Prognostic factors in neuroblastomas treated in Denmark from 1943 to 1980. A statistical estimate of prognosis based on 253 cases

Identification of patient subgroups with markedly disparate rates of MYCN amplification in neuroblastoma: A report from the International Neuroblastoma Risk Group project

BACKGROUND

MYCN gene amplification (MNA) is a hallmark of aggressive neuroblastoma. This study was performed to determine univariate and multivariate predictors of tumor MNA.

METHODS

Data from the International Neuroblastoma Risk Group were analyzed for a subset of 7102 patients with known MYCN status. Chi-square testing and logistic regression were used to identify univariate and multivariate predictors of MYCN status. Recursive partitioning was used to identify groups of patients with maximal differences in rates of MNA.

RESULTS

All clinical features (age ≥ 18 months, high ferritin levels, high lactate dehydrogenase [LDH] levels, International Neuroblastoma Staging System stage 4, and adrenal sites) and pathological/biological features (DNA index ≤ 1, high mitosis-karyorrhexis index [MKI], undifferentiated/poorly differentiated grade, unfavorable histology according to the International Neuroblastoma Pathology Classification, and segmental chromosomal aberrations [SCAs]) were significantly associated with MNA. LDH (odds ratio [OR], 8.4; P < .001) and chromosomal 1p loss of heterozygosity (OR, 19.8; P < .001) were the clinical and biological variables, respectively, most strongly associated with MNA. In logistic regression, all variables except chromosome 17q aberration and pooled SCAs were independently predictive of MNA. Recursive partitioning identified subgroups with disparate rates of MNA, including subgroups with 85.7% MNA (patients with high LDH levels who had poorly differentiated adrenal tumors with chromosome 1p deletion) and 0.6% MNA (localized tumors having hyperdiploidy and low MKIs and lacking chromosome 1p aberrations).

CONCLUSIONS

MNA is strongly associated with other clinical and biological variables in neuroblastoma. Recursive partitioning has identified subgroups of neuroblastoma patients with highly disparate rates of MNA. These findings can be used to inform investigations of molecular mechanisms of MNA.

Clinico-epidemiology of neuroblastoma in north east Egypt: A 5-year multicenter study

Neuroblastoma, an embryonal malignancy of the sympathetic nervous system, is the most frequent extracranial solid tumor The clinico-epidemiological features of neuroblastoma in infants and children were investigated between January 2005 and January 2010 at the Pediatric Oncology units of Mansoura, Zagazig, and Tanta University Children's Hospitals (Egypt). Of 142 cases of neuroblastoma, 10 were omitted from the study due to defective data. The median age of the patients was 30 months, with 75.8% aged ≥1 year and 24.2% aged <1 year at time of diagnosis. The male-to-female ratio was 1.06. Suprarenal glands were the most common primary tumor site (72.7%). The majority of the patients (76.7%) had stage IV disease. Favorable pathology was observed in 43.8% of patients, while 56.2% exhibited unfavorable pathology. The estimated survival rate of patients was 30.7±10.0%, and mean survival time was 24.2±5.2 months. The rate of mortality was 28.6% for patients aged <1 year, and 81.8% for those aged ≥1 year (P=0.005). For patients with favorable pathology, the rate of mortality was significantly lower (28.6%) compared with that of patients with unfavorable pathology (77.8%; P=0.049). Although the association between outcome and each of the primary tumor sites, children's oncology group risk and gender was statistically insignificant, a large effect size was identified between outcome and primary tumor site, as well as children's oncology group risk and a medium effect size was identified between outcome and gender. Additionally, an age of ≥1 year was associated with unfavorable pathology (P=0.024), stage IV disease (P=0.026) and a suprarenal primary tumor site (P=0.001).

