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Abbas AA, Samkari AMN. High-Risk Neuroblastoma: Poor Outcomes Despite Aggressive Multimodal
Therapy. CURRENT CANCER THERAPY REVIEWS 2022. [DOI: 10.2174/1573394717666210805114226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
:
Neuroblastoma (NBL) is a highly malignant embryonal tumor that originates from the
primordial neural crest cells. NBL is the most common tumor in infants and the most common extracranial
solid tumor in children. The tumor is more commonly diagnosed in children of 1-4 years
of age. NBL is characterized by enigmatic clinical behavior that ranges from spontaneous regression
to an aggressive clinical course leading to frequent relapses and death. Based on the likelihood
of progression and relapse, the International Neuroblastoma Risk Group classification system categorized
NBL into very low risk, low risk, intermediate risk, and high risk (HR) groups. HR NBL is
defined based on the patient's age (> 18 months), disease metastasis, tumor histology, and MYCN
gene amplification. HR NBL is diagnosed in nearly 40% of patients, mainly those > 18 months of
age, and is associated with aggressive clinical behavior. Treatment strategies involve the use of intensive
chemotherapy (CTR), surgical resection, high dose CTR with hematopoietic stem cell support,
radiotherapy, biotherapy, and immunotherapy with Anti-ganglioside 2 monoclonal antibodies.
Although HR NBL is now better characterized and aggressive multimodal therapy is applied, the
outcomes of treatment are still poor, with overall survival and event-free survival of approximately
40% and 30% at 3-years, respectively. The short and long-term side effects of therapy are tremendous.
HR NBL carries a high mortality rate accounting for nearly 15% of pediatric cancer deaths.
However, most mortalities are attributed to the high frequency of disease relapse (50%) and disease
reactiveness to therapy (20%). Newer treatment strategies are therefore urgently needed. Recent
discoveries in the field of biology and molecular genetics of NBL have led to the identification
of several targets that can improve the treatment results. In this review, we discuss the different
aspects of the epidemiology, biology, clinical presentations, diagnosis, and treatment of HR
NBL, in addition to the recent developments in the management of the disease.
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Affiliation(s)
- Adil Abdelhamed Abbas
- College of Medicine King Saud bin Abdulaziz, University for Health Sciences Consultant Pediatric Hematology / Oncology
& BMT The Pediatric Hematology/Oncology Section Princess Nourah Oncology Centre King Abdulaziz Medical
City, Jeddah, Saudi Arabia
| | - Alaa Mohammed Noor Samkari
- College of Medicine King Saud bin Abdulaziz, University for Health Sciences Consultant
Anatomical Pathologist Department of Laboratory Medicine King Abdulaziz Medical City, Jeddah, Saudi Arabia
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Saito Y, Urashima M, Takahashi Y, Ogawa A, Kiyotani C, Yuza Y, Koh K, Watanabe K, Kosaka Y, Goto H, Kikuta A, Okada K, Koga Y, Fujimura J, Inoue M, Sato A, Atsuta Y, Matsumoto K. Effect of high-dose chemotherapy plus stem cell rescue on the survival of patients with neuroblastoma modified by MYCN gene gain/amplification and remission status: a nationwide registration study in Japan. Bone Marrow Transplant 2021; 56:2173-2182. [PMID: 33911201 DOI: 10.1038/s41409-021-01303-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 03/24/2021] [Accepted: 04/09/2021] [Indexed: 02/05/2023]
Abstract
In high-risk neuroblastoma, the presence of an MYCN gain/amplification (MYCN-GA) is not always a risk factor of cancer-specific death. We herein examined the effect modification of high-dose chemotherapy with autologous hematopoietic stem cell rescue (HDC-autoSCR) in terms of the interaction between MYCN status and remission status (complete remission or very good partial remission [CR/VGPR] vs. partial remission or less [≤PR]). The present study recruited patient data from 1992 to 2017 in the Japan Society of Hematopoietic Cell Transplantation's national registry. The MYCN status was known in 586 of 950 patients with a single course of HDC-autoSCR. Cumulative hazard curves for neuroblastoma-specific death showed that a subgroup with MYCN-GA and ≤PR had a significantly poorer prognosis than three other subgroups, namely, the MYCN-NGA/ ≤ PR, MYCN-NGA/CR/VGPR, and MYCN-GA/CR/VGPR subgroups even after adjusting for non-infants and stage IV disease (hazard ratio: 2.79; 95% confidence interval: 1.91-4.09; P < 0.001). The interaction between MYCN-GA and ≤PR was significant (pinteraction = 0.006). Hence, the patients with MYCN-GA with non-remission status at HDC-autoSCR had a significantly poorer prognosis than the other subgroups, suggesting that HDC-autoSCR may be effective in patients with CR/VGPR regardless of MYCN gene status and in patients with MYCN-NGA regardless of remission status.
