Opsomyoclonus and neuroblastoma. Response to ACTH

Neuroblastoma found in a 4-year-old after rituximab therapy for opsoclonus-myoclonus

Opsoclonus-myoclonus, a rare paraneoplastic syndrome that may occur in patients with neuroblastoma, is thought to be a humorally mediated immune reaction to malignant cells that cross-react with autoantigens. This report describes the case of an occult neuroblastoma diagnosed in a 4-year-old female 2 years after presentation of opsoclonus-myoclonus. Although no mass was evident on previous imaging at an interval of 10 months, a computed tomographic scan 4 months after rituximab treatment and 20 months after presentation revealed a new left adrenal mass. Although neuroblastomas can be identified months after presentation of opsoclonus-myoclonus without treatment with rituximab, this report describes one of the longest intervals using up-to-date imaging techniques. Therefore the case raises two concerns: (1) whether the same immune process that causes opsoclonus-myoclonus may suppress neuroblastomas, and (2) whether immunosuppressive therapy with rituximab may inhibit the immune reaction to occult neuroblastomas in patients with unexplained opsoclonus-myoclonus.

Advances in the diagnosis and treatment of neuroblastoma

Neuroblastoma, a childhood neoplasm arising from neural crest cells, is characterized by a diversity of clinical behavior ranging from spontaneous remission to rapid tumor progression and death. To a large extent, outcome can be predicted by the stage of disease and the age at diagnosis. However, the molecular events responsible for the variability in response to treatment and the rate of tumor growth remain largely unknown. Over the past decade, transformation-linked genetic changes have been identified in neuroblastoma tumors that have contributed to the understanding of tumor predisposition, metastasis, treatment responsiveness, and prognosis. The Children's Oncology Group recently developed a Neuroblastoma Risk Stratification System that is currently in use for treatment stratification purposes, based on clinical and biologic factors that are strongly predictive of outcome. This review discusses the current risk-based treatment approaches for children with neuroblastoma and recent advances in biologic therapy.

Neuroblastic tumors associated with opsoclonus-myoclonus syndrome: histological, immunohistochemical and molecular features of 15 Italian cases

The aim of this study was to investigate the histological, immunohistochemical and molecular features of a series of children with neuroblastic tumors (NTs) and opsoclonus-myoclonus syndrome (OMS). Of 1187 children (age 0-15 years) with previously untreated NTs registered between 1979 and 1995, 15 (1.3%) had OMS at presentation. The majority of patients showed favorable biological characteristics, such as lack of amplification of the neuroblastoma-associated avian myelocytomatosis homolog MYCN oncogene and aneuploid nuclear DNA content. Tumor histology was reviewed according to the International Neuroblastoma Pathology Classification. Histology of the 15 cases of NTs with OMS was ganglioneuroblastoma, intermixed, in 10 patients; ganglioneuroma, maturing, in 1; and neuroblastoma in 4. Of 15 tumors, 12 (10 ganglioneuroblastomas, 2 neuroblastomas) showed abundant interstitial or perivascular lymphoid infiltrates, the latter often organized in secondary lymphoid follicles. The three remaining cases had only minimal infiltrates. A review of 91 cases of age- and stage-matched neuroblastic tumors not associated with OMS tested as controls showed that the degree of lymphoid infiltration was significantly lower than that detected in OMS-related tumors. Furthermore, lymphoid follicles were always present in the latter tumors, whereas they were detected only in a few ganglioneuroma, intermixed tumors from the control group. In conclusion, ganglioneuroblastoma, intermixed subtype, lack of MYCN amplification, aneuploid DNA content and presence of lymphoid infiltrates may contribute to favorable prognosis in NTs associated with OMS.

Opsoclonus-myoclonus-ataxia syndrome in neuroblastoma: clinical outcome and antineuronal antibodies-a report from the Children's Cancer Group Study

BACKGROUND

Opsoclonus-myoclonus-ataxia (OMA) is a paraneoplastic neurologic syndrome affecting 2-3% of children with neuroblastoma. Although children with OMA and neuroblastoma may have higher survival, many experience a significant amount of late neurologic impairment, which may be immunologically mediated. The aim of this study was to compare the outcome of neuroblastoma patients with and without OMA, relating to prognostic factors, treatment, and the presence or absence of anti-neuronal antibodies.

PROCEDURE

Questionnaires were mailed out requesting information on the current neurologic status of patients who submitted sera at diagnosis to the Children's Cancer Group serum bank from 1980 to 1994. Information was requested on clinical and biological patient characteristics as well as clinical aspects of the patients identified as having OMA syndrome, including presentation and treatment for OMA, late sequelae of OMA, the presence or absence of antineuronal antibodies, and survival. Sera from 16 of the OMA patients and 48 case-controls with neuroblastoma were assayed for anti-neuronal antibodies.