Does aggressive surgical resection improve survival in advanced stage 3 and 4 neuroblastoma? A systematic review and meta-analysis

The role of surgery in the management of advanced staged neuroblastoma (NBL) is controversial. A systematic review and meta-analysis is reported to address robust evidence for curative "gross total tumor resection" (GTR) in Stage 3 and Stage 4 neuroblastoma. Studies were identified using Medline, Embase, and Cochrane databases using pre-specified search terms. Primary outcomes were 5-year overall (OS) and disease-free survival (DFS) after GTR and subtotal resection (STR) in Stage 3 or 4 NBL. Data were analyzed using Review Manager. The Mantel-Haenszel method and a random effects model was utilized to calculate odds ratios (95% CI). Fifteen studies (five Stage 3 and 13 Stage 4) met full inclusion criteria. The pooled odds ratio for 5 year OS in Stage 3 following GTR compared to STR was 2.4 (95% CI 1.19-4.85). In Stage 4 disease, the pooled odds ratio for 5 year overall survival (OS) following GTR compared to STR was 1.65 (95% CI 0.96-1.91); a pooled odds ratio for 5 year DFS following GTR compared to STR was 1.55 (95% CI 1.12-2.14). A clear survival benefit is shown for GTR over STR in Stage 3 NBL only. Though some advantage can be demonstrated for GTR as defined by DFS in Stage 4 NBL GTR did not significantly improve OS in Stage 4 disease.

Clinical, biologic, and prognostic differences on the basis of primary tumor site in neuroblastoma: a report from the international neuroblastoma risk group project

PURPOSE

Neuroblastoma (NB) is a heterogeneous tumor arising from sympathetic tissues. The impact of primary tumor site in influencing the heterogeneity of NB remains unclear.

PATIENTS AND METHODS

Children younger than age 21 years diagnosed with NB or ganglioneuroblastoma between 1990 and 2002 and with known primary site were identified from the International Neuroblastoma Risk Group database. Data were compared between sites with respect to clinical and biologic features, as well as event-free survival (EFS) and overall survival (OS).

RESULTS

Among 8,369 children, 47% had adrenal tumors. All evaluated clinical and biologic variables differed statistically between primary sites. The features that were > 10% discrepant between sites were stage 4 disease, MYCN amplification, elevated ferritin, elevated lactate dehydrogenase, and segmental chromosomal aberrations, all of which were more frequent in adrenal versus nonadrenal tumors (P < .001). Adrenal tumors were more likely than nonadrenal tumors (adjusted odds ratio, 2.09; 95% CI, 1.67 to 2.63; P < .001) and thoracic tumors were less likely than nonthoracic tumors (adjusted odds ratio, 0.20; 95% CI, 0.11 to 0.39; P < .001) to have MYCN amplification after controlling for age, stage, and histologic grade. EFS and OS differed significantly according to the primary site (P < .001 for both comparisons). After controlling for age, MYCN status, and stage, patients with adrenal tumors had higher risk for events (hazard ratio, 1.13 compared with nonadrenal tumors; 95% CI, 1.03 to 1.23; P = .008), and patients with thoracic tumors had lower risk for events (HR, 0.79 compared with nonthoracic; 95% CI, 0.67 to 0.92; P = .003).

CONCLUSION

Clinical and biologic features show important differences by NB primary site, with adrenal and thoracic sites associated with inferior and superior survival, respectively. Future studies will need to investigate the biologic origin of these differences.

Incidence, ocular manifestations, and survival in children with neuroblastoma: a population-based study

PURPOSE

To determine the incidence, ophthalmic manifestations, and survival among children with neuroblastoma in a defined population.

DESIGN

Population-based retrospective cohort.

METHODS

The medical records of all pediatric (<19 years) residents of Olmsted County, Minnesota, diagnosed with neuroblastoma from January 1, 1969, through December 31, 2008, were retrospectively reviewed.

RESULTS

Fourteen children were diagnosed with neuroblastoma as residents of Olmstead County, Minnesota, during the 40-year period, yielding an age- and gender-adjusted incidence of 11.8 (95% confidence interval [CI]: 5.6-18.0) per million patients <15 years of age. The calculated incidence for patients presenting before the age of 5 in this cohort was 1 in 5970 children (95% CI: 3920-12 580 children). The mean age at diagnosis for the 14 study patients was 22.5 months (range, 10.4-42.6 months). Six of the 14 (43%; 95% CI: 18%-71%) had ocular manifestations, including orbital metastasis in 6 (100%), proptosis and ecchymosis in 4 (67%), ptosis in 2 (33%), and strabismus in 1 (17%). The Kaplan-Meier rate of survival for all 14 children was 57% at 1 year (95% CI: 36%-90%) and 50% at 5 years (95% CI: 30%-84%), while the 6 with eye findings had a survival rate of 17% at 9 months (95% CI: 3%-100%).

