Maturing neuroblastoma and ganglioneuroblastoma: a study of four cases with long survival

Roles of PET/Computed Tomography in the Evaluation of Neuroblastoma

Neuroblastoma is one of the most common pediatric malignant tumors. Functional imaging plays an important role in the diagnosis, staging, and therapy response monitoring of neuroblastoma. Although metaiodobenzylguanidine scan with single-photon emission computed tomography/computed tomography remains the mainstay in functional imaging of the neuroblastomas, PET/CT has begun to show increased utility in this clinical setting.

Posttreatment Maturation of Medulloblastoma into Gangliocytoma: Report of 2 Cases

INTRODUCTION

We report 2 cases of medulloblastoma maturing into gangliocytoma after receiving multimodal therapy. Here we present 2 cases of diagnosed medulloblastoma which on re-resection were noted to be gangliocytoma without heterogeneity, which is an extremely rare occurrence.

CASE PRESENTATION

The first patient, an 11-year-old boy diagnosed with high-risk (non-WNT, non-SHH) medulloblastoma, was treated with near-total surgical resection followed by craniospinal radiation therapy with weekly vincristine. He then received maintenance chemotherapy with vincristine, cyclophosphamide, and cisplatin. On surveillance MR imaging studies residual tumor in the lateral aspect of the tumor bed was noted to be slowly growing, eliciting gross-total resection of the residual tumor. Histopathology showed benign gangliocytoma without residual medulloblastoma. The second patient, a 3-year-old girl, was diagnosed with medulloblastoma, desmoplastic nodular variant. She was initially treated with gross total resection and chemotherapy with etoposide, carboplatin, and high-dose methotrexate. At 4 months off therapy, she was noted to have local recurrence along the resection cavity. Second-line therapy was started with irinotecan and temozolomide, but MRI assessment during treatment showed further disease progression. She then received craniospinal radiation. Eleven months off therapy, further radiographic progression was noted, and the patient underwent second-look surgery, with pathology showing gangliocytoma and treatment-related gliosis.

DISCUSSION/CONCLUSION

The maturation of medulloblastoma into a ganglion cell-rich lesion is very rare, with few well-characterized previous reports. Given the rare nature of this entity, it would be of great value to understand the process of posttreatment maturation and the genetic and treatment factors which contribute to this phenomenon.

Criteri Istologici per La Valutazione Prognostica Del Neuroblastoma

Gli autori espongono i risultati di uno studio statistico concernente le correlazioni tra quadro istopatologico e durata di sopravvivenza, in 41 bambini affetti da neuroblastoma. Dopo aver accennato alla significatività di alcuni elementi clinici, vengono descritti i reperti istologici che possono fornire indicazioni sul comportamento della neoplasia. Tali reperti sono rappresentati dal grado di differenziazione e dal grado di infiltrazione linfocitaria del tessuto neoplastico. Infatti dal confronto dell'incidenza di tali reperti nei soggetti deceduti ed in quelli sopravvissuti si sono rilevate differenze statisticamente significative (p < 0.001). Gli autori sottolineano, inoltre, che il grado di differenziazione cellulare si identifica con il numero degli elementi in evoluzione maturativa e non con il numero delle cellule del tutto mature.

Presence of differentiating neuroblasts in bone marrow is a favorable prognostic factor for bone marrow metastatic neuroblastoma at diagnosis

Background

The prognostic impact of the presence of differentiating neuroblasts in bone marrow (BM) remains unclear in BM metastatic neuroblastoma (NB). We aimed to identify the prognostic impact of differentiating neuroblasts in BM at diagnosis and after chemotherapy.

Methods

A total of 51 patients diagnosed with BM metastatic NB at Asan Medical Center between January 1990 and July 2005 were enrolled. BM histology and laboratory data along with overall survival (OS) were compared with regard to the differentiation status of neuroblasts in BM at diagnosis and after chemotherapy.

Results

Among the 51 patients, 13 (25.5%) exhibited differentiating neuroblasts in BM at diagnosis and 17/51 (33.3%) exhibited them after chemotherapy. The only significant difference among patient groups was the improved OS in patients with differentiated neuroblasts in BM at diagnosis (P=0.021). In contrast, the differentiation status of neuroblasts in BM after chemotherapy did not affect OS (P=0.852).

