Ganglioneuroblastoma of the posterior mediastinum: a clinicopathologic review of 80 cases

Development and validation of a prognostic nomogram for patients with ganglioneuroblastoma: A SEER-based study

Background

The objective of this study was to construct a prognostic nomogram for ganglioneuroblastoma (GNB), as the prognosis of GNB is difficult to accurately predict before therapy.

Methods

The data were collected from the Surveillance, Epidemiology, and End Results (SEER) database. The patients included in this study were randomly divided into a development group and a validation group at a ratio of 7:3. Univariate and multivariate Cox regression analyses were used to filter the variables. Receiver operating characteristic (ROC) curves and calibration curves were used to assess the nomogram. All patients were redivided into two groups based on their nomogram total points, and overall survival was compared.

Results

A total of 1194 GNB patients were retrospectively included, with 835 and 359 patients in the development and validation groups, respectively. Five independent prognostic factors, including age, primary tumor site, SEER stage, surgery and chemotherapy, were screened out and included in the nomogram. The consistency index (C-index) of the Cox regression model was 0.862 and 0.827 in the development group and the validation group, respectively. The areas under the receiver operating characteristic (ROC) curve (AUC) showed that the nomogram had good accuracy in predicting 3-, 5- and 10-year overall survival for GNB patients. The calibration curves of the nomogram showed good agreement between the predicted outcomes and the actual observations. The Kaplan-Meier (KM) survival curves revealed that patients with nomogram scores below the median had a better prognosis.

Conclusions

Age, primary tumor site, SEER stage, surgery and chemotherapy may be independent prognostic factors for GNB. We constructed a nomogram based on the SEER database to predict the prognosis of GNB, but further optimization by adding more risk factors is needed for clinical application.

High-Titer Anti-ZSCAN1 Antibodies in a Toddler Clinically Diagnosed with Apparent Rapid-Onset Obesity with Hypothalamic Dysfunction, Hypoventilation, and Autonomic Dysregulation Syndrome

Severe obesity in young children prompts for a differential diagnosis that includes syndromic conditions. Rapid-Onset Obesity with Hypothalamic Dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD) syndrome is a potentially fatal disorder characterized by rapid-onset obesity associated with hypoventilation, neural crest tumors, and endocrine and behavioral abnormalities. The etiology of ROHHAD syndrome remains to be established, but recent research has been focusing on autoimmunity. We report on a 2-year-old girl with rapid-onset obesity during the first year of life who progressed to hypoventilation and encephalitis in less than four months since the start of accelerated weight gain. The patient had a high titer of anti-ZSCAN1 antibodies (348; reference range < 40), and the increased values did not decline after acute phase treatment. Other encephalitis-related antibodies, such as the anti-NDMA antibody, were not detected. The rapid progression from obesity onset to central hypoventilation with encephalitis warns about the severe consequences of early-onset ROHHAD syndrome. These data indicate that serial measurements of anti-ZSCAN1 antibodies might be useful for the diagnosis and estimation of disease severity. Further research is needed to determine whether it can predict the clinical course of ROHHAD syndrome and whether there is any difference in antibody production between patients with and without tumors.

Anterior mediastinal neuroblastoma in an adult: an additional case of a rare tumor in an unusual location with review of the literature

Neuroblastoma is rare in the adult population, especially in thoracic or mediastinal locations, with only 25 previously reported cases. We report an additional example of primary thymic neuroblastoma in a previously asymptomatic 71-year-old man with an anterior mediastinal mass who underwent robotic excision with pericardium and adjacent lung. The tumor was a 5.2 cm partially encapsulated, white-tan and rubbery mass with grossly identifiable areas of necrosis (25%) and hemorrhage. Histologically, the specimen showed a rim of adipose tissue and residual thymic tissue with areas of cystic thymic epithelium and prominent lymphoid tissue containing Hassall's corpuscles. The tumor was composed of uniform, round cells with scant cytoplasm and small nuclei with inconspicuous nucleoli set within a background of conspicuous neuropil. Mitotic figures were easily found. By immunohistochemistry, the tumor cells expressed synaptophysin, chromogranin, NKX2.2 (diffuse, nuclear), GFAP (patchy), SMI31 (neurofilament) (focal, cytoplasmic), and TdT (diffuse, nuclear), while lacking expression of CD99, TTF-1, CK 20, MCPyV, PHOX2B, Olig2, OCT3/4, CD45, CD3 and PAX5. S100 protein was negative in the neuroblastic cells, with scattered positive cells in a vague sustentacular-like pattern. Fluorescence in situ hybridization for isochromosome 12p and EWSR1 gene rearrangement were negative. As thymic neuroblastoma is extremely rare in adults, a neuroblastic tumor of germ cell origin (either primary or metastatic) or spread from a sinonasal tract tumor should be excluded because of differing treatments and prognoses. The properties of these rare neoplasms appear similar to olfactory neuroblastoma rather than pediatric-type neuroblastoma.