CONCLUSIONS

The incidence of neuroblastoma in this population was 11.8 per million patients <15 years, with ophthalmic involvement observed in 6 of the 14 study patients (43%). Orbital metastasis in the 6 children in this cohort was associated with poor prognosis.

Unchanged incidence and increased survival in children with neuroblastoma in Denmark 1981-2000: a population-based study

Treatment results for neuroblastoma in Denmark have been poorer than in other Nordic countries, so we investigated whether a change in incidence, stage distribution and survival had occurred between 1981 and 2000. Clinical data were retrieved from the medical charts of 160 children <15 years of age with extra-cranial neuroblastoma (n=139) or ganglioneuroblastoma (n=21) diagnosed in Denmark between 1981 and 2000. The minimal follow-up time was 52 months. Statistical analyses were performed in STATA. The incidence was 8.55 per million children below 15 years of age (world standard 9.6) and 42.6 per million children below 12 months of age, and it has remained unchanged since 1970. The median age at diagnosis was 27 months. In all, 32% of the children were aged below 12 months at diagnosis, 53% had metastatic disease and in 12% the diagnosis was made incidentally. Prognostic factors such as age, stage and site of primary tumour were the same as in other studies and did not change. During the study period, the mortality rate decreased steadily, and the 5-year survival rate increased from 38% in 1981–1985 to 59% in 1996–2000, corresponding to the level found in other Western countries. Increased survival was also seen in children with metastatic disease. Participation in international studies, better supportive care and possibly postoperative autologous stem cell transplantation may have contributed to the increased survival.

The impact of gross total resection on local control and survival in high-risk neuroblastoma

BACKGROUND/PURPOSE

Gross total resection of the primary tumor in treatment of high-risk neuroblastoma remains controversial. Furthermore, there are few reports of the effect of primary tumor resection on local control as opposed to overall survival. The authors reviewed their institutional experience to assess the effect of primary tumor resection on local control and overall survival.

METHODS

A total of 141 patients were treated on protocol between November 1, 1979 and June 25, 2002 and are the subject of this report. Gross total resection was assessed by review of operative notes, postoperative computerized axial tomograms, and postoperative meta-iodobenzyl guanidine (MIBG)1 scans when available.

RESULTS

The median age was 3.3 years, and all patients were International Neuroblastoma Staging System (INSS) stage 4 with 79% having metastases to cortical bone. The primary site was the adrenal gland in 74%, the central abdominal compartment in 13%, the posterior mediastinum in 7%, and other sites in 6%. Gross total resection was accomplished in 103 (73%) but was more than 90% for the last 3 protocols. Five kidneys were lost overall. The probability of local progression was 50% in unresected patients compared with 10% in patients undergoing gross total resection (P <.01). Overall survival rate in resected patients was 50% compared with 11% in unresected patients (P <.01).

CONCLUSIONS

Our data indicate that local control and overall survival rate are correlated with gross total resection of the primary tumor in high-risk neuroblastoma. Gross total resection should be part of the management of stage 4 neuroblastoma in patients greater than 1 year of age.

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.

Biology and treatment of neuroblastoma

Neuroblastoma is an enigmatic tumor that has the highest rate of spontaneous regression of all human malignant neoplasms, yet has one of the poorest outcomes when occurring as disseminated disease in children. The emergence of neuroblastoma tumor biology, coupled with age and stage of diagnosis, has allowed more accurate routing of patients to risk-related therapy and refining of such therapy to minimize treatment for those with low risk for recurrent disease and searching out new treatment strategies for patients with high-risk disease. Continued assessment of tumor biologic features in all patients will provide new insights into tumorigenesis, cell differentiation, and death pathways, resulting in the potential for developing newer therapies for patients with high-risk disease.