Conclusions

Our study is the first report describing the presence of differentiating neuroblasts in BM. The presence of differentiating neuroblasts in BM at diagnosis may be a favorable prognostic factor for patients with BM metastatic NB; however, the same phenomenon after chemotherapy is irrelevant to prognosis.

Effect of STI-571 (imatinib mesylate) in combination with retinoic acid and gamma-irradiation on viability of neuroblastoma cells

Neuroblastoma (NB) expresses the tyrosine kinase receptors c-Kit, PDGFR-alpha and -beta-targets for STI-571. We investigated a possible combination therapy of STI-571 with retinoic acid (RA) and gamma-irradiation on NB cell viability in vitro. Expression of tyrosine kinase receptors and their ligands was examined in 6 NB cell lines by RT-PCR and FACS. The effect on cell viability was determined by MTT assay. Cell viability of all 6 NB cell lines was significantly inhibited after treatment with 20 microM STI-571 for 72h, two cell lines responding already to 10 microM. Cell lines responded irrespective of their mRNA status or cell surface expression of c-Kit, PDGFR-alpha and -beta. Co-incubation with 9-cis RA sensitized cells to the inhibitory effects of STI-571. However, pre-treatment with 9-cis RA resulted in resistance of NB cell lines to STI-571 and gamma-irradiation. Treatment of NB with STI-571 in combination with 9-cis RA might be a therapeutic strategy for patients in consolidation therapy who have completed gamma-irradiation therapy.

Retinoid therapy of childhood cancer

In vitro studies that showed RA could cause growth arrest and differentiation of myelogenous leukemia and neuroblastoma led to clinical trials of retinoids in APL and neuroblastoma that increased survival for both of those diseases. In the case of APL, ATRA has been the drug of choice, and preclinical and clinical data support direct combinations of ATRA with cytotoxic chemotherapy. For neuroblastoma, a phase I study defined a dose of 13-cis-RA, which was tolerable in patients after myeloablative therapy, and a phase III trial that showed postconsolidation therapy with 13-cis-RA improved EFS for patients with high-risk neuroblastoma. Preclinical studies in neuroblastoma indicate that ATRA or 13-cis-RA can antagonize cytotoxic chemotherapy and radiation, so use of 13-cis-RA in neuroblastoma is limited to maintenance after completion of cytotoxic chemotherapy and radiation. A limitation on the antitumor benefit of ATRA in APL is the marked decrease in drug levels that occurs during therapy as a result of induction of drug metabolism, resulting in a shorter drug half-life and decreased plasma levels. Although early studies sought to overcome the pharmacologic limitations of ATRA therapy in APL, the demonstration that ATO is active against APL in RA-refractory patients has led to a focus on studies employing ATO. Use of 13-cis-RA in neuroblastoma has avoided the decreased plasma levels seen with ATRA. It is likely that recurrent disease seen during or after 13-cis-RA therapy in neuroblastoma is due to tumor cell resistance to retinoid-mediated differentiation induction. Studies in neuroblastoma cell lines resistant to 13-cis-RA and ATRA have shown that they can be sensitive, and in some cases collaterally hypersensitive, to the cytotoxic retinoid fenretinide. Fenretinide induces tumor cell cytotoxicity rather than differentiation, acts independently from RA receptors, and in initial phase I trials has been well tolerated. Clinical trials of fenretinide, alone and in combination with ceramide modulators, are in development.

Conversion of multiple solid testicular teratoma metastases to fatty and cystic liver masses following chemotherapy: CT evidence of "maturation"

Testicular germ cell tumour metastases may undergo "retroconversion" to mature differentiated teratoma following chemotherapy or irradiation. We report a patient with testicular germ cell liver metastases in whom computed tomography (CT) scans following chemotherapy demonstrated a reduction in CT attenuation of the liver lesions to that of cystic and fatty density. This is believed to represent CT evidence of liver metastasis "retroconversion", which offers the potential for non-invasive monitoring of histological progression.

Pineal ganglioneuroblastoma in an adult

A 57-year-old male with pineal ganglioneuroblastoma was reported. The tumor was composed of a predominant ganglioneuromatous component and a small neuroblastic component. Primary ganglioneuroblastoma of the pineal region is extremely rare. To our knowledge, only three cases have been documented. This case may have a good prognosis because there is a predominant ganglioneuromatous component defined by both neurofilament triplet proteins and synaptophysin. The clinical significance of the neuronal differentiation in the present case and pathological considerations are discussed.