Primary thymic neuroblastomas in adults: A clinicopathological and immunohistochemical study of three cases

Three cases of primary neuroblastomas presenting as anterior mediastinal tumors are presented. The patients are two women and one man between the ages of 57 and 63 year. Clinically, the patients presented with symptoms of chest pain, cough, and shortness of breath. Diagnostic imaging revealed the presence of an anterior mediastina mass. Initial biopsy was non-diagnostic in two patients, while in one patient no biopsy was obtained. Surgical resection via thoracotomy was performed in all three patients. Grossly, the tumors vary in size from 3 to 4.5 cm in greatest dimension, and they were described as well circumscribed but not encapsulated, light brown in color. Areas of hemorrhage and/or necrosis were not described. Histologically, at low power the tumors were surrounded by a rim of adipose tissue containing remnants of thymic tissue with Hassall's corpuscles. At higher magnification, the tumors show the characteristic small round cell proliferation with varying amounts of neurophil. Mitotic activity was present but not in large number. Areas of necrosis and/or hemorrhage were not identified. Immunohistochemically, the tumors show positive staining for NSE, while synaptophysin highlighted neurophil. Other markers epithelial and neuroendocrine were negative. Clinical follow-up information shows that two patients have remained alive 8 and 12 months after initial surgical resection. One patient was lost to follow-up.

Mesenchymal Tumors of the Mediastinum: An Update on Diagnostic Approach

Mesenchymal tumors of the mediastinum are a heterogenous group of rare tumors with divergent lineages. Mediastinal mesenchymal tumors are diagnostically challenging due to their diversity and morphologic overlap with nonmesenchymal lesions arising in the mediastinum. Accurate histologic diagnosis is critical for appropriate patient management and prognostication. Many mediastinal mesenchymal tumors affect distinct age groups or occur at specific mediastinal compartments. Neurogenic tumors, liposarcoma, solitary fibrous tumor, and synovial sarcoma are common mesenchymal tumors in the mediastinum. Herein, we provide an update on the diagnostic approach to mediastinal mesenchymal tumors and a review of the histologic features and differential diagnosis of common benign and malignant mesenchymal tumors of the mediastinum.

Mediastinal neuroblastoma, ganglioneuroblastoma, and ganglioneuroma: Pathology review and diagnostic approach

Neuroblastic tumors are a group of tumors of the sympathetic ganglia and adrenal medulla that derive from primordial neural crest cells. These tumors include neuroblastoma, intermixed ganglioneuroblastoma, nodular ganglioneuroblastoma, and ganglioneuroma. Neuroblastomas are the most common extracranial solid tumor arising in childhood and may occur in different anatomic sites. Neuroblastic tumors are common mesenchymal tumors of the mediastinum. Herein, we describe advances in our understanding of neuroblastic tumor biology. Pathologists should be aware of diagnostic challenges associated with these tumors to ensure correct histologic diagnosis and appropriate clinical management. We describe updated mediastinal neuroblastic tumor pathology, focusing on morphological, immunohistochemical, and molecular features and differential diagnoses.

Posterior mediastinal ganglioneuroblastoma in an adolescent: A case report and review

Ganglioneuroblastoma is an uncommon malignant tumor of the sympathetic nervous system, which is considered a disease of children with the majority of cases in patients less than four years old and it rarely occurs in adults. We encountered a very unusual case of a posterior mediastinal ganglioneuroblastoma that developed in a 17-year-old male adolescent who underwent successful excision of the mediastinal mass and remained stable postoperatively. However, he developed lumbago one year after the surgery. Radiographic findings revealed osteolytic lesions in the lumbar vertebra and histological analysis confirmed bone metastasis of ganglioneuroblastoma. Here, we report the clinical course and present a review of the literature regarding adolescent and adult onset mediastinal ganglioneuroblastoma.

Ganglioneuroblastoma in a newborn with multiple metastases: a case report

Background

Ganglioneuroblastoma is a tumor of peripheral neuroblastic tissue which occurs predominantly in the pediatric age group; it is a rare occurrence in the newborn period with only one case reported at birth to date.

Case presentation

We report the case of a newborn male baby of Brahmin ethnicity from Nepal who presented with respiratory distress and blueberry muffin skin lesions after birth. A computed tomography scan showed a mass lesion in the posterior mediastinum, which was diagnosed as ganglioneuroblastoma on fine-needle aspiration cytology. He also had metastases to multiple sites including heart, lungs, skin and brain.

Conclusions

Ganglioneuroblastoma is a rare tumor in newborns. Any newborn presenting with respiratory distress associated with blueberry muffin skin lesions should be evaluated for neuroblastic tumor.

Ganglioneuroblastoma of filum terminale

Object

Neuroblastic tumors can be classified as neuroblastoma, ganglioneuroblastoma (GNB), or ganglioneuroma. Ganglioneuroblastomas consist of small, round, immature neuroblast cells and matured ganglion cells. They are most commonly found in the mediastinum and retroperitoneum; intraspinal GNBs are extremely rare. There are only 5 cases of intraspinal GNB reported in the English literature. The authors report a case of GNB of the filum terminale. The duration of follow-up after the initial treatment is longer than in any other published reports.

Methods

A 36-year-old woman underwent resection of an intradural extramedullary tumor at L1–2 in 1993. Pathological diagnosis was GNB. After surgery, her symptoms resolved and she recovered to a normal condition. In 2009, when she was 53 years old, she presented to the hospital with paralysis of both legs. Magnetic resonance imaging suggested recurrence of spinal tumor. She underwent subtotal resection of the tumors, followed by 4 weeks of radiation therapy.

Results

Neurological symptoms improved, and, after radiation therapy, the patient was able to walk with a crutch. Histological investigation of the excised tumor indicated that it was a nodular type GNB, which was consistent with the diagnosis from the time of the initial surgery in 1993. Follow-up MRI studies showed no growth of residual tumors in the 3 years following the surgery.

Conclusions

The authors present a rare case of spinal GNB. The duration of follow-up after the initial surgery in 1993 represents the longest description of clinical course after treatment for spinal GNB.

