Bone marrow changes in neuroblastoma

Study of Hemato-morphological Features in Neuroblastoma Infiltrating Marrow

Objective Neuroblastoma typically affects children within the first 5 years of life and accounts for 10% of all pediatric malignancies. Neuroblastoma at onset may manifest as a localized or metastatic illness. The aim of this study was to identify hematomorphological features in neuroblastoma infiltrating marrow as well as to ascertain the prevalence of bone marrow infiltration in neuroblastoma.

Materials and Methods This retrospective study included newly diagnosed 79 cases of neuroblastoma, which were referred for bone marrow examination for the staging of the disease. Medical records were retrieved to acquire hematomorphological findings of peripheral blood and bone marrow smears. Statistical Package for Social Sciences, IBM Inc., USA, version 21.0 was used to analyze the data.

Results The interquartile age range of neuroblastoma cases was 24.0 to 72.0 months (median = 48 months) with a male to female ratio of 2.7:1. Also, 55.6% (44/79) of cases in the study population showed evidence of marrow infiltration. The bone marrow infiltration was significantly linked to thrombocytopenia (p = 0.043) and nucleated red blood cells (p = 0.003) in peripheral blood. The bone marrow smears of cases with infiltration showed a significant shift to the left in the myeloid series (p = 0.001) and an increased number of erythroid cells (p = 0.001).

Conclusion For neuroblastoma patients, a diligent, exhaustive search for infiltrating cells in bone marrow is advised if thrombocytopenia or nucleated red blood cells are identified on a peripheral blood smear and bone marrow smears showed myeloid left shift with an increased number of erythroid cells.

The role of microscopic bone marrow examination and [123I]MIBG scintigraphy in detection of bone marrow involvement in patients with neuroblastoma

OBJECTIVES

For the detection of bone marrow (BM) metastases in patients with neuroblastoma, microscopic BM examination and [¹²³I]MIBG scintigraphy are advised. The aims of this study were to assess the concordance of [¹²³I]MIBG and microscopic BM examination (aspirate and biopsy) in detecting BM involvement and to compare invasive disease in BM biopsies and aspirates, both at diagnosis and before autologous stem cell collection (ASCC).

METHODS

Fifty-five patients with stage 4 or stage 4S disease were included, and 37 of them received an autologous hematopoietic stem cell transplantation (AHSCT). The concordance rate was measured and paired binary data were analysed by the McNemar test to look for a systematic difference between diagnostic tests.

RESULTS

At diagnosis and before ASCC, we found acceptable concordance rates for [¹²³I]MIBG versus microscopic BM examination (77.1% and 85.3% respectively). Discordant results were found in both directions and at both time points. The concordance rate for biopsy versus aspirate at diagnosis was 80.6%, however, before ASCC a much higher concordance rate between both microscopic examinations was found (94.1%). While none of the aspirates showed neuroblastoma cells before ASCC, two biopsies still showed tumor invasion.

CONCLUSION

For patients with neuroblastoma, a [¹²³I]MIBG scintigraphy and a microscopic examination of BM aspirate and its biopsy should be used as complementary tools in the evaluation of BM involvement, and this both at diagnosis and during treatment (before ASCC).

Comparison of three different methods to detect bone marrow involvement in patients with neuroblastoma

Purpose

Neuroblastoma (NB) is the most frequent extracranial tumor in children. The detection of bone marrow (BM) involvement is crucial for correct staging and risk-adapted treatment. We compared three methods regarding the detection of NB involvement in BM.

Methods

Eighty-one patients with NB were included in this retrospective study. BM samples were obtained at designated time points at study entry and during treatment or follow-up. The diagnostic tools for BM analysis included cytomorphology (CM), flow cytometry (FCM) and automatic immunofluorescence plus fluorescence in situ hybridization (AIPF).

Results

We analyzed 369 aspirates in 81 patients in whom AIPF, CM, and FCM were simultaneously available. During the observation period, NB cells were detected in 86/369 (23.3%) cases, by CM in 32/369 (8.7%), by FCM in 52 (14.1%), and by AIPF in 72 (19.5%) samples. AIPF and/or FCM confirmed all positive results obtained in CM and detected 11 additional positive BM aspirates in 294 CM negative samples (p < 0,001). Survival of patients with BM involvement at study entry identified solely by FCM/AIPF was 17.4% versus 0% for patients in whom BM involvement was already identified by CM.

Conclusion

The combination of AIPF/FCM yielded the highest detection rate of NB cells in BM. AIPF was the single, most sensitive method in detecting these cells. Although CM did not provide any additional positive results, it is still a useful, readily available and cost-effective tool. The prognostic significance of FCM and AIPF should be confirmed in a prospective study with a larger number of patients.

