one patient who received whole brain radiotherapy and developed a cataract and learning difficulties.

CONCLUSION

We have found an actuarial 5-year survival rate of 40.4% for patients with advanced neuroblastoma treated with BMT, which compares favorably with results of other published series. Disease recurrence following BMT was most common in previous sites of disease. The majority (64%) of these sites were amenable to a radiotherapy boost. An analysis of failure suggests that a low-dose radiotherapy boost improves control of these sites.

Cellular death in neuroblastoma: in situ correlation of apoptosis and bcl-2 expression

Apoptosis is the selective physiologic deletion of cells that are no longer required. Over-expression of the bcl-2 proto-oncogene extends survival of neurons otherwise destined for apoptosis. The unique capacity of neuroblastoma (NB) to undergo spontaneous regression and the prognostic dichotomy of children with this malignancy led us to evaluate bcl-2 expression and apoptosis in NB. An in situ DNA nick-labeling technique to detect apoptotic cells, as well as immunohistochemistry and morphology, were utilized in a selection of NB tumor specimens and in the human fetal sympathetic nervous system. bcl-2 expression was present in all 28 NB tumors examined and in sympathetic ganglia of the human fetus. Measurement of overall bcl-2 expression and of extent of apoptosis correlated with favorable prognosis. In low-stage tumors, bcl-2 expression was most intense in poorly differentiated tumor cells adjacent to fibrovascular stroma. Cells distant from the stroma exhibited increasing degrees of chromaffin differentiation, with apoptosis most evident in bcl-2-negative neuroblasts adjacent to well-differentiated NB cells. The spatial distribution of bcl-2 expression, apoptosis and chromaffin differentiation in favorable-prognosis NB may provide insight into mechanisms of persistent tumor existence or regression.

Comparison of ultrastructural features among neuroblastic tumors: maturation from neuroblastoma to ganglioneuroma

Neuroblastic tumors have the unique ability to differentiate and mature. This family of tumors is composed of the neuroblastoma, ganglioneuroblastoma, and ganglioneuroma. These tumors are derived from primordial neural crest cells that form the sympathetic nervous system. The purpose of this study was to characterize the ultrastructural features of neuroblastic tumors in a pediatric population. Forty-five neuroblastic tumors (15 neuroblastomas, 15 ganglioneuroblastomas, and 15 ganglioneuromas) were examined using standard transmission electron microscopic techniques. Undifferentiated neuroblastomas were composed of primitive cells with rare neurite-like processes containing clear secretory vesicles and no Schwann cell differentiation. Poorly differentiated and differentiating neuroblastomas showed more frequent neuritic processes with infrequent dense core granules and infrequent immature Schwann-like cells. Ganglioneuroblastomas possessed an admixture of cell types, including immature ganglion cells without associated satellite cells, intermediate cells, and differentiating neuroblasts. The neuropil contained immature Schwann cells encasing haphazardly arranged neuritic processes. Ganglioneuromas were composed of mature ganglion cells with occasional binucleation. The neuropil contained mature Schwann cells with well-organized neuritic processes and abundant collagen deposition. Differentiation or maturation of tumor cells, neuritic processes, and Schwann cells may thus be discerned ultrastructurally in primary neuroblastic tumors in pediatric patients.

Role of ultrasound in managing neuroblastoma detected by mass screening: a proposed ultrasonographic grading for children with neuroblastoma

The ultrasonographic (US) findings of 25 infant cases detected by the Japanese mass screening program for neuroblastoma (NB) were reviewed. The following results were obtained: An identification of the primary site was possible in 96% of the cases with abdominal US. An estimation of the tumor weight was possible based on the mass volume, which was calculated from US measurements. With the combination of the estimated mass volume, local involvement, and distant metastasis, the US grading of NB was possible and closely corresponded to the surgical staging (84%). The NB cases of adrenal origin at U1a, with a mass volume of less than 16 mL, were all found to be stage I and presented the possibility for spontaneous regression.