Cerebral ganglioneuroblastoma of adult onset: two patients and a review of the literature

Ganglioneuroblastoma is a rare tumor variant of neuroblastoma. Only five cases have been observed in the adult brain, and we report here on two more adult patients with cerebral ganglioneuroblastoma. Additionally, a review was carried out on all 50 published adult cases with ganglioneuroblastoma, located in the adrenal gland (9), mediastinum (8), retroperitoneal area (7), the brain parenchyma (7), or the spinal cord (3). Median age at onset was 39 years, and 52% of patients were female. For extracranial locations, treatment usually consisted of surgery followed by radiotherapy and adjuvant chemotherapy. Of the cases with cerebral involvement only one patient did not receive any treatment. The other six patients underwent surgical resection and radiation therapy, in four cases followed by chemotherapy with temozolomide. The median survival of cerebral ganglioneuroblastomas was 14 months and did not differ from the whole group of ganglioneuroblastomas (12 months). For cerebral ganglioneuroblastoma, the preferred regimen would seem to be neurosurgical removal, followed by chemoradiotherapy including temozolomide.

Tumors of the mediastinum and chest wall

Primary tumors of the mediastinum and chest wall comprise a diverse group of conditions with a wide range of presentations. A thorough knowledge of thoracic anatomy is essential for appropriate diagnosis and treatment. Given their proximity to critical structures, treatment of these tumors is often challenging. Although surgery is the mainstay of therapy for most mediastinal and chest wall tumors, a multidisciplinary approach is valuable in many cases.

[Neurogenic tumors of the mediastinum in adults]

In adults, mediastinal neurogenic tumours constitute the third group of mediastinal tumours, after thymomas and lymphomas. If the group of neurogenic tumour is frequent, each type of tumour is relatively unusual in everyday's clinic. Among them, nerve sheath tumours are the more frequent, followed by tumour of the autonomic system. Askin tumour remains uncommon. Treatment of this tumour requires complete preoperative work-up, including standard radiography, CT-scan, MRI, and sometimes nuclear imaging. In most cases, the treatment is based on surgical resection, and may be associated with radiotherapy or chemotherapy in case of malignant tumour or incomplete resection. Better understanding of these tumours, including their molecular abnormalities, may lead to new changes in their classifications, and to their management.

[Verner-Morrison syndrome revealing a ganglioneuroblastoma in an adult]

Most vasoactive intestinal peptide (VIP)-producing tumours are from epithelial origin. Tumours derived from the sympathetic nervous system can produce VIP as well. We report here the case of a Verner-Morrison syndrome in a 40-year-old woman revealing a metastatic ganglioneuroblastoma. The diarrhea resolved after the resection of primary tumour and liver metastases. Neuroblastic tumours occur extremely rarely in adults. Thus, the management of these tumours is poorly defined in adults.

Surgical treatment of malignant mediastinal neurogenic tumors in children

INTRODUCTION

The aim of this study was to identify the role of surgical resection in the treatment of malignant mediastinal neurogenic tumors in children.

MATERIALS AND METHODS

Thirty-eight consecutive children, who underwent surgical resection of a malignant mediastinal neurogenic tumor between 1986 and 2004, were included in this study. The tumor cell types were neuroblastoma in 23 patients (60.5%), ganglioneuroblastoma in 14 (36.8%), and malignant neuroepithelioma in 1 (2.6%). Surgery was performed for curative resection in localized tumors and salvage resection of residual mediastinal masses after chemotherapy in stage IV tumors. Of the 16 patients (42.1%) who underwent salvage resection, 14 had neuroblastoma and 2 ganglioneuroblastoma.

RESULTS

Mean patient age was 3.4+/-3.0 years (1 month-13 years) and 26 patients (68.4%) were symptomatic at presentation. Adjacent structure invasion was found in eight patients (21.1%), invasion of chest wall in four, heart and vena cava in two, lung in one, and chest wall and lung in one. Complete gross resection was possible in 30 patients (78.9%) and there was no surgical mortality. Surgical morbidity occurred in 10 patients (26.3%) and Horner's syndrome was the most frequent complication (n=7). The 5-year survival was 95.2% for a localized tumor and 52.5% for a stage IV tumor (p=0.004). The significant risk factors of long-term survival were adjacent structure invasion (p=0.002) and a stage IV tumor (p=0.002) by multivariate Cox regression analysis.

CONCLUSIONS

Surgical resection of localized malignant mediastinal neurogenic tumor in children showed good long-term survival, and salvage operations after chemotherapy showed acceptable long-term survival.

Actin-binding protein filamin A is displayed on the surface of human neuroblastoma cells

We previously reported the identification of natural human IgM antibodies, which recognize a M(r) 260 000 surface protein (NB-p260) and induce both complement-mediated cytotoxicity and apoptosis of human neuroblastoma cells. NB-p260 was shown to belong to the family of filamin proteins. Filamin A is a high molecular weight actin-binding protein, previously thought to be only located intracellularly. Here we show that NB cells as well as three NB-unrelated human cell lines express filamin A also on the cell surface. Our findings suggest new biological functions for filamins, including a role as mediators in anti-NB IgM-induced apoptosis, and they add to the growing body of evidence of the interaction of cytoskeletal proteins with the extracellular matrix.

