Das Ganglioneuroblastom, ein besonderer Typus im System der Neurome

Chronic Diarrhea Caused by Vasoactive Intestinal Peptide-Secreting Tumor

VIPomas are a type of neuroendocrine tumor that independently produces vasoactive intestinal peptide (VIP). VIPomas causing watery diarrhea, hypokalemia, and achlorhydria (WDHA) syndrome are not frequently observed in adult patients without pancreatic ailments. However, in children, the occurrence of a VIPoma originating in the pancreas is exceedingly uncommon. Instead, WDHA syndrome is more commonly associated with neurogenic tumors that secrete VIP, often located in the retroperitoneum or mediastinum. Among infants, chronic diarrhea is a prevalent issue that often necessitates the attention of pediatric gastroenterologists. The underlying causes are diverse, and delays in arriving at a definitive diagnosis can give rise to complications affecting the overall well-being of the child. The authors present the case of an infant with chronic watery diarrhea, subocclusion manifestations, mild hypokalemia, and metabolic hyperchloremic acidosis secondary to a VIPoma in the retroperitoneum that was diagnosed via abdominal ultrasound and tomography. The laboratory results revealed lowered potassium levels and an excessive secretion of VIP. Following the surgical removal of the tumor, the diarrhea resolved, and both electrolyte levels and the imbalanced hormone levels returned to normal. Immunohistochemical examination confirmed the diagnosis of ganglioneuroblastoma, with N-MYC negative on molecular biology tests. We present the clinical and histo-genetic aspects of this rare clinical entity, with a literature review.

High-Risk Neuroblastoma: Poor Outcomes Despite Aggressive Multimodal Therapy

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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.

Clinicopathological characteristics of ganglioneuroma and ganglioneuroblastoma: a report from the CCG and COG

BACKGROUND

The International Neuroblastoma Pathology Classification (INPC) was the first to clearly define prognostic subgroups in ganglioneuroma (GN) and ganglioneuroblastoma (GNB).

PROCEDURE

Histopathology and tumor resectability of 552 GN/GNB cases from the Children's Cancer Group (CCG) and Children's Oncology Group (COG) neuroblastoma studies were reviewed. The results were analyzed along with clinical information and biological data of the cases.

RESULTS

According to the INPC, 300 tumors were classified into the Favorable Histology (FH) group and 252 were into the Unfavorable Histology (UH) group. Tumors in the FH group included 43 ganglioneuroma-maturing (GN-M), 198 ganglioneuroblastoma-intermixed (GNB-I), and 59 ganglioneuroblastoma-nodular, favorable subset (GNB-N-FS), and were often (91%) resected completely by single or multiple surgical procedures. Patients with the FH tumors had an excellent prognosis with no tumor-related deaths. The UH group included ganglioneuroblastoma-nodular, unfavorable subset (GNB-N-US) tumors. Patients with the UH tumors had a high incidence (53%) of distant metastasis at the time of diagnosis, and their prognosis significantly depended on clinical stage (5-year EFS: 80.1% for non-stage 4 patients; 16.7% for stage 4 patients): Complete primary tumor resection was not beneficial to those GNB-N-US patients, regardless of whether metastasis was present or not. MYCN amplification was detected in four tumors in the FH group and six tumors in the UH group. The majority (160/191, 84%) of GN-M and GNB-I tumors had a diploid pattern determined by flow cytometry.

CONCLUSIONS

Stringent application of the INPC along with clinical staging was critical for prognostic evaluation of the patients with this group of tumors.

Characterization of the cholinergic neuronal differentiation of the human neuroblastoma cell line LA-N-5 after treatment with retinoic acid

Analysis of the molecular factors that control cellular differentiation in mammalian embryos is difficult due to the small amount of material available from embryos and their inaccessibility during gestation. One way to circumvent these limitations is to use model systems that allow the study of differentiation in vitro. In this study we have characterized the response of a human neuroblastoma cell line, LA-N-5, to the differentiation-inducing agent, all-trans retinoic acid (RA) using 23 markers that are characteristic of neural crest cells and some of their derivatives. Following induction with RA, the neural crest-like LA-N-5 cells undergo differentiation into cholinergic neurons with increased expression of a variety of neural-specific markers including neurofilaments, growth associated protein-43, tetanus toxin binding sites, receptors for neurotrophic factors, neuropeptides, choline acetyl transferase, vesicular acetylcholine transporter, and acetylcholinesterase with a concomitant decrease in the expression of non-neuronal markers. These results provide the basis for the use of retinoic acid-induced differentiation of LA-N-5 cells as a model system to study molecular events associated with the differentiation of cholinergic neurons.

Evidence for molecular heterogeneity in human ganglioneuroblastoma

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

Primary ganglioneuroblastoma of the anterior mediastinum in a 61-year-old woman

A case of primary ganglioneuroblastoma located in the anterior mediastinum is described. The tumour was found incidentally at autopsy in a 61-year-old woman who died of coronary artery thrombosis. There was no evidence of metastases. Histologically the tumour was a ganglioneuroblastoma of the diffuse type. There was no pure neuroblastomatous tissue present and maturation to ganglioneuroma was not observed. Regressive changes like fibrosis and calcification were present. Review of the literature failed to reveal any recorded cases of ganglioneuroblastoma occurring in the anterior mediastinum. Although ganglioneuroblastoma occurs predominantly in children, 24 cases occurring in adults have been reported in the literature.

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.

Ganglioneuroblastoma in adults

Ganglioneuroblastoma is a rare neoplasm of adults. Some information about the natural history and response to therapy can be obtained from two cases seen recently at our hospital and 17 cases in the literature. These tumors occur in adults of any age and are usually located in the retroperitoneum, mediastinum, or neck. Evidence of the tumor may be present years before diagnosis. Elevations of urinary catecholamines were documented in three cases and the levels correlated with progression or resection of the neoplasm. The tumor spreads either by local invasion or distant metastasis. Attempts at radiotherapy and chemotherapy in the treatment of unresectable or disseminated tumor has not resulted in objective improvement. This contrasts with the widely reported objective successes and cures of ganglioneuroblastomas occurring in childhood. Surgical excision of localized disease was the only curative therapeutic modality in the cases we reviewed.