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Affiliation(s)
- Yuya Saito
- Department of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan. .,Division of Molecular Epidemiology, Jikei University School of Medicine, Tokyo, Japan.
| | - Mitsuyoshi Urashima
- Division of Molecular Epidemiology, Jikei University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atsushi Ogawa
- Department of Pediatrics, Niigata Cancer Center Hospital, Niigata, Japan
| | - Chikako Kiyotani
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yuki Yuza
- Department of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Kenichiro Watanabe
- Department of Hematology and Oncology, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Hiroaki Goto
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Atsushi Kikuta
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Keiko Okada
- Department of Pediatric Hematology/Oncology, Osaka City General Hospital, Osaka, Japan
| | - Yuhki Koga
- Department of Pediatrics, Kyushu University Hospital, Fukuoka, Japan
| | - Junya Fujimura
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Masami Inoue
- Department of Hematology/Oncology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Atsushi Sato
- Department of Hematology and Oncology, Miyagi Children's Hospital, Sendai, Japan
| | - Yoshiko Atsuta
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
| | - Kimikazu Matsumoto
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
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Moreno L, Vaidya SJ, Schrey D, Pinkerton CR, Lewis IJ, Kearns PR, Machin D, Pearson ADJ. Long-term analysis of children with metastatic neuroblastoma treated in the ENSG5 randomised clinical trial. Pediatr Blood Cancer 2019; 66:e27565. [PMID: 30516328 DOI: 10.1002/pbc.27565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/24/2018] [Accepted: 10/30/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND The European Neuroblastoma Study Group 5 (ENSG5) trial showed that time-intensive "rapid" induction chemotherapy (COJEC) was superior to "standard" 3-weekly chemotherapy for children with high-risk metastatic neuroblastoma. Long-term outcomes of the ENSG5 trial were analysed. PROCEDURE Patients with metastatic neuroblastoma aged ≥12 months were randomly assigned to "standard" or "rapid" induction, receiving the same chemotherapy drugs and doses. Event-free survival (EFS) and overall survival (OS) were analysed and prognostic factors evaluated. Amongst patients surviving >5 years, a population of children with persistent metastatic disease after the end of treatment was identified and described. RESULTS Ten-year EFS was 18.2% (95% confidence interval: 12.2-25.2) for the "standard" arm and 26.8% (19.5-34.7) for the "rapid" arm (hazard ratio [HR] 0.85, P = 0.28). Ten-year OS for the "standard" arm was 19.7% (13.4-26.8) and 28.3% (20.8-36.2) for the "rapid arm" (HR 0.83, P = 0.19). There was a trend for worse EFS and OS for patients having MYCN amplification (HR 1.37 and 1.40, respectively) and those with partial and mixed response to induction (HR 1.69 and 1.75 for EFS and 1.66 and 2.00 for OS, respectively). Among 69 patients who survived >5 years, six had persistent metastatic disease after the end of treatment. CONCLUSION The benefit of the "rapid" induction regimen seems to be maintained in the long term, although the small number of survivors could justify the lack of statistical significance. MYCN amplification and poor metastatic response to induction could be associated with worse outcomes. A small group of patients with persistent metastatic disease that survived long term has been described.