Tumors of the mediastinum

Tumors of the mediastinum represent a wide diversity of disease states. The location and composition of a mass is critical to narrowing the differential diagnosis. The most common causes of an anterior mediastinal mass include the following: thymoma; teratoma; thyroid disease; and lymphoma. Masses of the middle mediastinum are typically congenital cysts, including foregut and pericardial cysts, while those that arise in the posterior mediastinum are often neurogenic tumors. The clinical sequelae of mediastinal masses can range from being asymptomatic to producing symptoms of cough, chest pain, and dyspnea. This article will review the anatomy of the mediastinum as well as the different clinical, radiographic, and prognostic features, and therapeutic options of the most commonly encountered masses.

Obstructive jaundice as a presentation of ganglioneuroblastoma

Obstructive jaundice is a rare symptom in the neuroblastic tumor. Seven cases of obstructive jaundice caused by neuroblastoma have been reported, and only three of these patients had the symptom at the onset of the disease. The authors report a case of ganglioneuroblastoma presenting with obstructive jaundice as a rare initial feature. After the histologic diagnosis with open biopsy, chemotherapy consisting of cisplatin, pirarubicin hydrochloride/doxorubicin, cyclophosphamide, and vincristine was given. The treatment resulted in reduction in the tumor size and relief of the obstructive jaundice. Complete resection of the tumor was possible after five courses of chemotherapy.

Revision of the International Neuroblastoma Pathology Classification: confirmation of favorable and unfavorable prognostic subsets in ganglioneuroblastoma, nodular

BACKGROUND

Ganglioneuroblastoma, nodular (GNBn) comprises one of the categories of peripheral neuroblastic tumors. All tumors in this category, according to the original International Neuroblastoma Pathology Classification, are classified into an unfavorable histology group. Subsequently, it has been reported that GNBn can be divided into two prognostic subsets, a favorable subset (FS) and an unfavorable subset (US).

METHODS

Histology slides from 70 patients who were enrolled in Children's Cancer Group studies 3881 and 3891 and who had a diagnosis of GNBn were reviewed jointly by the members of International Neuroblastoma Pathology Committee (INPC): 1) to confirm the diagnosis of GNBn, 2) to identify the FS and US by applying the same age-linked criteria that were used to distinguish the favorable histology group and unfavorable histology group in conventional neuroblastoma tumors from the neuroblastomatous component of GNBn tumors, and 3) to verify the significant prognostic difference between these two subsets. The patients had been used in a previous study, and survival data for the patients were updated since the time of their last report.

RESULTS

The review clarified and illustrated morphologic characteristics of classical GNBn and it variants. The diagnosis of GNBn was confirmed in 67 of 70 patients. There were 22 patients with GNBn in the FS and 45 patients with GNBn in the US. The estimated survival differences between the FS and US patients with GNBn were statistically significant (8-year event free survival rate: 86.1% vs. 32.2%; P = 0.0003; overall survival rate: 90.5% vs. 33.2%; P = 0.0003).

CONCLUSIONS

This study confirmed the recently defined prognostic subsets of GNBn. The INPC proposes to modify the International Neuroblastoma Pathology Classification by distinguishing the FS and the US among patients with GNBn tumors.

A dopamine-secreting pheochromocytoma

We describe a patient with pheochromocytoma, which secretes dopamine. He was admitted to hospital because of chronic diarrhea. After surgical resection of the tumor, dramatic cessation of the diarrhea and blood pressure elevation were observed. Decreased expression of dopamine beta-hydroxylase in the tumor was considered a possible mechanism of producing a pathophysiological concentration of dopamine. This case shows that excessive excretion of dopamine, a vasodilative hormone, may affect blood pressure.

Primary pulmonary ganglioneuroblastoma: a clinicopathologic and immunohistochemical study of two cases

We present two patients with primary ganglioneuroblastoma involving the bronchial wall. The first, a 38-year-old woman, presented with signs and symptoms suggestive of multiple endocrine neoplasia, including gastric ulceration and hypercalcemia. Chest radiographic studies revealed a 3-cm nodule in the hilus of the right lung and two less-pronounced lesions in the periphery of the right lung. The second, a 20-year-old asymptomatic woman, was evaluated for a solitary mass in the upper lobe of the left lung that was peribronchial and that impinged on the lumen of a bronchus. Grossly, both neoplasms extended from bronchi, were well-circumscribed, firm, tan or white, and homogeneous, and measured 5 x 5 cm and 3 x 3 cm, respectively. Histologically, both tumors were characterized by neuroblastoma with areas of neuropil and multifocal areas of ganglion cells. Immunohistochemical studies performed in one case showed focal staining for neurofilament protein and S-100 protein and diffuse staining for neuron-specific enolase. Follow-up information showed that one patient died a few days after admission to the hospital; the second patient has remained well and without evidence of recurrence or metastases 1 year after initial diagnosis. These two cases confirm that ganglioneuroblastoma can occur as a primary pulmonary tumor in adults, presumably arising from sympathetic ganglia of the bronchus.

Primary mediastinal tumors: part II. Tumors of the middle and posterior mediastinum

Lymphoma, mediastinal cysts, and neurogenic neoplasms are the most common primary middle and posterior mediastinal tumors. Lymphoma may involve the anterior, middle and/or posterior mediastinum, frequently as lymphadenopathy or as a discrete mass. Foregut cysts are common congenital mediastinal cysts and frequently arise in the middle mediastinum. Pericardial cysts are rare. Schwannoma and neurofibroma are benign peripheral nerve neoplasms, represent the most common mediastinal neurogenic tumors, and rarely degenerate into malignant tumors of nerve sheath origin. Sympathetic ganglia tumors include benign ganglioneuroma and malignant ganglioneuroblastoma and neuroblastoma. Lateral thoracic meningocele is a rare cause of a posterior mediastinal mass.

