Natural history of neuroblastoma found by mass screening

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.

Relapsed perinatal neuroblastoma after expectant observation

The Children's Oncology Group (COG) study ANBL00P2 showed that expectant observation of patients younger than six months of age with perinatal neuroblastoma presenting as a small adrenal mass yields excellent overall survival and spares surgical resection to the majority of patients. We report a 5-year-old female who was initially diagnosed with a perinatal neuroblastoma. The patient was observed on COG study ANBL00P2. By nine months of age she had no ultrasonographic or biochemical evidence of disease. She presented four years later with abdominal pain and was found to have high-risk stage 4 MYCN amplified neuroblastoma.

Retroperitoneal ganglioneuroblastoma resected 8 years after mass screening: a case report

An 8-year-old girl presented with abdominal tumor that was discovered incidentally. At surgery, the tumor originated from the retroperitoneal sympathetic trunk; and the histologic diagnosis was ganglioneuroblastoma, nodular (GNBn), unfavorable histology on Shimada's classification, International Neuroblastoma Staging System (INSS) stage 1. This patient was found positive for neuroblastoma (NB) by mass screening at 6 months old. There was no tumor detected, and tumor markers decreased to normal range by 18 months of age. We examined her previous computed tomographic films retrospectively and noticed a mass in the same region indicating that the tumor had been there for 8 years without treatment. This is the first report of infantile mass screening-positive NB appearing after long-term follow-up with unfavorable histology. And the follow-up interval was the longest ever reported. This case is suggestive of considering the natural history and treatment strategies for infantile NBs, and the relationship between infantile NB and ganglioneuroblastoma, nodular. It is important to follow mass screening-positive cases of NB over the long term if wait-and-see policy is adopted.

Successful treatment of chemoresistant stage 3 neuroblastoma using irinotecan as a single agent

The authors describe a 1-year-old boy who was diagnosed with neuroblastoma by mass screening at age 6 months. The tumor originated from the left retroperitoneum and extended over the midline, involving major vessels and invading the spine with compression of the spinal cord. Although seven courses of chemotherapy consisting of vincristine sulfate, cyclophosphamide, pirarubicin hydrochloride, and cisplatin were administered, there was no reduction in tumor size or decrease in tumor markers. The patient received irinotecan 180 mg/m per day for 3 days. Approximately 3 weeks later the tumor had regressed remarkably, and tumor markers normalized after the second course of irinotecan. This therapy was given a total of four courses every 4 weeks, with the tumor shrinking successively in each session. Four years after treatment there is no sign of recurrence and the patient is doing well. This case may be the first report showing the dramatic efficacy of irinotecan in the treatment of chemoresistant neuroblastoma without the use of other antitumor agents. Irinotecan might be a promising drug in the management of patients with high-risk neuroblastoma.

Neuroblastoma trends in Osaka, Japan, and Great Britain 1970-1994, in relation to screening

Japan pioneered and has maintained a nationwide mass screening programme for neuroblastoma since 1985 without prior evaluation among a target population. Convincing population-based evaluation of the ongoing programme has also been very limited because a population-based registry for childhood cancer has not been in operation. This report describes trends in incidence of and mortality from neuroblastoma in Osaka Prefecture, Japan, using Great Britain as an external control, between 1970 and 1994. Incidence and mortality rates were comparable between the 2 areas before the beginning of screening in Osaka. However, incidence rates were markedly increased in Osaka, especially among children younger than 1 year, from 25.9 per million children during 1970-1979 to 240.2 during 1991-1994, while age-standardized incidence rates for metastatic tumours among children aged 1 year or above did not decrease after introduction of the programme. Age-standardized mortality rates per million were unchanged at 3.9 (1970-1979) and 4.1 (1991-1994) in Osaka and 5.7 (1971-1979) and 5.0 (1991-1994) in Great Britain. Cumulative incidence rates among those up to 15 years old progressively increased from 103.4 per million (1970-1979) to 350.0 (1991-1994) in Osaka, though cumulative mortality rates did not decrease: 52.0 and 57.5, respectively. Corresponding figures in Great Britain were 101.0, 115.1, 78.6 and 70.1, respectively. The present findings show little beneficial effect of the screening programme.