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Affiliation(s)
- Lucas Moreno
- Clinical Trials Unit, Department of, Paediatric Haematology, Oncology and SCT, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
- Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Sucheta J Vaidya
- Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | - Dominik Schrey
- Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom
| | | | - Ian J Lewis
- Leeds Community Healthcare NHS Trust, Leeds, United Kingdom
| | - Pamela R Kearns
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - David Machin
- Department of Cancer Studies, Clinical Sciences Building, Leicester Royal Infirmary, University of Leicester, Leicester, United Kingdom
| | - Andrew D J Pearson
- Children and Young People's Unit, The Royal Marsden NHS Foundation Trust, Sutton, United Kingdom (retired)
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4
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Hung YP, Lee JP, Bellizzi AM, Hornick JL. PHOX2B reliably distinguishes neuroblastoma among small round blue cell tumours. Histopathology 2017. [DOI: 10.1111/his.13288] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Yin P Hung
- Department of Pathology; Brigham and Women's Hospital and Harvard Medical School; Boston MA USA
| | - John P Lee
- Department of Pathology; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Andrew M Bellizzi
- Department of Pathology; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Jason L Hornick
- Department of Pathology; Brigham and Women's Hospital and Harvard Medical School; Boston MA USA
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5
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Isolated late CNS relapse in a young adult 10 years after initial treatment for neuroblastoma. J Pediatr Hematol Oncol 2015; 37:75-7. [PMID: 24755834 DOI: 10.1097/mph.0000000000000163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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6
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Kushner BH, Modak S, Kramer K, LaQuaglia MP, Yataghene K, Basu EM, Roberts SS, Cheung NKV. Striking dichotomy in outcome of MYCN-amplified neuroblastoma in the contemporary era. Cancer 2014; 120:2050-9. [PMID: 24691684 DOI: 10.1002/cncr.28687] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/21/2014] [Accepted: 02/24/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND The authors exploited a large database to investigate the outcomes of patients with high-risk neuroblastoma in the contemporary era. METHODS All patients with high-risk neuroblastoma aged <12 years who were treated during induction at the authors' institution from 2000 through 2011 were studied, including 118 patients with MYCN-amplified [MYCN(+)] disease and 127 patients aged >18 months with MYCN-nonamplified [MYCN(-)] stage 4 disease. RESULTS A complete response/very good partial response (CR/VGPR) to induction was correlated with significantly superior event-free survival (EFS) (P < .001) and overall survival (OS) (P < .001) compared with a partial response or less. Patients with MYCN(+) and MYCN(-) disease had similar rates of CR/VGPR to induction (P = .366), and those with MYCN(+) and MYCN(-) disease who attained a CR/VGPR had similar EFS (P = .346) and OS (P = .542). In contrast, only MYCN(+) patients had progressive disease as a response to induction (P < .001), and early death from progressive disease (<366 days after diagnosis) was significantly more common (P < .001) among those with MYCN(+) disease. Overall, among patients who had a partial response or less, MYCN(+) patients had significantly inferior EFS (P < .001) and OS (P < .001) compared with MYCN(-) patients, which accounted for the significantly worse EFS (P = .008) and OS (P = .002) for the entire MYCN(+) cohort versus the MYCN(-) cohort. CONCLUSIONS Patients with MYCN(-), high-risk neuroblastoma display a broad, continuous spectrum with regard to response and outcome, whereas MYCN(+) patients either have an excellent response to induction associated with good long-term outcome or develop early progressive disease with a poor outcome. This extreme dichotomy in the clinical course of MYCN(+) patients points to underlying biologic differences with MYCN(+) neuroblastoma, the elucidation of which may have far-reaching implications, including improved risk classification at diagnosis and the identification of targets for treatment.
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Affiliation(s)
- Brian H Kushner
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
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Abstract
In a retrospective review of 24 metastatic medulloblastoma patients whose treatment included craniospinal irradiation, 5 patients presented with gross residual abnormalities at completion of therapy. This report describes 2 medulloblastoma patients with persistent residual abnormalities on serial follow-up imaging studies. The patients aged 2 and 2.5 years old at the time of diagnosis underwent surgery followed by multiagent chemotherapy. One patient progressed on therapy and underwent salvage craniospinal radiation. The second showed residual tumor on end of treatment imaging and received low-dose craniospinal irradiation. Despite persistent magnetic resonance imaging findings, the patients are alive and well 13 and 7 years after diagnosis with no further treatment applied. The nature of these residual abnormalities is discussed.