Bilateral intraabdominal ganglioneuroblastoma in an adult

Ganglioneuroblastoma is an unusual tumour in an adult. We present a case of bilateral intraabdominal ganglioneuroblastoma in an adult patient. The two tumours had different morphological features and origins. The appearances on ultrasound, CT and MRI are discussed. To the best of our knowledge, this is the first case of bilateral ganglioneuroblastoma reported in an adult patient with ultrasound, CT and MRI findings.

A cDNA encoding a putative 37 kDa leucine-rich repeat (LRR) protein, p37NB, isolated from S-type neuroblastoma cell has a differential tissue distribution

In human neuroblastoma cells in culture, three morphologically distinct types of cells are observed: neuroblastic N-type cells, Schwannian S-type cells, and intermediate I-type cells. To investigate the differences in gene expression between N-type LA1-55N and S-type LA1-5S cells of the human neuroblastoma cell line LA-N-1, we constructed a subtractive cDNA library from LA1-5S cells. One of the genes that are expressed more in S-type cells than in N-type cells was identified as previously undescribed and is the focus of this report. We cloned a full-length cDNA of this gene, p37NB, and determined its sequence. A homology search against the GenBank database showed that this was from a novel gene encoding a putative 37 kDa leucine-rich repeat (LRR) protein. Northern blot hybridization and RT-PCR showed that the p37NB gene was differentially expressed in S-type compared to N-type cells of a few neuroblastoma cell lines.

Herpetic viruses and spontaneous recovery in melanoma

The malignant melanoma may display extremely variable forms of development, from clinical forms with a lethal course to the unforeseeable situations of spontaneous cures. The basic immunotherapeutic procedures, as well as hypotheses regarding the mechanisms involved in courses towards spontaneous regressions, are presented. Since viruses of the herpes genus are involved in the mechanisms assumed to be at the basis of spontaneous regressions, it is suggested that these viruses (selected strains) be used in the clinic, in order to check the advanced hypothesis, an opportunity which could permit to study also the very probable therapeutic alternative offered by this virus, namely the association of the well-known immunotherapeutic methods.

Cytomorphology of some uncommon tumors of childhood and adolescence

With the advent of newer adjuvant chemotherapeutic regimes resulting in dramatic improvement in survival, it is mandatory to obtain quick correct diagnosis, which is provided by fine needle aspiration cytology (FNAC). Cytology of childhood tumors was studied to find any distinguishing features, which would help in arriving at a diagnosis. Cytomorphology of 386 childhood and adolescent (0-19 years) tumors diagnosed between 1984 and 1993 were studied. Lipoma was the commonest benign tumor in 0-14 years age group. Fibroadenoma of the breast was the common benign tumor in adolescent (10-19 yrs) girls and pleomorphic adenoma in adolescent (15-19 yrs) boys. Wilms' tumor was the most frequent solid malignant tumor in preschool children and Hodgkin lymphoma, mixed cellularity in the school going age (5-19 yrs). Malignant tumors were more frequent (199). In addition, some rare malignancies like hepatoblastoma, meningioma, ganglioneuroblastoma, adrenocortical carcinoma, clear cell sarcoma kidney and malignant histiocytosis were diagnosed. The cytological features and the differential diagnoses are discussed. It is possible to diagnose these uncommon tumors if particular attention is paid to the distinguishing cytomorphological features in correlation with clinicoradiological findings and cytochemistry.

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.

Neuroblastoma of the anterior mediastinum in an 80-year-old woman

A 7-cm anterior mediastinal tumor in an 80-year-old woman was found by light and electron microscopy to be a neuroblastoma. Immunoreactivity for neuron-specific enolase, synaptophysin, and chromogranin supported the diagnosis. Neuroblastoma is an uncommon tumor in adults and we are not aware of a previous report of such a tumor in a patient of this age.

Evidence for molecular heterogeneity in human ganglioneuroblastoma

Ganglioneuroblastomas are tumors of sympathetic cell origin that contain both primitive neuroblastomatous and mature ganglioneuromatous elements. It is thought that these tumors arise from a single cellular clone and that the morphologically distinct components of ganglioneuroblastomas represent cells in different stages of differentiation. Two pathologic variants of this tumor, composite and diffuse, have been described; metastasis is more commonly seen with composite ganglioneuroblastomas. We analyzed a composite ganglioneuroblastoma for N-myc copy number at initial resection and 2 years later after progressive disease. In the second sample the more differentiated portion of the tumor was analyzed separately from the neuroblastic foci for N-myc copy number and DNA ploidy. The DNA content and N-myc copy number differed in the two morphologically discrete areas of the tumor, suggesting that at least two clones were present. More composite ganglioneuroblastomas need to be examined to determine whether these tumors are largely composed of tumor cell populations with molecular heterogeneity.

Spinal ganglioneuroblastoma--complete response to chemotherapy alone

Ganglioneuroblastoma in the spinal region is rare, the treatment of choice being surgical excision. We present a 21 year old male who was diagnosed to have this condition in the dorsolumbar spinal region. The tumour was extending intraspinally and was unresectable. Combination chemotherapy with Adriamycin (doxorubicin hydrochloride), vincristine, cyclophosphamide, etoposide, ifosfamide and cisplatin resulted in histologically proven complete remission. No radiotherapy or curative resection was done. The patient is alive without evidence of disease 24 months later. Never before has chemotherapy been successfully used as the sole modality of treatment in this condition. Our report raises important questions about the management of this rare condition, particularly in a situation of unresectability.