Retinoic acid enhances killing of neuroblastoma cells by Newcastle disease virus

Newcastle disease virus (NDV), an avian pathogen, selectively replicates in and kills neuroblastoma (NB) cells, but not normal fibroblasts in vitro and in vivo in nude mice. NDV cytotoxicity towards NB cells is enhanced by N-myc oncogene amplification. To further define the antineoplastic effects of NDV, we examined NDV's interaction with NB cells following short-term exposure to the differentiating agent, all-trans retinoic acid (RA), and to neuraminidase. The human NB cell line IMR-32, after treatment with 50 mumol/L RA, became eight times more sensitive to NDV in a cytotoxicity assay. A time course study to determine the optimal incubation period of IMR-32 cells with RA indicated that a fourfold increase in sensitivity towards NDV killing occurred after only 8 hours of RA incubation prior to addition of virus. Maximal sensitivity was achieved at 24 hours of RA incubation and remained constant for longer incubation periods (up to 72 hours). The sensitization of IMR-32 NB cells to NDV was constant for RA doses between 3 mumol/L and 50 mumol/L. Plaque formation, which indicates replication, virus spread and cytotoxicity by a single infectious virus particle, was also enhanced by RA. This effect does not appear to require N-myc amplification in the target NB cells since RA had similar effects upon the high N-myc (IMR-32) and the low N-myc expressing cells (SK-N-SH). Enhanced sialylation has been shown by others to mediate the growth inhibitory effects of RA on a variety of tumor lines. Removal of sialic acid from the IMR-32 NB cell surface using Clostridium neuraminidase (2.7 mg/mL) inhibited 75% of NDV plaque formation. These results demonstrate that NDV killing of two NB cell lines is enhanced using clinically achievable levels of RA and that sialylation of the NB cell surface is important for virus binding and cytotoxicity.

Morphology of experimental tumors of the sympathetic nervous system

The morphology of experimental tumors of the sympathetic nervous system in rabbits and hamsters induced by administration of nitrose compounds and the use of modifying factors were studied. The tumors were localized in the mediastinum, retroperitoneal space, adrenals and kidneys. A predominant involvement of the female animals was observed. Histological, histochemical and electron microscopic studies of 33 tumors of the sympathetic nervous system were carried out. By their degree of maturity the tumors were classified as ganglioneuromas, ganglioneuroblastomas and neuroblastomas. By their structure the experimental tumors were similar to the analogous neoplasias of man.

Complete pathologic maturation and regression of stage IVS neuroblastoma without treatment

Spontaneous maturation of Stage IVS neuroblastoma has been postulated as a mechanism for its favorable prognosis, but this has rarely been documented pathologically. We report on a patient with congenital Stage IVS neuroblastoma who had extensive subcutaneous and bone-marrow involvement. Serial photographs, biopsies, and vanillomandelic acid determinations documented the tumor's initial progression which was followed by spontaneous maturation and involution of the patient's disease over a 6-year period. No cytotoxic therapy was administered. Favorable biologic prognostic factors were documented, including tumor DNA and protein analyses for N-myc amplification or overexpression and analysis for serum neuron-specific enolase and ferritin. Implications for management and therapy of Stage IVS neuroblastoma are discussed with reference to this case and the recent literature.

An outlier theory of cancer curability. Tumor cell differentiation as a therapeutic goal

Combinations of cytotoxic agents that cure a substantial percentage of patients with several childhood and adult malignancies are much less efficacious for the majority of solid tumors. Standard approaches for curability that rely solely on the concept of cytotoxicity may not be applicable for most epithelial and mesenchymal solid malignancies. Differentiation may play a more important role in cancer cure than heretofore suspected. Clinical and experimental evidence supports further investigation into models of inducing tumor cell differentiation. The question of why such models could predict for curative modalities of treatment is discussed.