Neuroblastoma

The neuroblastic tumours, derived from primordial neural crest cells which ultimately populate the sympathetic ganglia, adrenal medulla and other sites, (Brodeur GM and Castleberry RP. Neuroblastoma. In Pizzo PA, Poplack DG, eds, Principles and Practice of Pediatric Oncology. Philadelphia, J. B. Lippincott Co., 1997, 761-797) are an enigmatic group of neoplasms which have the highest rate of spontaneous regression of all human malignant neoplasms yet one of the poorest outcomes when occurring as disseminated disease in children. Significant advances in understanding and predicting the natural history of neuroblastoma have resulted from translational studies coupling tumour biology and clinical features to form prognostic strata and allowing more accurate routeing of patients to risk-related management. While this strategy has clarified the management for lower risk tumours, little improvement in survival for higher risk disease has been realised. Ironically, this latter patient subset, for which the most innovative therapeutic strategies are needed, is also the one from which the least tumour biology is gleaned owing to inadequate tissue sampling. This update will summarise the evolving biology of neuroblastoma and its relationship to current risk-related therapy and future management strategies. Throughout this report, prognostic grouping by age will be infants (< 1 year) versus children (> or = 1 year) since the change of risk according to age seems most distinct at this cut-off point.

trk A gene expression in neuroblastoma. The clinical significance of an immunohistochemical study

BACKGROUND

Neuroblastomas display a spectrum of morphologic and cytologic features of neural cells, and the prognosis of patients with these tumors varies widely. Expression of trk A in these tumors, as documented by Northern blot analysis, is associated with a favorable prognosis. To examine the expression of trk A at the cellular level in individual tumors and apply the results to routine clinical use, the authors designed this immunohistochemical study using an antibody with a predetermined specificity on formalin fixed, paraffin embedded tumor sections.

METHODS

Expression of trk A and Ha-ras genes in 105 neuroblastomas was examined by avidin-biotin-complex immunoperoxidase staining. N-myc gene amplification was examined in 81 of the tumors by Southern blot analysis.

RESULTS

Immunohistochemical expression in tumors correlated strongly with a favorable prognosis for trk A expression (P < 0.0001) and for Ha-ras expression (P < 0.0001). N-myc amplification was found in neuroblastomas with low expression of trk A and of Ha-ras genes. Kaplan-Meier analysis resulted in a favorable outcome associated with high trk A expression and no N-myc amplification, and a poor outcome associated with low trk A expression and demonstrable N-myc amplification (P < 0.0001). Univariate analysis showed that immunohistochemical expression of trk A at the time of diagnosis was a powerful predictor of the patient's prognosis, as were N-myc amplification and Ha-ras expression. trk A expression even correlated significantly with prognosis when the analysis was restricted to Stages III and IV tumors.

CONCLUSIONS

Immunohistochemical detection of the trk A gene product in tumor cells is strongly predictive of a favorable prognosis for patients with neuroblastomas. The coexpression of trk A and Ha-ras genes with clinical behavior of the tumor may indicate close linkage of these genes in the nerve growth factor signal transduction system. Prognostic evaluation at diagnosis based on such molecular and genetic information should be important clinically.

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).

Age-related profile of neuroblastoma: a comparison of tumors detected by mass-screening with those detected clinically

Infants with neuroblastoma are known to have a favorable prognosis compared to those over 1 year of age. However, there is little biological information about the age-related heterogeneity of neuroblastoma. We evaluated the biological profile comparing cases detected by mass screening with those detected clinically. A total of 238 patients with neuroblastoma were classified into four groups according to their age at diagnosis. Patients in group A were 0-5 months of age (n = 31). Patients in group B were detected clinically and were 6-11 months of age (n = 25). Patients in group C were 6-11 months of age and were detected by mass-screening (n = 97). Patients in group D were more than 12 months of age (n = 85). The age-related heterogeneity was evaluated by Kaplan-Meier survival analysis, several clinical markers (neuron specific enolase, ferritin, vanillylmandelic acid and homovanillic acid) at diagnosis, tumor Ha-ras p21 expression and tumor N-myc amplification. Infant neuroblastoma had unique features in comparison to neuroblastoma diagnosed over 12 months of age. Clinical outcome of the patients in groups A and C was quite favorable. Even patients with stage III or IV disease in group A had a favorable prognosis. However, stage IVs disease in group A was not necessarily associated with a good prognosis and the early death after diagnosis was also characteristic. The biological profile of tumors in group C was similar to that in group A but different from the profile in groups B and D. Tumors in group B had a biological profile intermediate between groups A and D.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of stage III neuroblastoma with emphasis on intensive induction chemotherapy: a report from the Neuroblastoma Group of the Spanish Society of Pediatric Oncology