Primary mediastinal neoplasms (other than thymoma)

Primary mediastinal neoplasms encompass a long list of histologically diverse lesions that can arise from a wide variety of mediastinal structures. Recent advances in diagnostic techniques have considerably enhanced the evaluation of the mediastinum with use of noninvasive or minimally invasive procedures. In adults, most primary mediastinal neoplasms can be classified in one of four categories: thymus-derived neoplasms, neurogenic tumors, lymphomas, or germ cell neoplasms. In children, neurogenic tumors (especially neuroblastomas) and lymphomas are most frequently encountered. Because of the presence of many vital structures in the confined thoracic cavity, even benign mediastinal neoplasms can cause severe symptoms from the mass effect and therefore warrant a carefully planned management strategy. With modern therapeutic and surgical interventions, associated morbidity and mortality can often be substantially decreased.

In vitro differentiation of human neuroblastoma cells induced by sodium phenylacetate

Sodium phenylacetate (NaPA) at concentrations ranging from 2 to 6 mM stimulated morphological differentiation of two human neuroblastoma cell lines IMR-32 and UKF-NB-3. These concentrations inhibited growth and DNA synthesis of the cells in a dose dependent manner without significant effect on cell viability. The differentiated cells showed pseudoganglia formation and extension of cellular processes. The morphological differentiation in both cell lines was accompanied by decreased expression of N-myc oncoprotein. These results suggest that NaPA at concentrations, which have been achieved in humans with no significant adverse effects, promotes differentiation of cultured human neuroblastoma cells in association with the reduced expression of the malignant phenotype.

Systematization of primary histopathologic and fine-needle aspiration cytologic features and description of unusual histopathologic features of neuroblastic tumors: a report from the Pediatric Oncology Group

On the basis of a detailed review of the primary histopathologic features of 239 cases and the fine-needle aspiration cytologic features of seven cases, a systematized schema of differentiation, progressive maturation and organization, and biologic behavior in neuroblastic tumors (NTs) is presented. The differentiation is of the gangliocytic and schwannian lineages. Maturation occurs in differentiating neuroblasts, leading to the formation of various stages of ganglion cells and Schwann cells. Organization is characterized by nesting pattern, rosette formation, parallel arrangement of neuropil, and alignment of Schwann cells along the neurites. According to this schema the NTs can be arranged in the following order: undifferentiated, poorly differentiated, and differentiating neuroblastoma; nodular, intermixed, and borderline ganglioneuroblastoma; and ganglioneuroma. Formulation of such a schema is helpful in gaining a better understanding of the complex pathologic features and in defining the criteria for various types of NTs. Therefore, the schema also would be helpful in achieving uniformity and reproducibility of the diagnosis of various types of NTs. Previously unreported features related to shape, size, nucleus, and cytoplasm of neuroblasts; secondary changes and patterns; changes in the fibrovascular septa; and other morphologic aspects of NTs and features (such as large tumor cells, karyorrhectic cells in fine-needle aspiration biopsy, tumor giant cells, anaplasia, and nesting pattern of tumor cells that have not been sufficiently emphasized) also are described. The importance of these previously unreported and insufficiently emphasized features relates to the histologic and cytologic diagnosis of NTs. For example, some of the features, such as starry sky appearance and spindle-shaped neuroblasts, may be misleading if seen in a small biopsy specimen. Others, such as tumor giant cells resembling ganglion cells and nesting pattern, will provide clues to the correct diagnosis. Some of the features, such as sclerosing pattern, hyalinization, and dense lymphoplasmacytic infiltration, may be related to the phenomenon of regression exhibited by neuroblastomas.

Posterior mediastinal masses

Solid mediastinal masses in infancy and childhood occur most frequently in the posterior mediastinum. From 1972 to 1989, 63 patients presented with a posterior mediastinal mass. The median age at diagnosis was 6 years (range, 1 day to 26 years). Thirty patients were female. Forty-five percent of the patients presented with respiratory symptoms or chest pain; 13% had neurologic symptoms, one half of which were related to spinal cord compression; and 5% had a palpable mass. In 32% of patients the mass was an incidental finding. The tumors were of neurogenic origin in 89% of patients, of which neuroblastoma was the most common. Of all patients with posterior mediastinal masses, 60% had malignant tumors. Median follow-up for 62 of 63 evaluable patients was 45 months (range, 1 to 289 months). One patient was lost to follow-up. Of the 62 patients followed, 84% are alive and free of disease. All but 4 of the 32 patients with neuroblastoma are alive and free of disease with a median follow-up of 73 months (range, 7 to 289 months). Patients with neuroblastoma who were diagnosed in the first year of life had a significantly better survival pattern than those presenting after the first year. There were seven deaths in the series: four from neuroblastoma, two from primitive neuroectodermal tumor, and one from malignant schwannoma. Preoperative diagnostic evaluation of a posterior mediastinal mass should include posteroanterior and lateral chest roentgenograms, and either CT or MRI of the chest and abdomen to assess the extent of the mass.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of cyclic AMP and serum factors upon expression of a retinoid-responsive gene in neuroblastoma cells