Primary cerebral neuroblastomas. A clinicopathological study of one adolescent and five adult patients

Neuronal differentiation was demonstrated by light microscopy, immunohistochemistry and electron microscopy in the cerebral neoplasms of one adolescent and five adult patients. The tumours exhibited a wide spectrum of cellular differentiation from low to high grade malignancy which seems to correlate well with their biological behaviour. The natural history of these 6 cerebral neuroblastomas is rather long compared to that of other malignant primary cerebral neoplasms of adulthood; however, 2 patients died, one survived about 5 yr after initial symptoms whilst an untreated patient survived more than 12 yr. It is suggested that morphological grading along the lines of Kernohan's system may be useful in determining the prognosis and postoperative management of patients with cerebral neuroblastomas.

Ganglioneuroma presenting with differentiated skeletal metastases. Report of a case

The authors report the case of a child with retroperitoneal ganglioneuroma and cytodifferentiated skeletal metastases. The primary tumor was surgically resected, and the child is alive and well 2 years later without additional therapy. This rarely documented phenomenon can be explained by spontaneous cytomaturation within both primary and metastatic tumor.

Prognostic factors in neuroblastomas

The clinical and histological factors affecting prognosis for 70 patients with neuroblastomas were tested with regression analysis. Generalized tumor disease was found to be of primary importance. Significant predictors for prognosis in patients without distant metastases were operation, with or without other therapy, age less than one year and histology. When all recorded factors were analyzed the explanation value only reached 0.42. This indicates that the variation in prognosis depends upon other factors as well.

Neuroblastoma and the differential diagnosis of small-, round-, blue-cell tumors

Of the solid tumors of childhood, neuroblastoma--the prototypic small-, round-, blue-cell neoplasm--occurs in the youngest patients and has shown the least predictable biologic behavior and response to therapy. It is often confused clinically and histologically with Wilms' tumor, rhabdomyosarcoma, lymphoma, and especially, Ewing's sarcoma. Certain clinical and histologic features that may be useful in prognosis have been identified, however, and a variety of distinctive light microscopic, electron microscopic, and immunohistochemical features may be useful in differentiating this and related tumors. Many of the varied techniques useful in the differential diagnosis of these tumors can now be employed routinely in most laboratories.

Spontaneous regression of stage IV neuroblastoma

Neuroblastoma presenting with wide spread osseous metastases (stage IV) is generally considered incurable. However, rare cases of spontaneous regression and cure are on record. This report deals with such a case in which an infant received steroids as sole treatment for developing skeletal pain. Established metastases to the brain, scalp and skeleton disappeared. Today 4 1/2 years later the patient is free from symptoms and signs of tumour.

Effects of multiple-drug chemotherapy (cis-diammine-dichloroplatinum, bleomycin, and vinblastine) on the maturation of retroperitoneal lymph node metastases of nonseminomatous germ cell tumors of the testis. No evidence for De Novo induction of differentiation

Investigating the mechanisms underlying maturation of metastases of nonseminomatous germ cell tumors on administration of chemotherapy, the histologic characteristics of primary testis tumors was compared to the histologic characteristics of their retroperitoneal metastases in three historical patient groups. The metastases in Group I (20 patients) were not treated; those in Groups II (nine patients) and III (24 patients) were treated, respectively, with three cycles of dactinomycin and with four cycles of cis-diammine-dichloroplatinum, vinblastine, and bleomycin, before retroperitoneal lymph node dissection. In Group III there was a significant increase of metastases consisting of differentiated teratoma only, as compared to the metastases of Group I. However, both with and without chemotherapy, the metastases contained fewer areas of differentiated teratoma than the primary lesions. Metastases containing differentiated teratoma with and without other components, with one exception in Group III, were derived from primary tumors containing mature areas as well. Components other than mature teratoma were almost completely eradicated in Group III. These findings strongly suggest that selective destruction of components other than differentiated teratoma causes the mature histologic characteristics in the metastases upon administration of chemotherapy. The results do not support the hypothesis of induction of differentiation by the chemotherapeutic agents.

Primary pulmonary ganglioneuroblastoma in an adult: maturation, involution and the immune response

The features of a primary pulmonary ganglioneuroblastoma occurring in an adult are presented. The tumour showed evidence of both maturation and involution. Maturation appeared to be occurring in a centrifugal manner, a rim of mature ganglioneuromatous tissue enclosing the primitive neuroblastoma. Necrosis of the neuroblastomatous element was widespread and associated with deposition in the walls of numerous small vessels of an amorphous eosinophilic amyloid-like material. Accumulation of this material had led to occlusion of some vessels with resultant necrosis of related tumour. A collarette of lymphocytes surrounded the tumour, and lymphocytic aggregates were prominent at the interface between neuroblastoma and ganglioneuroma. Despite widespread vascular invasion, the patient remains well and apparently tumour-free, 2 1/2 years post-resection. The appearances may represent a combined cellular and humoral host response, and a possible relationship of this response to tumour maturation is suggested. The potential role of immunostimulation in the treatment of neuroblastoma is discussed.