Recommendations for the standardization of bone marrow disease assessment and reporting in children with neuroblastoma on behalf of the International Neuroblastoma Response Criteria Bone Marrow Working Group

BACKGROUND

The current study was conducted to expedite international standardized reporting of bone marrow disease in children with neuroblastoma and to improve equivalence of care.

METHODS

A multidisciplinary International Neuroblastoma Response Criteria Bone Marrow Working Group was convened by the US National Cancer Institute in January 2012 with representation from Europe, North America, and Australia. Practical transferable recommendations to standardize the reporting of bone marrow disease were developed.

RESULTS

To the authors' knowledge, the current study is the first to comprehensively present consensus criteria for the collection, analysis, and reporting of the percentage area of bone marrow parenchyma occupied by tumor cells in trephine-biopsies. The quantitative analysis of neuroblastoma content in bone marrow aspirates by immunocytology and reverse transcriptase-quantitative polymerase chain reaction are revised. The inclusion of paired-like homeobox 2b (PHOX2B) for immunohistochemistry and reverse transcriptase-quantitative polymerase chain reaction is recommended. Recommendations for recording bone marrow response are provided. The authors endorse the quantitative assessment of neuroblastoma cell content in bilateral core needle biopsies-trephines and aspirates in all children with neuroblastoma, with the exception of infants, in whom the evaluation of aspirates alone is advised. It is interesting to note that 5% disease is accepted as an internationally achievable level for disease assessment.

CONCLUSIONS

The quantitative assessment of neuroblastoma cells is recommended to provide data from which evidence-based numerical criteria for the reporting of bone marrow response can be realized. This is particularly important in the minimal disease setting and when neuroblastoma detection in bone marrow is intermittent, where clinical impact has yet to be validated. The wide adoption of these harmonized criteria will enhance the ability to compare outcomes from different trials and facilitate collaborative trial design. Cancer 2017;123:1095-1105. © 2016 American Cancer Society.

Bone Marrow Involvement in Neuroblastoma: A Study of Hemato-morphological Features

Bone marrow involvement in neuroblastoma indicates advanced stage of disease. The recent use of autologous bone marrow "rescue", has provided an additional important reason for accurate assessment of bone marrow status in newly diagnosed patients. In this study, we analyzed 44 cases of neuroblastoma for bone marrow infiltration status and their hematological parameters. Eighty-eight bone marrow aspirate and trephine touch imprint smears and 44 trephine biopsy sections were examined in these 44 patients. Of these, 24 cases (54.5 %) showed marrow infiltration. Leucopenia and bicytopenia were significantly (p < 0.05) associated with marrow infiltration. Both bone marrow aspirate and biopsy were positive for infiltration in 16 out of 24 positive cases. Only aspirate smears were positive in 4 and only trephine biopsy in another 4 cases. The pattern of infiltration consisted of rosette formation in 40.7 % cases on aspirate smears and 22.2 % cases in trephine biopsies. Remaining cases showed diffuse and interstitial presence of tumor cells and cases positive only on trephine biopsy, showed marked stromal reaction. Bilateral trephine biopsies combined with aspirate smears picked up all positive cases compared to when they were assessed alone.

Vacuolated cells in bone marrow aspirate of children with neuroblastoma

Cytoplasmic vacuoles that have been seen in FAB L3-type lymphoblasts are not usual in neuroblastoma. The authors report three children with neuroblastoma having vacuolated cells mimicking L3-type lymphoblasts on bone marrow aspiration smears.

Vacuolated neuroblastoma cells mimicking FAB L(3) lymphoblasts in bone marrow aspirates

Abundant cytoplasmic vacuolation of neuroblasts has been noted on bone marrow aspirate (BMA) smears of two patients with metastatic neuroblastoma. Occasional tumor cells were dispersed as individual cells as well as in clumps. These cells had basophilic cytoplasm and several nucleoli, reminiscent of L(3) lymphoblast morphology. Flow cytometric analysis of the bone marrow mononuclear cells and neuron-specific enolase staining of the bone marrow biopsy samples further distinguished the cells as neuroblasts. Cytoplasmic vacuolations of neuroblasts may be a feature of metastatic neuroblastoma cells in BMA smears.

Metastatic tumors in bone marrow: histopathology and advances in the biology of the tumor cells and bone marrow environment

The nonhematopoietic tumors most often diagnosed in the bone marrow are metastatic. Currently, accurate diagnosis of tumor metastasis requires integration of the clinical findings; morphological features; and results of immunohistochemical stains, cytogenetics, and molecular studies. This review focuses on a practical approach to the diagnosis of metastatic tumors in the bone marrow according to current standards of practice and discusses recent advances in understanding of tumor metastasis and the interaction between tumors and the bone marrow environment.