RESULTS

Of the 675 responses received, 21 patients had OMA. Ninety percent of OMA patients presented with non-metastatic disease, vs. 35% of non-OMA patients. Estimated 3-year survival for the OMA patients with nonmetastatic disease (stage I, II, III) greater than 1 year of age was 100% vs. 77% for similar non-OMA patients (P = 0.0222). At follow-up, 14/19 evaluable OMA patients displayed some form of developmental or neurologic abnormality. There was no significant correlation of late sequelae with antineuronal antibodies, age, time between OMA symptoms and diagnosis, or treatment given for tumor or OMA. There was a significant correlation of late sequelae with lower stage disease (I and II) compared to more advanced disease (III and IV).

CONCLUSIONS

Patients with OMA and neuroblastoma have excellent survival but a high risk of neurologic sequelae. Favorable disease stage correlates with a higher risk for development of neurologic sequelae. The role of anti-neuronal antibodies in late sequelae of OMA needs further clarification.

Neuroblastoma associated with seizures and arrested development

Two unrelated cases of childhood peripheral neuroblastoma associated with infantile seizures and developmental problems (but without opsoclonus-myoclonus) are presented. The considerable body of evidence supporting the view that the opsoclonus-myoclonus syndrome associated with neuroblastoma has an immunologic basis is reviewed. Patients with neuroblastoma and opsoclonus-myoclonus syndrome commonly have subsequent developmental problems and, rarely, may have seizures. The authors postulate that the seizures and developmental problems in their two patients may result from an immunologic mechanism similar to that suggested for the opsoclonus-myoclonus syndrome of neuroblastoma. The only laboratory evidence to support an immunologic mechanism in these two patients was the presence of raised cerebrospinal fluid immunoglobulins in Patient 2. Specific antineuronal antibody tests in Patient 2 were negative. It is therefore possible that the association reported in these two unrelated cases is coincidental. However, reasonably extensive investigations did not uncover an alternative etiology for the presence of the seizures and developmental delay.

Neurological sequelae of the dancing eye syndrome

Fifty-four patients with dancing eye syndrome (DES), presenting over a 25-year period, were reviewed retrospectively. One third of them were on active follow up at the time of the study. Malignancy was uncommon, diagnosed in only 4 patients, neuroblastoma in 3 cases and acute lymphoblastic leukaemia (ALL) in 1. An intercurrent illness preceded onset of DES in 51% of the children and was of equivocal significance. There was no clear temporal relationship to immunization. The acute phase of the illness was severe and caused total immobilization in 88% of patients. A favourable initial response to treatment with prednisolone or corticotrophin gel was observed in all patients. Although corticotrophin seemed to produce a more rapid response, overall improvement was similar with both treatments. Long-term neurological morbidity was a major problem with 91% of children suffering either persisting symptoms or repeated relapses. A persisting disability was found in 88% and was considered severe in 61% of patients. No features prognostic of neurological severity or outcome were identified.

CONCLUSION

Demonstrable malignancy is uncommon in the dancing eye syndrome. The neurological legacy of DES is often evident well into adult life.

Outcome of children with opsoclonus-myoclonus regardless of etiology

Within the past 11 years, 11 patients with opsoclonus and myoclonus, with or without a history of neuroblastoma, have been admitted to Children's Memorial Hospital. Eight of the 11 children had an occult neuroblastoma. Eight children have had subsequent delayed development with motor incoordination and speech delay (7 with neuroblastoma, 1 without). Nine of 11 children initially were treated with ACTH, 1 child was treated with prednisone, and 1 was not treated. Nine of the 10 children who were treated had recurrences of symptoms during the gradual withdrawal or discontinuation of ACTH. Often the ACTH had to be restarted or increased, although several times the episodes were self-limited, not requiring treatment after ACTH was withdrawn. We found prednisone was ineffective in controlling opsoclonus-myoclonus regardless of etiology. The majority of children with opsoclonus-myoclonus, regardless of etiology, have developmental delay, more severe and at a higher rate than previously reported. When a neuroblastoma was present, tumor removal did not improve symptoms. Although limited in size, our study indicates patients with opsoclonus-myoclonus without an associated neuroblastoma have a better chance for normal neurologic development (2/3 versus 1/8).

ACTH induced adrenal enlargement in infants treated for infantile spasms and acute cerebellar encephalopathy

ACTH is used in childhood to treat infantile spasms and acute cerebellar encephalopathy (opsoclonus-cerebellar ataxia syndrome). We report two infants with ultrasonographic and CT evidence of massive, reversible adrenal enlargement secondary to exogenous ACTH therapy for these disorders.

Adrenocorticotropic hormone-secreting ganglioneuroblastoma associated with opsomyoclonic encephalopathy: a case report with immunohistochemical study

This report describes a case of a 3-year-old female with Cushing's syndrome associated with ganglioneuroblastoma and opsomyoclonic encephalopathy. Immunohistochemistry showed the tumor to be adrenocorticotropic hormone-secreting. At autopsy, a cerebellar degenerative lesion was also demonstrated.