Cyclic AMP can profoundly influence the growth and differentiation of neuronal cells in culture. In this study, the relationship between this second messenger signal transduction pathway, cell differentiation, and the expression of a retinoid-responsive, thymosin beta-10 gene was examined. Thymosin beta-10 and cognate mRNA were expressed at high levels in actively proliferating rat B104 neuroblastoma cells cultured in medium containing 10% FCS. These cells were induced to differentiate in the presence of the cAMP analog N6, 2'-O-dibutyryladenosine 3':5'-cyclic monophosphate (Bt2-cAMP) (1 mM) and the phosphodiesterase inhibitor 3-isobutyl-1-methylxanthine (IBMX) (100 microM). Expression of thymosin beta-10 mRNA was markedly inhibited (greater than 90% and 70%, respectively) by these compounds. Addition of sodium butyrate (NaB, 1 mM) indicated that at least part of the inhibitory actions of Bt2-cAMP were due to esterase-induced release of butyrate from this compound. Adenosine (50 microM), a metabolic precursor to endogenous cyclic AMP, also inhibited accumulation of thymosin beta-10 mRNA (to less than 70% of control levels). The inhibitory action of Bt2-cAMP upon thymosin beta-10 mRNA levels was time dependent; levels were inhibited by greater than 50% 24 hours after addition of the cAMP analog and by greater than 90% after 72 hours. Serum starvation (0.2% FCS for seven days) provoked a marked increase in neurite out-growth; this morphological change was also accompanied by a modest inhibition of thymosin beta-10 mRNA accumulation. These findings together with previous observations imply that both cyclic AMP-dependent and retinoid-responsive mechanisms coordinate thymosin beta-10 gene expression during neuroembryogenesis.

Recommendations for modification of terminology of neuroblastic tumors and prognostic significance of Shimada classification. A clinicopathologic study of 213 cases from the Pediatric Oncology Group

To develop consistency in terminology and pathologic criteria, the authors reviewed the literature and 213 cases of neuroblastic tumors (NT) registered with Pediatric Oncology Group (POG) protocols 8104 and 8441. The patients were given standardized therapy stratified according to POG stage and patient age, and four or more histologic sections of primary tumor resected before therapy were available in each of these 213 cases. All stages were represented. The recommended nomenclature combines conventional terms and criteria with those used by Bove and McAdams and Shimada et al. The main features of the recommended nomenclature are as follows: (1) the terms neuroblastoma (NB) and ganglioneuroblastoma (GNB) are retained instead of stroma-poor NB and stroma-rich NB, recommended by Shimada et al.; (2) undifferentiated NB is considered a subtype separate from poorly differentiated NB; and (3) the term GNB is used only when there is a predominant ganglioneuromatous component admixed with the minor neuroblastomatous component. With the use of these criteria and terms, the Shimada classification was determined in the 213 cases. The results showed that, even after stratification for age, POG stage, and primary site, there is a statistically significant difference in survival rate between favorable histologic and unfavorable histologic prognostic subgroups. The authors recommend that definitive prognostic categorization of an NT according to Shimada classification should be done only when adequate histologic material is available from a primary tumor resected before any other therapy. Categorization done on histologic material from small biopsy specimens, previously treated primary tumors, or metastatic sites should be considered tentative.

Characterization of 5-hydroxytryptamine 1A-like binding sites in human ganglioneuroblastoma

Tumors derived from primitive neural crest cells are the most common malignant neoplasms of infancy and early childhood. We recently reported [3H]8-hydroxy-2-(di-n-propylamino)tetralin specific binding in one such tumor, the ganglioneuroblastoma. We now characterize this binding and compare it with 5-hydroxytryptamine 1A (5-HT1A) sites in human and rat cortex. In competition studies, the rank order of drug affinities was suggestive of a 5-HT1A binding site: 5-HT greater than 8-OH-DPAT, RU24969 greater than methysergide, methiothepin, 1-2,5-dimethoxy-4-iodophenyl aminopropane (DOI), ketanserin greater than mianserin. Regression analysis showed a correlation with drug affinities in human cortex. [3H]8-OH-DPAT binding was saturable and linear with absence of cooperativity, indicative of a single population of sites. The density of sites in ganglioneuroblastoma was two- to four-fold less than in human or rat cortex. [3H]5-HT binding also identified 5-HT1 binding sites in ganglioneuroblastoma, comparable in density to [3H]8-OH-DPAT-labelled sites. No specific binding was found using [3H]paroxetine, [3H]DOB, [3H]ketanserin, or [3H]mesulergine to label other types of 5-HT recognition sites. These data confirm the presence of a 5-HT1A-like binding site in human ganglioneuroblastoma.