From October 87 to April 92, 172 children were admitted in the N-I-87 protocol of the Spanish Society of Pediatric Oncology for the diagnosis and treatment of neuroblastoma. Forty-eight were considered Evans stage III, 33 of them being older than 1 year. All children were treated with induction chemotherapy (IC) and surgery. IC consisted of three courses of high-dose cisplatin-VM-26 alternating with three further courses of cyclophosphamide-doxorubicin (CAD). Infants less than 1 year received the same drugs at lower doses. After surgery, maintenance chemotherapy was administered to all children during 14 months. It consisted of four pairs of drugs rotated every 4 weeks. Radiotherapy was administered exclusively to patients older than 1 year with residual tumor after IC and surgery. Response was evaluated after IC and surgery. In children older than 1 year, response was obtained in 28/33 (88%). Fifteen of them (47%) achieved complete remission (CR), seven (22%) good partial response (GPR), six (19%) partial response (PR); and in three patients (9%) there was progressive disease (PD). Actuarial survival at 48 months was 0.60 +/- 0.10 and EFS was 0.61 +/- 0.12. Audiologic impairment was considered the worst toxicity. In children less than 1 year the response rate to IC and surgery was 93% (14/15); nine infants obtained complete response and four had GPR. Only one patient experienced PD in the first 6 months of therapy and died. The other 14 are alive and well at a mean follow-up time of 48 months. Chemotherapy toxicity was mild and reversible.

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.

Double megatherapy and autologous bone marrow transplantation for advanced neuroblastoma: the LMCE2 study

In the LMCE1 study using a single course of megatherapy most of the relapses occurred during the first 2 years after autologous bone marrow transplantation. A second pilot study (LMCE2) was therefore set up using a double harvest/double graft approach with two different megatherapy regimens. Objectives were to test the role of increased dose intensity on response status, relapse pattern and overall survival. Thirty-three patients (20 boys, 13 girls) with a median age of 53 months at first megatherapy (range, 17-202 months) entered this study. They were cases either with refractory disease in partial response after second line treatment for stage 4 neuroblastoma (n = 25) or after relapse from stage 4 (n = 5) or stage 3 disease (n = 3). All patients received Etoposid and/or Cisplatinum (or Carboplatin) containing treatments before megatherapy. The first megatherapy regimen was a combination of Tenoposid, Carmustine and Cisplatinum (or Carboplatin), the second applied Vincristin, Melphalan and Total Body Irradiation. The first harvest was scheduled 4 weeks after the last chemotherapy, the second 60 to 90 days after megatherapy. All marrows were purged in vitro by an immunomagnetic technique. Median follow up time since first megatherapy is 56 months. Response rates for evaluable patients were 65% (complete response rate: 16%) for megatherapy 1 and 60% (complete response rate: 25%) for megatherapy 2. Considering that only patients with delayed response or relapse were eligible for this pilot study the overall survival was encouraging with 36% at 2 years and still 32% at 5 years. The costs for these survival rates were high in terms of morbidity (four early and four late toxic deaths; toxic death rate: 24%). Double harvesting may have the disadvantage of delayed engraftments related in part to a disturbance of marrow microenvironment by megatherapy 1. This double megatherapy approach achieved a prolonged relapse free interval (median 11 months, range 2-31 months) in patients reaching megatherapy 2 and justifies further evaluation of concepts with consecutive dose-escalation.

Survival trends for neuroblastoma patients in Finland: negative reflections on screening

Based on 257 neuroblastoma patients in the age group 0-14 years and reported to the Finnish Cancer Registry, the 5-year cumulative survival rates have improved from 15% in the 1950s to 57% in 1980-1986. The potential benefit of screening for neuroblastoma was assessed on the basis of these nationwide survival trends. It is likely that any decrease in the overall neuroblastoma mortality due to screening would be small, because the survival rates of the Finnish neuroblastoma patients are already, even without screening, similar to those in Japan, which has a nationwide public health policy to screen for neuroblastoma.