The role of bone marrow evaluation in the staging of patients with otherwise localized, low-risk neuroblastoma

BACKGROUND

Bone marrow aspirations and biopsies are standard staging procedures for neuroblastoma because the tumor frequently metastasizes to the bone marrow. The presence of bone marrow metastases indicates stage 4 or 4S neuroblastoma by International Neuroblastoma Staging System (INSS) criteria; these stages are also associated with other metastatic sites of disease. We questioned whether bone marrow studies changed the staging or treatment of children with localized, completely resected tumors if there was no other evidence of metastatic spread. If stage of disease rarely changed with bone marrow results, it might be possible to avoid this procedure in a subset of patients with neuroblastoma.

PROCEDURE

The staging studies of patients with INSS stage 1 (n = 29), 4 (n = 60), and 4S (n = 13) neuroblastoma from two institutions were reviewed.

RESULTS

There were no patients upstaged from stage 1 to 4 or 4S by bone marrow metastases alone. Fifty-nine of 60 stage 4 patients had other sites of metastases on imaging studies, the remaining patient had an unresectable primary tumor and marrow disease. All subjects with stage 4S disease had liver metastases.

CONCLUSIONS

Bone marrow studies did not contribute data that changed the stage of patients who had surgically resectable tumors and no evidence of metastatic spread on imaging studies. When present, metastatic spread to the marrow was associated with advanced local tumors or other sites of metastatic disease. Given the relatively small size of our study population, further studies are warranted that investigate the utility of bone marrow studies for patients who otherwise have INSS stage 1 neuroblastoma.

Detecting minimal residual disease in neuroblastoma patients-the present state of the art

While cyto- and histological screening of bone marrow samples are still accepted as the gold standard for initial staging of neuroblastoma patients, these applications are insufficient during or after therapy because it is not always possible to detect tumour cell infiltration below the level of 1% by morphology alone. For monitoring of minimal residual disease, techniques offering a considerably higher sensitivity have been developed. Immunocytology, RT-PCR and flow cytometry are most frequently used, but differ with regard to targets (single cells, RNA transcripts), measured parameters (tumour cell number, antigen expression, cytomorphology, cytogenetic aberrations, level/number of RNA transcripts), specificity (uni-/multi-parameter analysis) and sensitivity (number of investigated cells). The pros and cons of these methods are reviewed. Precise quantification of residual tumour cells in bone marrow and blood may show a future impact on risk grouping and therapeutic strategies for patients with disseminated disease, but the potential clinical application of these techniques has to be preceded by thorough standardisation and validation in multi-centre studies.

Which MRI sequence of the spine best reveals bone-marrow metastases of neuroblastoma?

BACKGROUND

MRI is an effective tool in evaluating bone marrow metastases. However, no study has defined which MRI sequences or image characteristics best correlate with bone-marrow metastases in neuroblastoma.

OBJECTIVE

To identify and refine MRI criteria and sequence selection for the diagnosis of bone-marrow metastases in children with neuroblastoma.

MATERIALS AND METHODS

Ninety-one children (mean age: 3.2 years; standard deviation: 2.8 years) enrolled in the RDOG IV study participated in our study. Forty-five children had bone metastases determined by bone-marrow aspiration or biopsy (n=4), radionuclide imaging (n=2), or both (n=39). Spine lesions were characterized using coronal T1-weighted (T1W) sagittal short tau inversion recovery (STIR) and coronal gadolinium-enhanced T1-weighted (GAD) MR sequences. Contingency table analysis was performed to determine which MRI sequences and characteristics were associated with metastases. The MRI criteria for metastatic disease were then developed for each imaging sequence. The sensitivity, specificity, predictive values, and accuracy of these criteria were determined for the whole group, children younger than 12 months old, and children 12 months and older.

RESULTS

The MR characteristics that had significant (P<or=0.05) associations with metastases were homogeneous low T1-signal intensity, homogeneous high STIR-signal intensity, and heterogeneous pattern on T1, STIR, or GAD. Homogeneous low T1-signal had the highest sensitivity (88%), but a specificity of 62% for detecting metastases. A heterogeneous pattern on GAD was highly specific (97%), but relatively insensitive (65%) for detecting metastases. These MR characteristics were most accurate in children 12 months and older.

CONCLUSION

The combination of non-contrast-enhanced T1W and GAD sequences can be used to determine the presence of spinal metastases in children with neuroblastoma, particularly those children who are 1 year and older.

Staging of neuroblastoma at imaging: report of the radiology diagnostic oncology group

PURPOSE

To compare the accuracies of computed tomography (CT), magnetic resonance (MR) imaging, and bone scintigraphy in staging disease in patients with neuroblastoma.

MATERIALS AND METHODS

Ninety-six children with newly diagnosed neuroblastoma were enrolled in a multicenter prospective cohort study. CT, MR, and bone scintigraphy were used to evaluate tumor stage. Sensitivity and specificity values and receiver operating characteristic (ROC) curve analyses were used to compare the accuracy of CT, MR, and scintigraphy for tumor staging.