Expression of integrin receptors on 45 clinical neuroblastoma specimens

Immunohistological expression of integrins has been analyzed on 45 neuroblastoma specimens representative of the different clinical and histological forms of the tumor. None of the specimens expressed the alpha 5 chain of the integrins. The beta 1 chain was expressed on all specimens, the alpha 1 chain on 44 specimens and the alpha 3 chain on 42; the 4 specimens which lacked alpha 1 or alpha 3 were stage-4 neuroblastomas. The alpha 2 chain was expressed on 18 specimens, and the alpha 6 chain on 17; 15 reacted with both. Their reactivity was related to the maturation of the tumor rather than the stage of the disease: they were expressed on low-grade, well-differentiated specimens; stage 3-4 neuroblastoma specimens analyzed at diagnosis were negative, but usually expressed both chains when analyzed after in vivo differentiation by chemotherapy. alpha v reacted with 18 specimens and beta 3 with 12, without strict relation with the stage of the disease and/or its degree of differentiation; 9 well-differentiated specimens expressed the beta 4 chain; only 4 well-differentiated specimens expressed the alpha 4 chain. The 4 specimens which lacked alpha 1-beta 1 or alpha 3-beta 1 expression had n-myc amplification, whereas those which expressed either alpha 4, beta 4, beta 3 or alpha v had no amplification. Furthermore, the expression of the 3 heterodimers alpha 4-beta 1, alpha v-beta 3 and alpha 6-beta 4 was essentially observed on primary tumors which developed in the mediastinum. The expression of alpha 2-beta 1 and alpha 6-beta 1 was observed on both n-myc-positive and -negative specimens. beta 1 and alpha 3 were diffusely expressed on all counterparts of these tumors, from undifferentiated neuroblasts to ganglion and Schwann cells. The alpha 1 chain reacted with undifferentiated and intermediate neuroblasts as well as with Schwann cells, but ganglion cells were negative. alpha 2 and alpha 6 chains were negative on undifferentiated neuroblasts, variably expressed on intermediate neuroblasts, and restricted to Schwann cells in ganglioneuroma. The expression of alpha 4 and beta 4 was restricted to Schwann cells. alpha v and beta 3 occasionally reacted with undifferentiated and intermediate neuroblasts; alpha v was strongly positive on Schwann cells but negative on ganglion cells, whereas beta 3 was positive on both neuronal and non-neuronal populations.

Mediastinal masses in childhood: a review from a paediatric pathologist's point of view

From 1970 to 1989, 121 children with mediastinal masses of various sorts were seen in the Department of Pathology, Royal Children's Hospital, Melbourne. The series is considered representative of the true incidence of these conditions in the state of Victoria, which had an average paediatric population during the time of this series of 900,000 children. The commonest cause of a mediastinal mass was NHL (36 cases). This was followed by HD (24 cases), then neuroblastoma and ganglioneuroma (16 and 9 cases respectively), duplication cysts (10 cases), teratomas (7 cases), neurofibroma (4 cases) and lymphangioma (3 cases). A great variety of rare conditions made up the remainder of the series and included mediastinal abscess, thymic cyst, pericardial cyst, accessory lobe of lung, plasma cell granuloma, fibromatosis, paravertebral Ewing's tumour, carcinoid tumour and neurofibrosarcoma. Presentation of the children with NHL was often acute with respiratory distress, while the child with HD was usually older and symptoms were more often systemic than local. The surgeon's role in diagnosis of these most frequently encountered mediastinal masses can be crucial and biopsy when indicated must be carried out with great care to produce material that is adequate for diagnosis and for the performance of cell marker studies and chromosome analysis. Neuroblastoma (NBL) and ganglioneuroma (GN) together were the third largest group. Children with neuroblastoma were usually young; 15 of the 18 cases were less than 2 years old. One-third of the infants with neuroblastoma presented with paraplegia and one-third with respiratory symptoms including wheeze, stridor and respiratory difficulty. Three children had Horner's syndrome. Prognosis of children with thoracic neuroblastoma is very good and contrasts with the poor outlook for those with abdominal neuroblastoma. Stage at presentation is probably the most important single prognostic variable. Ganglioneuroma presents at a later age than neuroblastoma and symptoms may be present for a long time or may be completely absent. Catecholamines, usually raised in neuroblastoma, are mostly normal in ganglioneuroma. Duplication cysts were the next most frequent group. Symptoms can often be acute and life threatening, although in three of our ten cases the cyst was an incidental finding on chest X-ray. However, only three of our patients had a normal respiratory examination. Teratomas were usually large and more often benign than malignant. Excision is the mandatory treatment and is usually curative. Although teratomas in young infants are often cellular and composed of many immature tissue types, their behaviour is benign.(ABSTRACT TRUNCATED AT 400 WORDS)

Primary renal ganglioneuroblastoma in an adult

A rare case of primary renal ganglioneuroblastoma in a 68 year old female is presented. The authors believe this to be the first case report of this tumour arising in the kidney of an adult patient.

Histopathologic features of composite ganglioneuroblastoma. Immunohistochemical distinction of the stromal component is related to prognosis

Histopathologic features of 18 cases of composite ganglioneuroblastoma (CGNB) were studied with immunohistochemical staining techniques using antibodies against S-100 protein (S-100), ferritin (FER), and leukocytic common antigen (LCA). Cases of CGNB were divided on the basis of the morphologic features of neuroblastic elements into three prognostic subgroups: "Type A Intermixed," having individual microscopic nests of neuroblasts (N = 4, 100% survival); "Type B Intermixed," having microscopic aggregates of multiple neuroblastic nests (N = 6, 67% survival); and "Nodular," having grossly visible nodule(s) of neuroblastic proliferation (N = 8, 0% survival). Survival rates are significantly different for the prognostic subgroups (P less than 0.025). Each prognostic subgroup demonstrated an immunohistochemically distinct pattern of stromal cell composition in the neuroblastic elements: Type A Intermixed had numerous S-100 cells and no FER cells, Type B Intermixed contained many S-100 cells and a moderate number of FER cells, and Nodular had few S-100 cells with many FER cells. The S-100 and FER scores, determined by counting the positive cells through a line sampling method, differed significantly between these prognostic subgroups. Lymphocytic aggregations in tumor tissue evaluated by volumetric assessment with LCA staining, on the other hand, showed no contribution in predicting the outcome of the patients. There was also an inverse relationship between S-100 and FER score, suggesting a relationship between the relative predominance of these stromal cell types, tumor histopathologic features, and the biologic behavior of CGNB.