Prognostic importance of DNA flow cytometrical, histopathological and immunohistochemical parameters in neuroblastomas

In 42 tumour samples of human neuroblastoma, histological classification by differentiation (Shimada) was significantly correlated with strong positivity for neuron-specific enolase (NSE) and inversely correlated with rosette formation. Most ganglioneuroblastomas were positive for S-100 protein and reacted strongly with NSE antibody. Histological signs of high proliferative activity included intermediate or high mitosis-karyorrhexis index, necrosis and lack of calcification, which were significantly correlated with each other. Flow cytometric DNA analysis demonstrated that 88% of the tumour samples had DNA aneuploid stem lines. High S phase fraction (greater than or equal to 0.20) was significantly correlated with necrosis and lack of calcification. Univariate analysis of prognosis for 26 patients whose tumour samples were obtained before adjuvant treatment showed that five factors were significantly related to a better outcome: early stage of the disease (stages I, II, IV-S), S phase fraction less than 0.20, favourable Shimada histology, positivity for S-100 protein, and strong positivity for NSE. In multivariate analysis, only S phase fraction or stage of disease remained significantly associated with prognosis. DNA index did not correlate with prognosis in this study.

Bilateral primary neuroblastomas in the inguinal canal

The incidental finding of a nodular mass in the inguinal canal in children usually occurs during surgical exploration for an inguinal hernia. We report an unusual occurrence of neuroblastomas bilaterally and simultaneously in the inguinal canals of an infant with no evidence of metastatic disease.

Lymphocyte count as a prognostic factor in childhood cancer

To evaluate the significance of the peripheral lymphocyte count in the prognostication of childhood cancer, 173 children with cancer (neuroblastoma, non-Hodgkin's lymphoma, malignant lymphogranuloma, nephroblastoma, Ewing's sarcoma, and rhabdomyosarcoma) were studied. All patients with the above-mentioned diagnoses admitted for the first time between 1985 and 1987 without prior treatment and acute infection were eligible for the study. Elevated peripheral lymphocyte count seems to be an independent indicator of survival from neuroblastoma but not from other tumors.

A significant association of Ha-ras p21 in neuroblastoma cells with patient prognosis. A retrospective study of 103 cases

To evaluate biologic characteristics of neuroblastoma, the authors examined the expression of Ha-ras gene (Ha-ras p21) in 103 primary tumors obtained at the time of diagnosis. Higher expression of the Ha-ras p21 in tumor cells showed a significant association with lower clinical stage of the tumor at diagnosis (chi-square = 35.418, degrees of freedom [df] = 9, P less than 0.001) and survival of the patients (chi-square = 37.111, df = 3, P less than 0.001). Thirty-six (84%) of 43 patients with decreased Ha-ras p21 expression died of aggressive disease. The Ha-ras DNA was examined in the 32 tumors by Southern blot analysis. Neither augmentation nor deletion of the Ha-ras DNA was observed. Amplification of the N-myc DNA was also examined in 43 cases in comparison with Ha-ras p21 expression. N-myc amplification was detected in 12 (55%) of 22 patients who died, and 19 (86%) of the 22 patients showed a low expression of the Ha-ras p21 in tumor cells. Eighteen (86%) of 21 survivors showed a high expression of the Ha-ras p21. The expression of Ha-ras p21 was thought to be a clinically important marker for prognosis in children with neuroblastoma.

Trends in survival for childhood cancer in Britain diagnosed 1971-85

Survival rates were analysed for a population-based series of over 15,000 childhood cancers registered in Great Britain during 1971-85. There were highly significant improvements (P less than 0.001 for trend) in survival for many major diagnostic groups. Between 1971-73 and 1983-85 the actuarial 5-year survival rates increased from 37% to 70% for acute lymphoblastic leukaemia, from 4% to 26% for acute non-lymphoblastic leukaemia, from 76% to 88% for Hodgkin's disease, from 22% to 70% for non-Hodgkin's lymphoma, from 61% to 72% for astrocytoma, from 24% to 42% for medulloblastoma, from 15% to 43% for neuroblastoma, from 58% to 79% for Wilms' tumour, from 17% to 54% for osteosarcoma, from 26% to 61% for rhabdomyosarcoma, from 59% to 94% for malignant testicular germ-cell tumours and from 43% to 77% for malignant ovarian germ-cell tumours. These increases in population-based survival rates reflect the substantial advances in treatment of a wide range of childhood cancers since 1970. The two principal diagnostic groups for which there was no evidence of any trend were retinoblastoma, which already had an excellent prognosis with a 5-year survival rate of over 85%, and Ewing's sarcoma, for which the survival rate remained below 45%.