Bcl-2 oncoprotein expression and apoptosis in neuroblastoma

Bcl-2 protooncogene, originally discovered at the chromosomal breakpoint of the t(14;18) in follicular lymphoma, is known to regulate the process of programmed cell death or apoptosis. The inhibition of apoptosis is thought to be one of the mechanisms involved in the development of tumors. To investigate the possible association of bcl-2 protooncogene with the tumorigenesis of neuroblastomas, the authors examined bcl-2 expression by immunohistochemistry in 49 neuroblastomas and 7 ganglioneuromas. The distribution of apoptotic cells was also examined by the TUNEL method (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling). Bcl-2 oncoprotein was detected in the cytoplasm in 40 of 49 neuroblastomas (81.6%). There was no correlation between bcl-2 oncoprotein expression and the clinical features of neuroblastoma. The incidence of bcl-2-positive tumors in ganglioneuroma was significantly lower than that in neuroblastoma (28.6%) (P < .01). TUNEL stained the nuclei of tumor cells in 11 of 34 (32.4%) neuroblastomas. TUNEL-positive cells tended to be located around calcifications in neuroblastomas in patients less than 1 year old. Examination of serial sections showed that apoptotic cells were distributed in the area where bcl-2 oncoprotein was not expressed. What we have observed indicates that apoptosis of neuroblastoma cells may be regulated by bcl-2 expression. Our observations suggest that the survival of neuroblastoma cells might be promoted by bcl-2 expression and that bcl-2 might be associated with the tumorigenesis of neuroblastomas.

Retrospective analysis of biological factors in a recurrent IV-S neuroblastoma with intermediate-grade malignancy

A clinical stage of IV-S neuroblastoma is known to include heterogeneous tumors. The authors report a case of IV-S neuroblastoma that relapsed after regression 4 years and 10 months after diagnosis. Multiagent chemotherapy was necessary to control the disease, and the patient has been doing well with no evidence of disease for more than 5 years. Although Shimada's classification showed favorable characteristics, N-myc protein was positive and DNA ploidy was diploidy in the tumor at diagnosis. Discrepancy in DNA ploidy was observed and aneuploidy was shown in tumor specimens at recurrence. Experience in this case showed the following important clinical features: (1) IV-S neuroblastoma of intermediate-grade malignancy does exist, and patients with such a disease may be cured by aggressive treatment; (2) Identifying IV-S patients with an unfavorable clinical course is possible by examining biological prognostic factors.

Prognostic value of proliferating cell nuclear antigen (PCNA) immunostaining in neuroblastoma

Immunostaining for proliferating cell nuclear antigen (PCNA), a marker of cell proliferation, is being increasingly used to study the proliferative activity of tumors, and the PCNA labeling index has been correlated with the prognosis of several malignant neoplasms. Formalin-fixed, paraffin-embedded tissue specimens of 24 primary neuroblastomas were immunostained using an anti-PCNA monoclonal antibody and the PCNA index was calculated. Then the relationship between the PCNA index, prognosis, and various other factors was assessed, retrospectively. The mean PCNA index was 11.0%. Patients having tumors with a high PCNA index (> or = 11.0%) showed a significantly lower survival rate than those possessing tumors with a low PCNA index (P < 0.001). Moreover, the tumors showing N-myc amplification had a high mean PCNA index of 15.6%, while those without N-myc amplification had a low mean index of 1.7% (P < 0.01). The PCNA index was closely related to the prognosis of neuroblastoma and to N-myc amplification. It has the potential to be a useful prognostic indicator of the patients with neuroblastoma.

Neuroblastoma in infants aged less than 6 months: is more aggressive treatment necessary? A report from the Pediatric Oncology Study Group of the Kyushu area

Infants with neuroblastoma are known to have a better prognosis than older children. In Japan in 1985, mass screening for neuroblastoma in infants aged 6 months was introduced. With this policy, there has been an increase in the number of patients seen with neuroblastoma between 6 and 11 months of age. In a previous report the authors described the management and prognosis of infants with disease detected by mass screening, but there is still little information regarding the strategies of management for infants with neuroblastoma aged less than 6 months. The authors analyzed the data regarding 27 patients aged less than 6 months registered in their region (population 15 million) from 1985 to 1992, and compared it with that of the previous 8-year period. In the younger age group, there was a significantly higher rate of advanced disease stages (III and IV). In spite of the variation in treatment related to the choice of individual institutions, infants with stages I, II, and III disease had a good outcome, suggesting that aggressive chemotherapy is not necessary unless poor prognostic factors are present. One patient with stage IV disease died of disseminated disease and one with stage IVs and 22 copies of N-myc oncogene also died of tumor relapse in spite of aggressive chemotherapy. It is therefore concluded that the prognosis in infants with stage IV and IVs neuroblastoma under the age of 6 months is not as good as had previously been believed, and that such patients, therefore, require special consideration.