Stephen L. Gans overseas lecture. Mass screening for neuroblastoma in Japan: lessons learned and future directions

BACKGROUND/PURPOSE

Since 1985, a nationwide mass screening program (MS) for neuroblastoma has been conducted for 6-month-old infants throughout Japan, resulting in the detection of more than 1,900 cases of neuroblastoma. The outcome of these patients has been excellent: more than 97% of them are alive. Yet, several reports suggest that the number of advanced-stage neuroblastoma patients over 1 year of age has not changed substantially. The current report focuses on the 15-year experience with MS of the Kyushu Pediatric Oncology Study Group.

METHODS

The clinical and biological features of neuroblastoms detected (n = 320) and not detected by MS (n = 245) were compared. Regional and national statistics for neuroblastoma before and after 1985 were analyzed using standard epidemiologic measures for the occurrence of disease.

RESULTS

The majority of the MS-positive cases were biologically favorable and had an excellent outcome. In contrast, the majority of non-MS patients in whom neuroblastoma later developed had advanced-stage, unfavorable-prognosis tumors. The overall mortality rate of neuroblastoma in the Kyushu area was not improved by MS.

CONCLUSIONS

The optimal time for screening is the point at which neuroblastomas regressing spontaneously can no longer be detected, but more aggressive disease can be found. A birth cohort study could determine the optimal timing for a second screening. Identification of other new prognostic factors may be required.

Clinical and biologic characteristics for recurring neuroblastoma at mass screening cases in Japan

BACKGROUND

It is said that most cases detected by neuroblastoma mass screening at 6 months of age tend to have a favorable clinical course after a surgical resection either with or without mild chemotherapy. However, a few cases have an unfavorable outcome. In the current study, the authors analyzed the clinical and biologic characteristics for recurring neuroblastoma in mass screening cases.

METHODS

In 245 cases detected through mass screening in the Kyushu area in Japan, the clinical data and biologic features (N-myc status, DNA ploidy, Shimada histology, neuron-specific enolase (NSE), ferritin) were investigated, whereas, in particular, the data for recurring cases also were analyzed.

RESULTS

Of 245 cases, 28 tumors had one or more biologically unfavorable prognostic factors, and 6 patients experienced recurrence. Three of the six patients with recurring disease underwent a complete resection of the primary tumor, whereas three cases had undergone an incomplete resection of the tumor. Regarding the initial chemotherapy, three cases received mild chemotherapy, two cases received no chemotherapy, and one case had high-dose multidrug chemotherapy. Regarding biologic prognostic factors, four of six cases with recurring disease had one or more unfavorable factors, whereas two cases had no unfavorable factors. Regarding the outcome after recurrence, four cases are CR, one case has a stable residual tumor, and one case died of disease with N-myc amplification.

CONCLUSIONS

Most neuroblastomas detected by mass screening at 6 months of age have biologically favorable factors. However, approximately 10% of the cases had one or more unfavorable factors and thus might have a higher risk of recurrence than the patients with no unfavorable factors. Conversely, some cases with recurring disease had no unfavorable factors; however, the reason for this is still unclear. A long-term follow-up for mass screening cases is important, and it also might be necessary to research the established biologic factors and identify other new prognostic factors.

Observation of untreated patients with neuroblastoma detected by mass screening: a "wait and see" pilot study

BACKGROUND

Recent studies have indicated that mass screening for neuroblastoma detects tumors that otherwise would have regressed spontaneously without recognition. Therefore, we started an observation program for these patients to determine how frequently spontaneous regression occurs.

PROCEDURE

Eighteen patients were detected by mass screening between June 1994 and December 1996. Eight of these cases matched the following criteria and entered the observation program: Stage I or II, less than 5 cm in diameter; no involvement of large vessels or organs; not difficult to resect; informed consent. If there were an increase in tumor size, an elevation of tumor markers, or evidence of metastasis, the tumor would be immediately resected.

RESULTS

Five of the eight cases showed spontaneous regression. Although the remaining three tumors were resected 6-10 months after diagnosis, all patients survived without evidence of recurrence.

CONCLUSIONS

At least 60% of neuroblastoma cases who entered our observation program regressed spontaneously.

Risk of unfavorable character among neuroblastomas detected through mass screening. The Japanese Infantile Neuroblastoma Cooperative Study

Current study shows that about 50% of neuroblastomas (NBs) detected through mass screening had factor(s) indicating an unfavorable biological nature and that early intervention after the screening might improve clinical outcome of the patients. On the other hand, favorable properties were detected in the remaining half of the mass-screening NBs. Some of them might have the ability to regress spontaneously. Therapeutic modality should be determined according to their biological nature. Further investigation for their biologic properties is necessary to evaluate the benefits of the mass screening.