The proposed role of neurotransmitter receptors in the pathophysiology of human myoclonic disorders

The hypothesis that central neurotransmitter receptor abnormalities are the basis of human myoclonic disorders is novel. Receptor abnormalities in any of several different neurotransmitter systems implicated in myoclonus may be genetic or the consequence of various brain injuries. These abnormalities might define pharmacologic subgroups of possible relevance to the clinical, neurophysiologic, and pathologic heterogeneity of myoclonus. Receptor abnormalities may be the primary pathophysiologic defect, involving the surface recognition site or effector-transducer mechanisms in the defect, involving the surface recognition site or effector-transducer mechanisms in the post-synaptic cell. Alternatively, changes in receptor density or affinity may be adaptive (recovery of function) or maladaptive (supersensitivity, subsensitivity, dysregulation). Drug treatments, then, could be targeted at the receptor changes, reversing abnormalities and enhancing compensatory mechanisms. Current therapy may inadvertently have such an effect. Polytherapy may be justified to target more than one component of the "pharmacologic receptor". Identification of receptor abnormalities in human post-mortem brain may have diagnostic and therapeutic significance. New advances in the pharmacologic selectivity of receptor agonists and antagonists and in the measurement of receptors should be applied to the problem of myoclonus.

Clinical outcome in children with acute cerebellar encephalopathy and neuroblastoma

Acute cerebellar encephalopathy (ACE)--ataxia often associated with opsoclonus, polymyoclonus, and irritability--may be associated with neuroblastoma and should be suspected in a child who presents with ACE. The survival in ten children with ACE associated with neuroblastoma was 100%. Most of the tumors were ganglioneuroblastomas. The abdomen was the most common location for the tumor in this study although it also can be found in the mediastinum. All patients with this syndrome had a localized tumor. With ACTH therapy, ACE may resolve early postoperatively, but it tends to recur in most patients, continuing for as long as 3 years after the initial operation. Treatment with ACTH or prednisone modifies and rapidly clears the symptoms during the acute episode of recurrent ACE as well as helps to resolve subsequent neurologic sequelae. Significant neurologic sequelae persisted in seven of ten patients and included deficits in cognition or intellect, hyperactivity, impulsivity, emotional lability, and mild motor deficits. Seizures were seen in one patient.

Effect of antiepileptic and antimyoclonic drugs on serotonin receptors in vitro

To determine if the mechanism of action of clinical and investigational antiepileptic and antimyoclonic drugs or neuropeptides involves direct actions at serotonin (5-HT) receptors, the activity of various compounds in vitro at 5-HT1 (with subtypes) and 5-HT2 sites was measured in adult rat brainstem, spinal cord, and neocortex. Adrenocorticotropic hormone (ACTH1-39) noncompetitively inhibited specific binding at 5-HT1, 5-HT1A, and 5-HT2 sites in brainstem and neocortex [concentrations required to displace 50% of ligand binding (IC50S) 4-8 X 10(-5) M]. ACTH1-24, ACTH1-17, and ACTH4-10 were sequentially less active, and ACTH34-39 and corticosterone were inactive. D-Ala2, Leu5-enkephalinamide, but not D-Ala2, Met5-enkephalinamide, also displaced spinal and neocortical 5-HT2 sites (IC50 6 X 10(-5) M). Piracetam, glycine, and the clinical antiepileptics valproate, phenacemide, phenytoin, carbamazepine, phenobarbital, diazepam, clonazepam, nitrazepam, and ethosuximide did not displace serotonergic radioligands, but melacimide showed some activity at 5-HT1 sites (IC50 7-9 X 10(-5) M). Anticonvulsant inactivity at 5-HT receptors in vitro correlates with the lack of antimyoclonic activity in 5-HT lesion myoclonic models but not with antimyoclonic efficacy in humans. These data indicate that acute effects of these anticonvulsants cannot be attributed to direct action at the 5-HT receptor recognition site in the rat. In contrast, ACTH showed mild in vitro displacement and regional specificity but only at micromolar concentrations.

Neuroblastoma

Neuroblastoma originates in the adrenal medulla or anywhere in the body that sympathetic tissue normally is present. It may present with a variety of symptoms due to primary tumor, metastatic disease, or unusual signs and symptoms such as opsoclonus-myoclonus or severe diarrhea. Despite the fact that this neoplasm responds to a variety of therapeutic modalities, it remains one of the most frustrating and difficult childhood tumors to treat and cure.

The association of neuroblastoma and myoclonic encephalopathy: an imaging approach

Myoclonic encephalopathy is a unique clinical syndrome of infants and children that is associated with a neurogenic tumor of ganglion-cell origin in approximately half of cases. A review of the literature as well as our personal experience with two recent infants suggests an imaging approach that includes chest radiography and abdominal computed tomography (CT). Ultrasonography, neck CT, and chest CT myelography may be required in selected patients. An expedient clinical and imaging evaluation of infants and children with opsomyoclonus is important to detect those patients with neurogenic tumors.

Opsomyoclonus and neuroblastoma

Three cases of neuroblastoma with opsomyoclonus are reported, reconfirming favorable prognostic significance of the association. In one case, computed tomography of the abdomen was the only confirmatory diagnostic study. Two of the cases also were unusual in that the patients had a concomitantly inherited genetic disorder not known to be associated with childhood cancer.