Results of a prospective clinical trial JN-L-10 using image-defined risk factors to inform surgical decisions for children with low-risk neuroblastoma disease: A report from the Japan Children's Cancer Group Neuroblastoma Committee

Beyond image defined risk factors (IDRFs): a delphi survey highlighting definition of the surgical complexity index (SCI) in neuroblastoma

PURPOSE

Preoperative evaluation of Image Defined Risk Factors (IDRFs) in neuroblastoma (NB) is crucial for determining suitability for upfront resection or tumor biopsy. IDRFs do not all carry the same weighting in predicting tumor complexity and surgical risk. In this study we aimed to assess and categorize a surgical complexity (Surgical Complexity Index, SCI) in NB resection.

METHODS

A panel of 15 surgeons was involved in an electronic Delphi consensus survey to identify and score a set of shared items predictive and/or indicative of surgical complexity, including the number of preoperative IDRFs. A shared agreement included the achievement of at least 75% consensus focused on a single or two close risk categories.

RESULTS

After 3 Delphi rounds, agreement was established on 25/27 items (92.6%). A severity score was established for each item ranging from 0 to 3 with an overall SCI range varying from a minimum score of zero to a maximum score of 29 points for any given patient.

CONCLUSIONS

A consensus on a SCI to stratify the risks related to neuroblastoma tumor resection was established by the panel experts. This index will now be deployed to critically assign a better severity score to IDRFs involved in NB surgery.

Role of surgery in neuroblastoma

Neuroblastoma is the most common malignant solid tumor handled by pediatric surgeons. It is well-known that neuroblastoma shows variable biological and clinical behaviors. In this review article, surgical strategy in neuroblastoma was described by risk stratification. Also, strategy of biopsy and clinical conditions that require special considerations such as neuroblastoma detected by mass screening, relapsed neuroblastoma, patients with stage MS and dumbbell type tumors was mentioned. As multimodal systemic treatments have been expanding, the role of surgery in neuroblastoma has become relatively less significant but requisite. We surgeons should decide therapeutic strategy based on the correct understanding of biology of neuroblastoma thinking of the better future of children.

Correlation between image-defined risk factors and surgical complications in patients with neuroblastoma: a retrospective study

BACKGROUND

Image-defined risk factor (IDRF) is a common tool used for neuroblastoma risk group classification. We speculated that anatomical evaluation by IDRF might be correlated with surgical complications and the oncologic outcome. Here, we investigated correlation between IDRF with outcomes of surgery of neuroblastoma patients.

METHODS

Medical records and computed tomography images of neuroblastoma patients who underwent a surgery at Songklanagarind Hospital between 2002 and 2019 were retrospectively reviewed. IDRFs were analyzed for correlation with surgical complications, overall survival, progression-free survival and local recurrence within 2 years.

RESULTS

Forty-five patients were enrolled in the study. Sixteen (35%) patients had low IDRF score at diagnosis (score ≤ 5). Other 29 (64%) patients had high IDRF score (score ≥ 6). High IDRF group significantly had higher incidence of organ injury and more intraoperative blood loss. At post-chemotherapy, high IDRF was not only associated with higher operative complications, but also associated with 2-year overall survival and progress-free survival.

CONCLUSIONS

Neuroblastoma patients whose IDRF score, either at diagnosis or after neoadjuvant therapy, was 6 or higher had increased risk of surgical complication. This evidence prompts pediatric surgeons to prepare more for safe surgery in this group of patients.

A Metastatic Neuroblastic Tumor in a 28-Month-old Boy: Unusual Spontaneous Regression From Neuroblastoma to Ganglioneuroma?

Neuroblastoma with bone metastasis is well known to have an extremely poor prognosis. We experienced the case of a patient with adrenal ganglioneuroblastoma (GNB) with metastases of subcutaneous nodules, a lymph node, and multiple bones. A pathologic examination of tumors from different sites revealed both GNB and ganglioneuroma. A genetic comparison between these tumors identified the same molecular signatures, suggesting the possibility of spontaneous differentiation in the remaining GNB. The patient has been healthy without aggressive chemotherapy, and the patient's pathologic urinary catecholamines normalized. Even if unusual, we have to recognize probable spontaneous differentiation from neuroblastoma to GNB and then to ganglioneuroma, even in sites of bone metastasis.

Arterial constriction after resection of neuroblastic tumors in children: Two-center retrospective study

BACKGROUND/PURPOSE

Neuroblastic tumors are the most common pediatric extracranial solid tumors in infants and very young children. Although, especially in newborns, there is an increasing number of situations in which observation alone is used, surgery remains an important step in the treatment of neuroblastoma but can be complicated by arterial vasospasm in the surgical field. The aim of this two-center retrospective study was to analyze the occurrence of arterial constriction as a complication of neuroblastic tumors resection.

METHODS

Medical records of patients who were treated surgically for neuroblastic tumors in the years 2012-2019 were reviewed.

RESULTS

For 8 years, 113 children were treated for neuroblastic tumors. The treatment included both primary and delayed surgery after initial chemotherapy carried out according to SIOPEN protocols. In 11 out of 113 cases (9.7%) local arterial constriction was observed. In 6 out of 11 cases an attempt was made to save the organ, however, two patients suffered from kidney atrophy, two other partial kidney infarctions, one child suffered from partial limb paresis, and another from brain ischemia and death.