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Cheung NKV, Zhang J, Lu C, Parker M, Bahrami A, Tickoo SK, Heguy A, Pappo AS, Federico S, Dalton J, Cheung IY, Ding L, Fulton B, Wang J, Chen X, Becksfort J, Wu J, Billups CA, Ellison D, Mardis ER, Wilson RK, Downing JR, Dyer MA. Association of age at diagnosis and genetic mutations in patients with neuroblastoma. JAMA 2012; 307:1062-71. [PMID: 22416102 PMCID: PMC3527076 DOI: 10.1001/jama.2012.228] [Citation(s) in RCA: 310] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Neuroblastoma is diagnosed over a wide age range from birth through young adulthood, and older age at diagnosis is associated with a decline in survivability. OBJECTIVE To identify genetic mutations that are associated with age at diagnosis in patients with metastatic neuroblastoma. DESIGN, SETTING, AND PATIENTS Whole genome sequencing was performed on DNA from diagnostic tumors and their matched germlines from 40 patients with metastatic neuroblastoma obtained between 1987 and 2009. Age groups at diagnosis included infants (0-<18 months), children (18 months-<12 years), and adolescents and young adults (≥12 years). To confirm the findings from this discovery cohort, validation testing using tumors from an additional 64 patients obtained between 1985 and 2009 also was performed. Formalin-fixed, paraffin-embedded tumor tissue was used for immunohistochemistry and fluorescence in situ hybridization. Telomere lengths were analyzed using whole genome sequencing data, quantitative polymerase chain reaction, and fluorescent in situ hybridization. MAIN OUTCOME MEASURE Somatic recurrent mutations in tumors from patients with neuroblastoma correlated with the age at diagnosis and telomere length. RESULTS In the discovery cohort (n = 40), mutations in the ATRX gene were identified in 100% (95% CI, 50%-100%) of tumors from patients in the adolescent and young adult group (5 of 5), in 17% (95% CI, 7%-36%) of tumors from children (5 of 29), and 0% (95% CI, 0%-40%) of tumors from infants (0 of 6). In the validation cohort (n = 64), mutations in the ATRX gene were identified in 33% (95% CI, 17%-54%) of tumors from patients in the adolescent and young adult group (9 of 27), in 16% (95% CI, 6%-35%) of tumors from children (4 of 25), and in 0% (95% CI, 0%-24%) of tumors from infants (0 of 12). In both cohorts (N = 104), mutations in the ATRX gene were identified in 44% (95% CI, 28%-62%) of tumors from patients in the adolescent and young adult group (14 of 32), in 17% (95% CI, 9%-29%) of tumors from children (9 of 54), and in 0% (95% CI, 0%-17%) of tumors from infants (0 of 18). ATRX mutations were associated with an absence of the ATRX protein in the nucleus and with long telomeres. CONCLUSION ATRX mutations were associated with age at diagnosis in children and young adults with stage 4 neuroblastoma. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00588068.
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Affiliation(s)
- Nai-Kong V. Cheung
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065
| | - Jinghui Zhang
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Charles Lu
- The Genome Institute, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
| | - Matthew Parker
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Armita Bahrami
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Satish K. Tickoo
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065
| | - Adriana Heguy
- Human Oncology and Pathogenesis, Memorial Sloan-Kettering Cancer Center, New York, NY 10065
| | - Alberto S. Pappo
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Sara Federico
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - James Dalton
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Irene Y. Cheung
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065
| | - Li Ding
- The Genome Institute, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
- Department of Genetics, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
| | - Bob Fulton
- The Genome Institute, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
- Department of Genetics, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
| | - Jianmin Wang
- Hartwell Center for Bioinformatics & Biotechnology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Xiang Chen
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Jared Becksfort
- Hartwell Center for Bioinformatics & Biotechnology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Jianrong Wu
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Catherine A. Billups
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - David Ellison
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Elaine R. Mardis
- The Genome Institute, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
- Department of Genetics, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
- Siteman Cancer Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
| | - Richard K. Wilson
- The Genome Institute, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
- Department of Genetics, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
- Siteman Cancer Center, Washington University School of Medicine in St. Louis, St. Louis, Missouri 63108, USA