How frequent is spontaneous remission of neuroblastomas? Implications for screening

The 'true' incidence of spontaneous regression of neuroblastomas is uncertain. However, the frequency of spontaneous regression is important when the benefits of screening procedures are considered. In the population-based Danish neuroblastoma survey 1943-80, spontaneous regression was documented in less than 2% of cases. However, the 'true' incidence may be higher. The epidemiological findings of increased incidence and survival rates with an unchanged mortality rate may suggest the inclusion of borderline lesions among 'truly' malignant neuroblastomas in recent decades in Denmark. However, it is more likely to be a result of improved diagnosis, changes in the social composition of the population and possibly unidentified environmental agents. However, if some premalignant lesions in fact had been included, they are most likely to be stages I-II tumours of infancy. In this study we describe cases of spontaneous regression of neuroblastoma from the Danish population-based survey 1943-80.

Pelvic neuroblastoma

Neuroblastoma usually presents as an upper abdominal mass arising from the adrenal gland. Recent experience with neuroblastoma of the spermatic cord, bladder and pelvis demonstrates the propensity of this tumor to arise in unusual areas. The need for unusual and unexpected masses in children to be evaluated thoroughly for neuroblastoma and for therapy to be individualized based on histological criteria, patient age and location of the tumor is demonstrated.

Prognostic factors in neuroblastoma. Clinical, histopathologic, and immunohistochemical features and DNA ploidy in relation to prognosis

Tumor samples from 58 patients diagnosed and treated for neuroblastoma or ganglioneuroblastoma in a single institution from 1967 to 1981 were included in a study of prognostic factors. Histopathology, certain immunohistochemical markers, and DNA ploidy were evaluated along with clinical variables such as tumor stage, primary site, and patient's age at diagnosis. Children under 1.5 years of age at diagnosis had a much better prognosis than did older ones, and this variable was the best prognostic indicator. Tumor Stages I to II and IVS, primary tumor site above the diaphragm, and tumor differentiation were also related to a better prognosis. The Shimada classification was of no additional prognostic value in our study. Neither was the immunohistochemical marker pattern, but it was sometimes helpful in establishing the tumor diagnosis. Tumor-cell ploidy, however, seemed to afford additional prognostic information because the 11 patients with aneuploid tumors under the age of 1.5 years at diagnosis all survived in contrast to only five of nine patients with diploid tumors in the same age group. It is possible that this was due to a better response to treatment in the aneuploid group. Our results suggest that patients with diploid neuroblastomas of undifferentiated histology and those over the age of 1.5 years at diagnosis might be selected for more intense treatment.

Neurogenic tumors of the thorax

Neurogenic tumors of the thorax are observed in all age groups, although they are rare in the elderly. They are more likely to be malignant in the child than in the adult. Tumors of the autonomic system are common in children, whereas the nerve sheath tumors are more likely to be found in adults. The malignant lesions are almost always symptomatic and the benign lesions asymptomatic, except in the child, in whom a benign lesion may result in symptoms because of its size relative to the volume of the child's thorax. Intraspinal canal extension, although relatively infrequent, should be sought for in all paravertebral tumors, for a significant percentage of these may be initially asymptomatic. Excision of such an hourglass tumor without foreknowledge of such extension may lead to serious spinal cord complications. Surgical excision of most of these tumors is sufficient except for the malignant lesions, especially in infancy and childhood, for which the addition of postoperative irradiation and chemotherapy may be beneficial. The prognosis after the removal of benign neurogenic tumors of the thorax is excellent. In the infant or child with Stage III or IV neuroblastoma, ganglioneuroblastoma, or an Askin tumor, the prognosis is poor. In the adult with a malignant neurogenic sarcoma or a malignant paraganglioma, the prognosis likewise is grave.