Disomy 1 with terminal 1p deletion is frequent in mass-screening-negative/late-presenting neuroblastomas in young children, but not in mass-screening-positive neuroblastomas in infants

The mass screening (MS) of neuroblastoma has been undertaken in Japan by measuring urinary catecholamine metabolites in infants at the age of 6 months. To clarify the biological characteristics of MS-positive (MS+) tumors in infants and MS-negative (MS-)/late-presenting tumors in young children, metaphase cytogenetic and/or interphase 2-color FISH analyses using terminal 1p and pericentromeric 1q probes were performed on 246 (186 MS+ and 60 MS-) patients with neuroblastomas. The 246 tumors were classified into 4 groups on the basis of the constitution of chromosome 1; 22 tumors had disomy 1 with no 1p deletion (Dis1Norm1p); 41 tumors had disomy 1 or tetrasomy 1, all with the 1p deletion (Dis1Del1p); 164 tumors had trisomy 1, pentasomy 1, or a mixed population of cells with trisomy 1 and cells with tetrasomy 1, none with 1p deletion (Tris1Norm1p); 19 tumors with the same copy numbers of chromosome 1 as the Tris1Norm1p group, had 1p deletion (Tris1Del1p). mycn amplification was absent in the Dis1Norm1p and Tris1Del1p groups, frequent in the Dis1Del1p group (24/41), and rare in the Tris1Norm1p group (3/164) (p < 0.0001). Event-free survival at 5 years was lowest [19.5%; 95% confidence interval (CI), 5.1-33.9] in the Dis1Del1p group, highest in the Tris1Norm1p (96.3%; 95% CI, 93.5-99.2) and Tris1Del1p (94.7%; 95% CI, 84.7-104.8) groups, and intermediate but varied (54.5%; 95% CI, 33.7-75.4) in the Dis1Norm1p group (p < 0.0001). Of the MS+ tumors, 90% were Tris1Norm1p or Tris1Del1p, and 55% of the MS- tumors were Dis1Del1p. The finding that the Dis1Del1p tumors were frequent in MS- but not in MS+ tumors suggests the limited efficacy of the MS program into reducing mortality from neuroblastoma.

Mass screening for neuroblastoma at 6 months of age: difficult to justify

BACKGROUND/PURPOSE

A statistical analysis of the mass screening for neuroblastoma in Japan based on a population study rarely has been reported. This study aims to evaluate retrospectively the effectiveness of mass screening at 6 months of age using the available population data.

METHODS

The data on the neuroblastoma cases registered by the Committee for Pediatric Solid Malignant Tumors in the Kyushu area were analyzed based on both screened and unscreened populations in the Kyushu area.

RESULTS

From 1988 to 1992, the cumulative incidence of neuroblastoma in children less than 5 years of age was 82 in 484,599 for screened children, and 11 in 92,966 for unscreened children, respectively. Fourteen of the 82 screened patients had negative findings at 6 months of age (MS-negative cases). No significant difference was observed in the cumulative mortality rates from neuroblastoma in children younger than 5 years of age between the screened children and the unscreened children. Six of seven patients who died among the screened children were MS-negative cases with stage III or IV disease. In addition, no significant difference was found in the cumulative mortality rates from the neuroblastoma cases in patients less than 5 years of age between the children screened from 1988 to 1992 (7 of 484,599) and all children from 1980 to 1984 (14 of 668,084).

CONCLUSIONS

These findings suggests that the majority of the patients detected by mass screening had a favorable prognosis, and, mass screening in Japan for children less than 6 months of age was not observed to reduce the incidence and mortality from neuroblastoma. Therefore, mass screening at 6 months of age was not found to improve substantially the prognosis of patients with unfavorable neuroblastoma identified over 1 year of age, which is the primary purpose of such mass screening for neuroblastoma.

Pathology review of screening negative neuroblastomas: a report from the Quebec Neuroblastoma Screening Project

BACKGROUND

The Quebec Neuroblastoma Screening (QNS) Project completed a 5-year program for measuring urinary vanillylmandelic acid (VMA)/homovanillic acid (HVA) levels at age 3 weeks and/or 6 months in 89% of 476,603 Quebec-born infants from 1989-1994; 45 screening positive preclinical cases (S-positive cases) and 20 congenital/neonatal (C/N) cases were identified. As of April 1997, an additional 59 cases in the same birth cohort were diagnosed clinically; these neuroblastomas developed after screening verified normal VMA/HVA levels (S-negative cases).