Prognostic indicators for neuroblastoma: stage, grade, DNA ploidy, MIB-1-proliferation index, p53, HER-2/neu and EGFr--a survival study

Neuroblastoma, a tumor of the sympathetic nervous system, is one of the most common solid malignancies in infants and represents 7% of all cases of childhood cancer outside of the central nervous system. Thirty-five samples of neuroblastoma from 31 patients were obtained from Duke University Medical Center between 1979 and 1991 and studied to determine the relative prognostic value of a number of clinical, histologic, nuclear, and oncogenic features. The features studied were: stage, Shimada classification, DNA ploidy, MIB-1-proliferation index and status for HER-2/neu, p53 and epidermal growth factor receptor (EGFr). Only age (P = .03), HER-2/neu (P = .01), and p53 (P = .02) reached statistical significance as prognostic indicators. The median survival for patients with HER-2/neu expression was 12 months; median survival for patients with no HER-2/neu expression was 138 months. Similarly, the median survival for patients with p53 expression was 12 months; patients with no p53 expression had a median survival was 144 months. The combination of either HER-2/neu or p53 positivity was especially strong as a prognostic indicator (P = .002).

Sensitive detection of numerical and structural aberrations of chromosome 1 in neuroblastoma by interphase fluorescence in situ hybridization. Comparison with restriction fragment length polymorphism and conventional cytogenetic analyses

Chromosome I abnormalities are indicators of prognosis in neuroblastoma (NB) but are not yet routinely exploited because conventional methods are technically demanding. We evaluated the pertinence of interphase cytogenetics fluorescence in situ hybridization (FISH) for the analysis of chromosome I in NB, compared with conventional methods. Deletion of Ip was detected in 8 of 9 cell lines analyzed by both FISH and restriction fragment length polymorphism (RFLP), but was evidenced in only 2 cases by conventional cytogenetics, painting analysis being required to reveal the other cases. The chromosome I number evaluated by FISH reflected the total chromosome modal number obtained by cytogenetics. Twenty-eight specimens obtained from ultrasound-guided punctures, surgical biopsies of the primary tumor and bone-marrow aspirates were studied by FISH on frozen cytocentrifuged smears; 12 had a chromosome I trisomy and 16 a disomy. Requirements for a reliable control analysis of Ip deletion by RFLP were met in only 23 cases. The retention of 2 alleles was observed in 15 cases and Ip deletion in 7, by both techniques. In one case, an interstitial deletion of Ip was evidenced only by RFLP, and one of 5 cases analyzed only by FISH had a Ip deletion. Although FISH might be improved by using additional probes, it presents major advantages for routine exploitation. Determining Ip deletion in individual cells makes it possible to analyze small and heterogeneous tumoral specimens; the technique requires only a few hours and can easily be standardized in non-specialized laboratories. The number of chromosome I homologues per cell might serve as a rapid screening for ploidy.

Immunohistochemical analysis of proliferating cell nuclear antigen expression in human neuroblastoma

Proliferative cell nuclear antigen (PCNA) is a cell-cycle-related nuclear protein that is maximally elevated in late G1 and S phase of proliferating cells. In this study, PCNA was identified immunohistochemically using paraffin section in 67 human neuroblastomas. Percentage of the PCNA-positive nuclei (PCNA index: PCI) ranged from 0% to 75%. There were significant relations between the PCNA expression and mitotic karyorrhexis index (MKI), histological classification, cell concentration, tumor weight, clinical stage, local invasion, lymph node metastasis, liver metastasis, or DNA ploidy. PCI was significantly low in patients who received aggressive chemotherapy before surgery. Patients with PCI higher than 30% showed a worse survival rate compared with those with PCI lower than 10% (P < .01). High PCI significantly related with poor survival, so that PCI may be an independent prognostic factor in neuroblastoma. Although further studies are required, PCNA immunostaining may be useful for assessing proliferating activity and for providing prognostic information in human neuroblastoma.

Allelic loss of chromosome 1 and additional chromosome 17 material are both unfavourable prognostic markers in neuroblastoma

In neuroblastoma, N-myc amplification and loss of heterozygosity for the short arm of chromosome 1 (LOH 1p) are common genetic abnormalities. We have recently shown that the presence of additional material of the long arm of chromosome 17 (add.17q) also occurs relatively frequently. In the present study, we analyzed a series of 55 tumors for LOH 1p, N-myc amplification and add.17q, using Southern blot analysis with polymorphic DNA probes of pairs of tumor and constitutional DNA. We determined the correlation of these parameters with clinical variables, such as age, stage, serum lactate dehydrogenase (LDH) and ferritin and also with outcome. LOH 1p occurred in 20 out of 55 cases (36%) and was found more often in stage III/IV tumors and in the older age group, although both correlations were not statistically significant. N-myc amplification was only demonstrated in 12 tumors with concomitant LOH 1p and was not present in the 35 cases without LOH 1p. Add.17q was found in 20/53 (38%) informative cases. LOH 1p was shown to be the most significant predictor of a poor outcome (P < 0.00001), independent of age and stage. LOH 1p is also of prognostic value in those cases without N-myc amplification, indicating a stronger prognostic value for LOH 1p. Add.17q was also associated with an unfavourable prognosis, although this was less significantly then with LOH 1p (P = 0.00004).