CONCLUSIONS

Local arterial constriction constitutes a relatively common (10% of cases) and severe complication of neuroblastic tumors resection. Efficacy of local application of papaverine based on our experience remains unproven hence further research is warranted.

Implication of Image-Defined Risk Factors for the Extent of Surgical Resection and Clinical Outcome in Patients with Pelvic Neuroblastoma

INTRODUCTION

 Pelvic neuroblastoma (NB) is a rare entity and occurs in 2 to 5% of all NBs. Surgery in the pelvic area is-even for the experienced oncological surgeon-technically challenging, as injuries of bladder and/or rectal innervation may carry lifelong consequences for the patient. Several studies have proven the impact of image-defined risk factors (IDRFs) for outcome, complications and extent of resection in NB; however, the specific role of IDRF in pelvic NB has not been investigated yet.

MATERIALS AND METHODS

 Patient charts were retrospectively evaluated for International Staging System stage, IDRF status, MYCN amplification, and outcome parameters.

RESULTS

 Between 2003 and 2019, 277 NBs were surgically resected in the department of pediatric surgery of Dr. von Hauner Children's Hospital. Out of these, 11 patients (3.9%) had pelvic NB. Evaluation of the preoperative imaging showed two patients without IDRF (stage L1) and eight patients in stage L2. One patient had stage M according to distant metastasis. Patients without IDRF underwent complete macroscopical resections, whereas complete tumor removal was not possible without mutilation in patients with IDRF. At time point of diagnosis, only patients with IDRF had functional neurological problems. Three patients developed perioperative complications; all of them had at least one IDRF. Three patients developed local recurrence during the course of the disease, all of them had at least one IDRF.

CONCLUSION

 Our results indicate on a preliminary level the importance of IDRF as a prognostic tool for surgical removal of pelvic NB.

Development of a Selective Tumor-Targeted Drug Delivery System: Hydroxypropyl-Acrylamide Polymer-Conjugated Pirarubicin (P-THP) for Pediatric Solid Tumors

Simple Summary

Hydroxypropyl acrylamide polymer-conjugated pirarubicin (P-THP), an innovative polymer-conjugated anticancer agent, theoretically has highly tumor-specific distribution via the enhanced permeability and retention (EPR) effect. While anthracyclines are extremely important in the treatment of most pediatric solid tumors, P-THP may serve as a less toxic and more effective substitute for conventional anthracyclines in both newly diagnosed and refractory/recurrent pediatric cancers.

Abstract

Most pediatric cancers are highly chemo-sensitive, and cytotoxic chemotherapy has always been the mainstay of treatment. Anthracyclines are highly effective against most types of childhood cancer, such as neuroblastoma, hepatoblastoma, nephroblastoma, rhabdomyosarcoma, Ewing sarcoma, and so forth. However, acute and chronic cardiotoxicity, one of the major disadvantages of anthracycline use, limits their utility and effectiveness. Hydroxypropyl acrylamide polymer-conjugated pirarubicin (P-THP), which targets tumor tissue highly selectively via the enhanced permeability and retention (EPR) effect, and secondarily releases active pirarubicin molecules quickly into the acidic environment surrounding the tumor. Although, the latter rarely occurs in the non-acidic environment surrounding normal tissue. This mechanism has the potential to minimize acute and chronic toxicities, including cardiotoxicity, as well as maximize the efficacy of chemotherapy through synergy with tumor-targeting accumulation of the active molecules and possible dose-escalation. Simply replacing doxorubicin with P-THP in a given regimen can improve outcomes in anthracycline-sensitive pediatric cancers with little risk of adverse effects, such as cardiotoxicity. As cancer is a dynamic disease showing intra-tumoral heterogeneity during its course, continued parallel development of cytotoxic agents and molecular targeting agents is necessary to find potentially more effective treatments.

Comparison of the Efficacy of Minimally Invasive and Open Surgery on Children with Neuroblastoma: A Meta-Analysis

Purpose: Evaluate the clinical efficacy and safety of minimally invasive surgery (MIS) and open surgery in the treatment of neuroblastoma (NB) in children by a meta-analysis. Materials and Methods: This is a meta-analysis. We searched for random or nonrandomized controlled study of MIS group and OPEN surgery group for the treatment of childhood NB included in PubMed, ClinicalTrials, EMBASE, and Cochrane library before January 31, 2020. Data extraction was performed in a standard format for the included studies, including tumor diameter, operation time, intraoperative bleeding, length of hospital stay (LOHS), complications, recurrence, and MYCN. Results: Seven retrospective studies were finally included, with a total of 571 children, including 162 in MIS group and 409 in the OPEN surgery group. Compared with the OPEN surgery group, the MIS group had reduced intraoperative bleeding (mean difference [MD] = -12.72, 95% CI: -24.84 to -0.61, P < .05), and reduced l LOHS (MD = -3.35, 95% CI: -5.55 to -1.15, P < .05) and decreased postoperative recurrence (MD = 0.20, 95% CI: 0.05-0.75, P < .05). The differences between the groups were statistically significant. There was no significant difference between groups in tumor diameter (MD = -18.84, 95% CI: -48.12 to 10.43, P > .05), operation time (MD = -21.7, 95% CI: -97.52 to 54.13, P > .05), and MYCN results (odds ratio = 2.27, 95% CI: 0.56-9.18, P > .05). Conclusions: Preliminary evidence indicates that the treatment of NB with MIS has the advantages of less intraoperative bleeding, shorter LOHS, and less postoperative recurrence compared with open surgery.