| | - James R. Downing
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
| | - Michael A. Dyer
- Department of Developmental Neurobiology, St. Jude Children’s Research Hospital, Memphis, Tennessee 38105, USA
- Department of Ophthalmology, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
- Howard Hughes Medical Institute, Chevy Chase, Maryland 20815, USA
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London WB, Castel V, Monclair T, Ambros PF, Pearson ADJ, Cohn SL, Berthold F, Nakagawara A, Ladenstein RL, Iehara T, Matthay KK. Clinical and biologic features predictive of survival after relapse of neuroblastoma: a report from the International Neuroblastoma Risk Group project. J Clin Oncol 2011; 29:3286-92. [PMID: 21768459 DOI: 10.1200/jco.2010.34.3392] [Citation(s) in RCA: 224] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Survival after neuroblastoma relapse is poor. Understanding the relationship between clinical and biologic features and outcome after relapse may help in selection of optimal therapy. Our aim was to determine which factors were significantly predictive of postrelapse overall survival (OS) in patients with recurrent neuroblastoma--particularly whether time from diagnosis to first relapse (TTFR) was a significant predictor of OS. PATIENTS AND METHODS Patients with first relapse/progression were identified in the International Neuroblastoma Risk Group (INRG) database. Time from study enrollment until first event and OS time starting from first event were calculated. Cox regression models were used to calculate the hazard ratio of increased death risk and perform survival tree regression. TTFR was tested in a multivariable Cox model with other factors. RESULTS In the INRG database (N = 8,800), 2,266 patients experienced first progression/relapse. Median time to relapse was 13.2 months (range, 1 day to 11.4 years). Five-year OS from time of first event was 20% (SE, ± 1%). TTFR was statistically significantly associated with OS time in a nonlinear relationship; patients with TTFR of 36 months or longer had the lowest risk of death, followed by patients who relapsed in the period of 0 to less than 6 months or 18 to 36 months. Patients who relapsed between 6 and 18 months after diagnosis had the highest risk of death. TTFR, age, International Neuroblastoma Staging System stage, and MYCN copy number status were independently predictive of postrelapse OS in multivariable analysis. CONCLUSION Age, stage, MYCN status, and TTFR are significant prognostic factors for postrelapse survival and may help in the design of clinical trials evaluating novel agents.
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Affiliation(s)
- Wendy B London
- Children's Oncology Group Statistics and Data Center and Dana-Farber Children's Hospital Cancer Center, Boston, MA, USA
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Kushner BH, Kramer K, Modak S, Cheung NKV. Sensitivity of surveillance studies for detecting asymptomatic and unsuspected relapse of high-risk neuroblastoma. J Clin Oncol 2009; 27:1041-6. [PMID: 19171710 DOI: 10.1200/jco.2008.17.6107] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Relapse-free survival (RFS) is a powerful measure of treatment efficacy. We describe the sensitivity of standard surveillance studies for detecting relapse of neuroblastoma (NB). PATIENTS AND METHODS The patients were in complete/very good partial remission of high-risk NB; routine monitoring revealed asymptomatic and, therefore, unsuspected relapses in 113 patients, whereas 41 patients had symptoms prompting urgent evaluations. Assessments every 2 to 4 months included computed tomography, iodine-131-metaiodobenzylguanidine (131)I-MIBG; through November 1999) or iodine-123-metaiodobenzylguanidine ((123)I-MIBG) scan, urine catecholamines, and bone marrow (BM) histology. Bone scan was routine through 2002. RESULTS (123)I-MIBG scan was the most reliable study for revealing unsuspected relapse; it had an 82% detection rate, which was superior to the rates with (131)I-MIBG scan (64%; P = .1), bone scan (36%; P < .001), and BM histology (34%; P < .001). Among asymptomatic patients, (123)I-MIBG scan was the sole positive study indicating relapse in 25 (27%) of 91 patients compared with one (4.5%) of 22 patients for (131)I-MIBG scan (P = .04) and 0% to 6% of patients for each of the other studies (P < .001). Patients whose monitoring included (123)I-MIBG scan were significantly less likely than patients monitored by (131)I-MIBG scan to have an extensive osteomedullary relapse and had a significantly longer survival from relapse (P < .001) and from diagnosis (P = .002). They also had significantly longer survival than patients with symptomatic relapses (P = .002). CONCLUSION (123)I-MIBG scan is essential for valid estimation of the duration of RFS of patients with high-risk NB. Without monitoring that includes (123)I-MIBG scan, caution should be used when comparing RFS between institutions and protocols.
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Affiliation(s)
- Brian H Kushner
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.