Correlating telomerase activity levels with human neuroblastoma outcomes

Telomerase activity was analysed in 100 neuroblastoma cases. Although telomerase activity was not detected in normal adrenal tissues or benign ganglioneuromas, almost all neuroblastomas (94%) did express it, suggesting an important role for telomerase in neuroblastoma development. Neuroblastomas with high telomerase activity had other genetic changes (for example, N-myc amplification) and an unfavourable prognosis, whereas tumours with low telomerase activity were devoid of such genetic alterations and were associated with a favourable prognosis. Three neuroblastomas lacking telomerase activity regressed (stage IVS). Thus telomerase expression may be required as a critical step in the multigenetic process of tumorigenesis, and two different pathways may exist for the development of neuroblastoma.

Complete surgical resection combined with aggressive adjuvant chemotherapy and bone marrow transplantation prolongs survival in children with advanced neuroblastoma

BACKGROUND

A multi-modality approach combining surgery with aggressive chemotherapy and radiation is used to treat advanced neuroblastoma. Despite this treatment, children with advanced disease have a 20% 2-year survival rate. Controversy has developed regarding the efficacy of combining aggressive chemotherapy with repeated surgical intervention aimed at providing a complete surgical resection (CSR) of the primary tumor and metastatic sites. Several prospective and retrospective studies have provided conflicting reports regarding the benefit of this approach on overall survival. Therefore, we evaluated the efficacy of CSR versus partial surgical resection (PSR) using a strategy combining surgery with aggressive chemotherapy, radiation, and bone marrow transplantation (BMT) for stage IV neuroblastoma.

METHODS

A retrospective study was performed with review of the medical records of 52 consecutive children with neuroblastoma treated between 1985 and 1993. Twenty-eight of these 52 children presented with advanced disease, 24 of which had sufficient data to allow for analysis. All children were managed with protocols designed by the Children's Cancer Group (CCG). Statistical analysis was performed using Student's t test, chi 2 test, and Kaplan-Meier survival curves.

RESULTS

Mean survival (35.1 months) and progression-free survival (29.1 months) for the CSR children was statistically superior to that of the PSR children (20.36 and 16.5 months, p = 0.04 and 0.04, respectively). Similar significance was demonstrated using life table analysis of mean and progression-free survival of these two groups (p = 0.05 and < 0.01, respectively). One-, 2-, and 3-year survival rates for the CSR versus the PSR group were 100%, 80%, and 40% versus 77%, 38%, and 15%, respectively. An analysis of the BMT group compared with those children treated with aggressive conventional therapy showed improvement in mean and progression-free survival.

CONCLUSIONS

Aggressive surgical resection aimed at removing all gross disease is warranted for stage IV neuroblastoma. CSR is associated with prolonged mean and progression-free survival. BMT prolongs mean and progression-free survival in children with stage IV disease. These results suggest that CSR and BMT offer increased potential for long-term remission in children with advanced neuroblastoma.

Surgical management and outcome of locoregional neuroblastoma: comparison of the Childrens Cancer Group and the international staging systems

Although precise anatomic staging is prognostically important in neuroblastoma, most widely employed staging systems remain incompatible. The International Neuroblastoma Staging System (INSS) was formulated to incorporate the basic elements of several systems to and define the significance of tumor resectability, anatomic "midline," and lymph node involvement. The authors sought to determine the applicability and value of the INSS compared with the classic Evans system. Between 1980 and 1992, 424 children with the diagnosis of local or regional neuroblastoma were entered in Childrens Cancer Group (CCG) clinical trials. The patients were assigned to Evans stage I, II, or III, by clinical and surgicopathologic assessment, and were treated uniformly by Group-wide therapy protocols. INSS stage 1, 2A, 2B, or 3, was applied, by retrospective analysis, to the children in the earlier studies, and by prospective evaluation of recent patients in the current studies. Survival and relapse-free survival (RFS) rates were determined and compared, based on age at diagnosis, extent of resection, and staging reassignment. All 87 Evans stage I patients were classified as INSS stage 1 and had a 92% 3-year RFS rate. Of the 144 Evans stage II patients, 65 also qualified as INSS stage 1 patients, with an 82% RFS rate. The other 79 stage II children remained in INSS stage 2A or 2B and had a 70% RFS rate (P = .10). Of the 193 Evans stage III patients, 24 were reassigned to INSS stage 1 (85% RFS rate) and 33 to stage 2A or 2B (65% survival rate; 61% RFS rate).(ABSTRACT TRUNCATED AT 250 WORDS)