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

The pathology and clinical course of 80 cases of ganglioneuroblastoma (GNB) of the posterior mediastinum are presented. Many neoplasms in this series had previously been classified as differentiating neuroblastomas or immature ganglioneuromas. The prognosis for this group is far better than that for either neuroblastomas or intra-abdominal GNBs. Follow-up was obtained for 72 patients, of whom 55 were followed for 2-23 years. The five-year actuarial survival rate was 88%. Prognosis was related to histologic growth pattern, age, and extent of disease at diagnosis. Stage I tumors were curable by simple excision; children with Stage II tumors treated with surgery and radiation responded as favorably as did those who received adjunctive chemotherapy. In contrast to those associated with late recurrences, the only examples of fatal primary tumors, with one exception, were those patients with Stage IV lesions at the time of initial diagnosis. The therapeutic implications and need for uniform terminology in classifying GNBs are discussed.

Ganglioneuroblastomas of the cervical sympathetic nerve

Although ganglioneuroblastomas occur infrequently in the head and neck area, if they are recognized and completely excised initially, the chances of cure are greatly increased. Two patients are reported who demonstrate some of the more important aspects of diagnosis and treatment. The first patient, whose retropharyngeal tumor was diagnosed when he was 12 years of age, was treated with transoral excisional biopsy. He is alive and tumor-free 3 1/2 years later. The second patient, a 2-year-old , was treated by incisional biopsy without a major resection. He died on year later. The diagnostic evaluation of a patient with suspected neurogenic tumor includes a complete physical examination for distant adenopathy, abdominal masses, hypertension, and neurological impairment. Intraoperatively, neurosurgical and pathological consultation should be available.

Vasocative intestinal polypeptide (VIP)-producing ganglioneuroma in a child with chronic diarrhea

In a 2 1/2-year-old girl with persistent watery diarrhea a retroperitoneal tumour and lymph node composed of benign ganglioneuroma cells were found. The histological picture was compatible with an original metastasizing neuroblastoma which has passed through a stage of late maturation. Electron microscopy of the ganglioneuroma showed cytological evidence of increased secretory activity. The tumour contained large amounts of vasoactive intestinal polypeptide (VIP) and preoperative plasma concentration of this peptide was increased. Postoperatively the VIP concentration was normalized, and the diarrhea ceased. Analysis of catecholamine metabolites in urine was normal. The findings suggest that the watery diarrhea was due to the benign VIP-producing neural crest tumour.

Ganglioneuroma arising in accessory adrenal gland

We believe a first case of ganglioneuroma arising in an accessory adrenal gland is reported. Evidence suggests the ganglioneuroma is a benign tumor of neural crest origin that arises by spontaneous maturation from malignant neuroblastoma.

The in vivo differentiation of murine neuroblastoma

C1300 neuroblastoma was implanted with regenerating skeletal muscle to study the role of tissue interactions during tumor cell differentiation. Combined tumor-muscle implants, placed subcutaneously or within diffusion chambers were compared with control tumors implanted without muscle. Neuroblastoma implanted with injured muscle undergoes a partial neuronal differentiation. The tumor cells lose their normal round cell configuration and develop numerous cytoplasmic processes. Accompanying these outward changes are an increased content of microtubules in the neuritic processes; the appearance of glial-like processes containing abundant microfilaments; and the occurrence of growth vesicles identical to those of the growth cones of normal neurites. Although the implants usually contain large numbers of regenerated myofibers, tumor cell differentiation is not dependent upon the presence of these newly formed fibers. Tumor differentiation occurs equally well on the surfaces of degenerating muscle fragments, fibrin deposits and on the membrane surfaces of the diffusion chambers. These observations suggest that non-specific cell surface phenomena, rather than neuromuscular interactions were primarily responsible for the tumor cell differentiation in vivo.