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12
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Abstract
Management of cases of refractory neuroblastoma remains a challenge. As intensive chemotherapy sometimes results in severe regimen-related toxicity and poor quality of life, palliative chemotherapy with modest toxicity may be considered for these cases. We report 2 cases of stage 4 neuroblastoma with poor performance status that received low-dose protracted schedules of irinotecan. This regimen achieved not only disease stabilization but also dramatic improvements of quality of life for significant periods. A low-dose protracted schedule of irinotecan was tolerable even if the patient's performance status was poor, and thus might be useful as a palliative chemotherapy for advanced neuroblastoma.
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13
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Santana VM, Furman WL, McGregor LM, Billups CA. Disease control intervals in high-risk neuroblastoma. Cancer 2008; 112:2796-801. [PMID: 18429000 DOI: 10.1002/cncr.23507] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Current salvage therapy for recurrent high-risk neuroblastoma is rarely curative. Assessment of the effectiveness of new, primarily cytostatic agents requires the redefinition of study endpoints to reflect disease stabilization rather than tumor response or regression. The intervals of disease control in the patients in the current study with recurrent neuroblastoma were characterized to provide comparison criteria for exploratory studies of new agents. METHODS Disease control intervals, disease-free survival, postrecurrence survival, and median time to treatment failure were estimated in 90 patients with high-risk neuroblastoma treated between January 1991 and June 2002 on 3 St. Jude neuroblastoma protocols. RESULTS The estimated median time to disease recurrence was 18.3 months (95% confidence interval [95% CI], 15.9-22.4 months) for the first recurrence, 8.7 months (95% CI, 5.0-12.2 months) for the second recurrence, and 3.8 months (95% CI, 2.5-5.4 months) for the third recurrence. The 5-year estimate of survival after the first disease recurrence was 11%+/-4%. Patients with longer initial disease control had a postrecurrence survival advantage:the 5-year estimated postrecurrence survival was 15.3%+/-6.3% for patients with initial disease control>or=16 months and 8.1%+/-5.5% for others (P=.006). The median disease control interval was approximately halved after each disease recurrence. CONCLUSIONS The previous disease control interval should be considered in stratification schemes for future phase 2 testing of new agents for the treatment of neuroblastoma. For the optimal evaluation of new treatment strategies that incorporate cytostatic agents, study design and selection of endpoints must take into account the current patterns of recurrence or progression of neuroblastoma.
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Affiliation(s)
- Victor M Santana
- Department of Oncology, St. Jude Children's Research Hospital, and Department of Pediatrics, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee 38105-2794, USA.
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14
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Abstract
The diversity of neuroblastoma and its clinical course depends on histology, biology and clinical features. We report a male presenting at 4 months of age with an abdominal mass and multiple subcutaneous nodules. The diagnosis was made by histological examination of a subcutaneous nodule and elevated urinary markers. The patient remained well during the subsequent 9 years. During that time no cytostatic treatment was given. Attempt to treat with cis-retinoic acid 10 years later did not result in any significant change of the clinical course. The patient has remained in good clinical condition for a 15-year observation period, having both progressing and regressing distant subcutaneous metastases. Skin nodules are the hallmarks of the indolent clinical course of the disease. We suggest the use of the "chronic neuroblastoma" as a term to describe patients with neuroblastoma showing indolent disease course over a very long period of time, but never achieving complete remission.
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Affiliation(s)
- Bernarda Kazanowska
- Department of Bone Marrow Transplantation, Paediatric Oncology and Haematology, Wroclaw Medical University, Wroclaw, Poland
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15
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Uttenreuther-Fischer MM, Krüger JA, Fischer P. Molecular characterization of the anti-idiotypic immune response of a relapse-free neuroblastoma patient following antibody therapy: a possible vaccine against tumors of neuroectodermal origin? THE JOURNAL OF IMMUNOLOGY 2006; 176:7775-86. [PMID: 16751426 DOI: 10.4049/jimmunol.176.12.7775] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Neuroblastoma treatment with chimeric antidisialoganglioside GD2 Ab ch14.18 showed objective antitumor responses. Production of anti-idiotypic Abs (Ab2) against ch14.18 (Ab1) in some cases was positively correlated with a more favorable prognosis. According to Jerne's network theory, a subset of anti-idiotypic Abs (Ab2beta) carries an "internal image" of the Ag and induces Abs (Ab3) against the original Ag. The molecular origin of an anti-idiotypic Ab response in tumor patients was not investigated previously. To clone anti-idiotypic Abs, B cells of a ch14.18-treated neuroblastoma patient with Ab2 serum reactivity were used to construct Ab phage display libraries. After repeated biopannings on ch14.18 and its murine relative, anti-GD2 mAb 14G2a, we selected 40 highly specific clones. Sequence analysis revealed at least 10 of 40 clones with different Ig genes. Identities to putative germline genes ranged between 94.90 and 100% for V(H) and between 93.90 and 99.60% for V(L). An overall high rate of replacement mutations suggested a strong Ag-driven maturation of the anti-idiotypic Abs. Two clones that were analyzed further, GK2 and GK8, inhibited binding of ch14.18 to GD2 just as the patient's serum did. GK8 alone inhibited >80% of the patient's anti-idiotypic serum Abs in binding to ch14.18. Rabbits vaccinated with GK8 or GK2 (weaker) produced Ab3 against the original target Ag GD2. GK8 may be useful as a tumor vaccine for GD2-positive [corrected] tumors.