METHODS

Pathology specimens from 45 of 59 S-negative cases were reviewed centrally and classified according to the Shimada system. Results were compared with clinical data and also with S-positive and C/N cases.

RESULTS

Of 45 S-negative cases, 27 tumors had favorable histology (FH) and 18 had unfavorable histology (UH). Approximately 52% of FH tumors were diagnosed before age 1 year, whereas UH tumors were nearly exclusively (94%) diagnosed after age 1 year (P < 0.01). Approximately 89% of FH tumors were Stage I, II, or IV-S, whereas 72% UH tumors were Stage III or IV (P < 0.001). All children with FH tumors were alive at last follow-up (range of follow-up period: 9-79 months; median, 35 months), whereas 8 children with UH tumors died of disease even after limited follow-up (range of follow-up period: 0-60 months; median, 20 months). By contrast, S-positive and C/N cases were predominantly (97%) FH tumors, often (76%) Stage I, II, or IV-S, with excellent clinical outcome (survival rate of 98%).

CONCLUSIONS

The majority of the UH neuroblastomas that developed in the birth cohort of the QNS Project were included in the group of S-negative cases and could not be detected by the screening at age 3 weeks and/or 6 months.

Is there a future for neuroblastoma mass screening?

It is apparent that mass screening at the age of six months in Japan detects significant numbers of otherwise spontaneously regressing tumors. Nishi et al. estimated that at least 50% of tumors detected by screening with the HPLC method would otherwise regress spontaneously [31]. Considering that not all patients found by screening who were treated and survived required therapy to obtain that result, the proportion of spontaneously regressing NBLs would be even larger. Nobody can deny that screening at the age of six months detects some tumors that would otherwise be found clinically later on. Indeed, our data show that screening led to some decrease in incidence at the age of 3 years [10]. However, this study also showed that the tumors detected by screening would, if not picked up on screening, have grown very slowly over 3 years. That is, they were not rapidly progressing tumors. There is evidence showing that evolution from tumors with favorable biologic features to tumors with unfavorable ones is unlikely [32], while no convincing example of such evolution has been reported.

Surgical treatment of neuroblastomas in infants under 12 months of age

BACKGROUND

Surgical treatment of neuroblastomas, both those detected by screening and those detected clinically, in infants less than 12 months of age, is controversial, because some tumors in this age group potentially have the ability to regress spontaneously.

METHODS

From January 1985 to March 1997, the authors treated 50 infants (under 1 year of age) with neuroblastoma: 23 boys and 27 girls. Forty-one cases were detected preclinically by screening when the patients were 6 to 11 months of age (median, 7 months), and nine patients were discovered to have clinical manifestations at the age of 1 to 10 months (median, 4 months).

RESULTS

The tumor was INSS stage 3 or 4 in 10 patients (24%) with screening-detected tumor and in five (56%) with clinically detected tumor, although the difference was not statistically significant. Four screening-positive patients had multifocal primary tumors, and three of them were synchronous bilateral adrenal neuroblastomas. There was no statistically significant difference between the screening-detected tumors and the clinically detected tumors in biological characteristics such as Shimada's histology, DNA ploidy, and N-myc amplification. Complete resection of the primary lesion was accomplished by either primary surgery or second look (delayed primary) surgery in 46 patients (92%), and the resection was incomplete in the remaining four. In patients with bilateral adrenal tumors, the larger one was primarily resected, and the smaller contralateral tumor was enucleated or resected by partial adrenalectomy. Surgical complications included postoperative adhesive ileus (n=2), Horner's syndrome (n=2), renal atrophy (n=1), renal failure (n=1), phrenic nerve injury (n=1), chylous ascites (n=1), chylothorax (n=1) and intussusception (n=1). One patient died of respiratory failure caused by a complication, but 49 patients (98%) were alive at the time of evaluation.

CONCLUSION

When considering surgical treatment of infants with biologically favorable neuroblastoma, the risk involved in treatment should be weighed against the risk inherent in a tumor capable of spontaneous regression, and aggressive surgery is unacceptable.