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MESH Headings
- Amino Acid Sequence
- Animals
- Antibodies, Anti-Idiotypic/biosynthesis
- Antibodies, Anti-Idiotypic/chemistry
- Antibodies, Anti-Idiotypic/genetics
- Antibodies, Monoclonal/chemistry
- Antibodies, Monoclonal/metabolism
- Antibodies, Monoclonal/therapeutic use
- Bacteriophage M13/genetics
- Binding Sites, Antibody
- Binding, Competitive
- Cancer Vaccines/immunology
- Cancer Vaccines/therapeutic use
- Cloning, Molecular
- Combinatorial Chemistry Techniques
- Gangliosides/immunology
- Gangliosides/metabolism
- Humans
- Immunoglobulin Variable Region/chemistry
- Immunoglobulin Variable Region/metabolism
- Immunoglobulin kappa-Chains/chemistry
- Immunoglobulin kappa-Chains/genetics
- Immunoglobulin kappa-Chains/metabolism
- Immunoglobulin lambda-Chains/chemistry
- Immunoglobulin lambda-Chains/genetics
- Immunoglobulin lambda-Chains/metabolism
- Mice
- Molecular Sequence Data
- Neoplasm Recurrence, Local/immunology
- Neoplasm Recurrence, Local/therapy
- Neuroblastoma/immunology
- Neuroblastoma/therapy
- Neuroectodermal Tumors/immunology
- Neuroectodermal Tumors/prevention & control
- Peptide Library
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16
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Tabori U, Sung L, Hukin J, Laperriere N, Crooks B, Carret AS, Silva M, Odame I, Mpofu C, Strother D, Wilson B, Samson Y, Bouffet E. Distinctive clinical course and pattern of relapse in adolescents with medulloblastoma. Int J Radiat Oncol Biol Phys 2005; 64:402-7. [PMID: 16198067 DOI: 10.1016/j.ijrobp.2005.07.962] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2005] [Revised: 07/13/2005] [Accepted: 07/16/2005] [Indexed: 11/28/2022]
Abstract
PURPOSE To report the clinical course of adolescents with medulloblastoma, with specific emphasis on prognosis and pattern of relapse. METHODS AND MATERIALS We retrospectively studied the clinical course and outcomes of children aged 10-20 years with medulloblastoma, treated at centers throughout Canada between 1986 and 2003. To better assess time to relapse, a cohort of patients aged 3-20 years at diagnosis was generated. RESULTS A total of 72 adolescents were analyzed. Five-year overall survival and event-free survival rates were 78.3%+/-5.4% and 68.0%+/-6.2%, respectively. Late relapses occurred at a median of 3.0 years (range, 0.3-6.8 years). In univariate analysis, conventional risk stratification and the addition of chemotherapy to craniospinal radiation did not have prognostic significance. Female patients had improved overall survival (p=0.007). Time to relapse increased with age in a linear fashion. After relapse, patients faired poorly regardless of treatment modality. Patients who did not receive chemotherapy initially had improved progression-free survival at relapse (p=0.05). CONCLUSIONS Our study suggests that adolescents with medulloblastoma might have a unique prognosis and pattern of relapse, dissimilar to those in younger children. They might benefit from different risk stratifications and prolonged follow-up. These issues should be addressed in future prospective trials.
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Affiliation(s)
- Uri Tabori
- Pediatric Brain Tumor Program, The Hospital for Sick Children, Toronto, and Department of Hematology/Oncology, McMaster University, Hamilton, Ontario, Canada.
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17
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Kushner BH, Kramer K, Modak S, Cheung NKV. Five-day courses of irinotecan as palliative therapy for patients with neuroblastoma. Cancer 2005; 103:858-62. [PMID: 15637685 DOI: 10.1002/cncr.20846] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The authors describe a large experience using short courses of irinotecan for palliative therapy in patients with neuroblastoma (NB). Quality of life was a major issue in choosing this regimen for patients whose disease was resistant to standard anti-NB therapies. METHODS A retrospective review was conducted of all patients who were followed by the Department of Pediatrics at Memorial Sloan-Kettering Cancer Center and treated for resistant NB with irinotecan at 50 mg/m2 per day for 5 days as a 1-hour intravenous infusion. Treatment was outpatient, and there was a minimum 2-week rest period between courses. Granulocyte colony-stimulating factor was used to keep the absolute neutrophil count >500-1000/mL. RESULTS Forty-four patients had been treated aggressively and/or extensively before they received one or more five-day courses of irinotecan. Emetogenic, diarrheal, and myelosuppressive effects were readily managed. Hospitalizations were limited to three patients with bacteremia. Twenty-three patients had a change in therapy, although they did not have progressive disease (PD) after receiving 1 (n=10), 2 (n=3), 3 (n=1), 4 (n=6), 7 (n=1 patient), 22 (n=1 patient), or 24 (n=1) courses. The most common reasons for changing treatment were to intensify retrieval therapy or to pursue immunotherapy. Of those 23 patients, 15 patients had stable disease, 7 were not evaluable for response because of concurrent radiotherapy, and 1 patient had a major response. Twenty-one patients had PD after 1 (n=3, 2 (n=9), 4 (n=2), 5 (n=1), 6 (n=3), 7 (n=1), 9 (n=1), and 11 (n=1) courses. CONCLUSIONS In heavily treated patients, the regimen studied was well tolerated, allowed patients to continue most normal life activities, and produced anti-NB effects. Its modest toxicity supported use with other antitumor agents.
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Affiliation(s)
- Brian H Kushner
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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18
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Lau L, Tai D, Weitzman S, Grant R, Baruchel S, Malkin D. Factors influencing survival in children with recurrent neuroblastoma. J Pediatr Hematol Oncol 2004; 26:227-32. [PMID: 15087949 DOI: 10.1097/00043426-200404000-00003] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Despite advances in multimodal therapy for neuroblastoma, survival from advanced disease remains poor. Children are now offered a wide variety of salvage regimens following relapse. A retrospective review was performed on 31 patients with recurrent neuroblastoma treated at one institution between 1995 and 2001. At initial diagnosis, 27 patients had metastatic disease and 11 had N-myc amplification (NMA). The median time to recurrence from diagnosis was 16.1 months. Seventeen patients received salvage therapy, with a median of three salvage regimens per patient. The median survival time from relapse was 8.4 months. The median survival time was significantly shorter for recurrence less than 6 months after stem cell transplantation (2.9 vs. 13.3 months; P = 0.003) and for patients with NMA (2.7 vs. 15.1 months; P < 0.0001). Overall, salvage therapy led to a significantly longer median survival time (22.4 vs. 3.3 months; P = 0.0003); however, salvage therapy extended the median survival time only from 2.2 to 3.2 months for patients with NMA and from 0.7 to 5.8 months for patients with early relapse after stem cell transplantation. Multiple salvage regimens prolong survival significantly, especially for patients with no NMA and for relapses more than 6 months after stem cell transplantation, but the long-term disease-free survival after recurrent disease remains dismal.
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Affiliation(s)
- Loretta Lau
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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19
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Abstract
The clinical use of N-myc amplification in neuroblastoma management has served as a paradigm for "bench to bedside" medicine. It is hoped that the quest for molecular markers such as neurotrophin, TrkA, and TrkB will continue to advance the understanding of neuroblastoma. In addition, animal models of neuroblastoma (N-myc transgenic mice, and neuroblastoma xenografts) have been established to assess the efficacy of novel treatments. These advances are likely to improve clinical practice in the future.
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Affiliation(s)
- Keith L Lee
- Department of Urology, S-287 Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305-5118, USA
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