RESULTS

Eighty-eight patients were eligible for staging analysis, and 45 patients who underwent surgery at initial diagnosis were eligible for analysis of local tumor extent. CT and MR had sensitivities of 43% and 83%, respectively (P <.01), and specificities of 97% and 88%, respectively (P >.05), for detection of stage 4 disease. Areas under the ROC curves for CT and MR were 0.81 and 0.85, respectively (P =.06); that for scintigraphy was 0.83. Addition of scintigraphy to both CT and MR increased the areas under the ROC curves to 0.90 and 0.88, respectively. Accuracy of CT and MR for staging disease confined to the chest or abdomen (stages 1, 2, and 3) was poor.

CONCLUSION

MR alone and CT and MR combined with bone scintigraphy enable the accurate detection of stage 4 disease. Both CT and MR perform poorly for local tumor staging.

What is marrow fibrosis after treatment of neuroblastoma?

AIMS

To test the hypothesis that the abnormal fibrous stroma of bone marrow found after treatment of disseminated neuroblastoma represents traumatic scarring.

METHODS

Twenty six restaging bone marrow biopsy specimens from 14 children with disseminated neuroblastoma were compared with 37 from 37 children with acute lymphoblastic leukaemia. They were assessed independently by two observers for the presence of abnormal fibrous stroma. All biopsies were performed 23 to 50 days after the initial diagnostic biopsy, and from the same iliac crest. A further nine restaging bone marrow biopsy specimens from previously unbiopsied iliac crests from four children with neuroblastoma were examined and the appearances of the diagnostic bone marrow specimens in those with neuroblastoma recorded. Between diagnostic and restaging biopsies, the children received combination chemotherapy regimens.

RESULTS

In neuroblastoma abnormal stromal material was observed in 17 of 26 rebiopsied iliac crests as opposed to only 9 of 37 of those with acute lymphoblastic leukaemia (p < 0.005). In addition, four of nine restaging biopsy specimens taken from previously unbiopsied crests in patients with neuroblastoma contained abnormal stroma. All 11 children with neuroblastoma whose restaging specimens contained abnormal stroma had similar abnormalities in one or more biopsy specimens at diagnosis.

CONCLUSIONS

Abnormal fibrous stromal material in restaging marrow biopsy specimens of previously biopsied iliac crests occurs much more frequently in neuroblastoma than in acute lymphoblastic leukaemia. We suggest that factors other than traumatic scarring are responsible. This is supported by finding similar abnormalities in previously unbiopsied iliac crests and in the diagnostic biopsy specimens of children with neuroblastoma.

Immunohistochemistry on needle biopsies of childhood malignancies

Ultrasound-guided percutaneous needle biopsy proved to be a reliable and safe method to obtain material for histopathological and immunohistochemical diagnosis prior to treatment in childhood malignancies. A principal tumour identification could be obtained by a combined morphological and phenotypic examination of 38 small-sized tumour biopsy specimens using a fairly limited panel of immunological reagents, including antibodies to leucocyte common antigen (CD 45), certain B- and T-cell markers, various intermediate filaments (cytokeratin, desmin and vimentin), and neuroblastoma cells (UJ 167.11, A2B5, and UJ 13A; the latter recognizes NCAM). Five undifferentiated neuroblastomas were all positive with the neuroblastoma antibodies but negative for the other markers, including vimentin. The negative reactivity for desmin and vimentin was the major immunohistochemical distinction between neuroblastomas and rhabdomyosarcomas. In addition, limited reactivity with the neuroblastoma antibodies was seen in blastematous parts of Wilms' tumour, duct-like structures in a hepatoblastoma, and in tumour cells in a few undifferentiated myelo- and lympho-proliferative lesions. This study shows the importance of a combined evaluation of morphology and the pattern of immunoreactivity employing multiple markers.

A prospective comparison between magnetic resonance imaging, meta-iodobenzylguanidine scintigraphy and marrow histology/cytology in neuroblastoma

A prospective comparison between magnetic resonance imaging (MRI), 123I meta-iodobenzylguanidine (mIBG) scintigraphy and posterior iliac crest marrow aspiration and trephine biopsy in 30 assessments (19 patients) showed concordance between the three techniques in 16 assessments (53.3%). In 10 (33.3%), MRI and mIBG revealed abnormalities not detected by marrow biopsy. MRI was the only technique to demonstrate marrow abnormality in four assessments (13.3%). In addition, MRI revealed more sites of abnormality in 16 parallel assessments. We conclude that MRI shows promise as a non-invasive means of detecting bone marrow infiltration by neuroblastoma, but that further evaluation of the specificity of MRI in this setting is indicated.

Routine histological compared with immunohistological examination of bone marrow trephine biopsy specimens in disseminated neuroblastoma

The ability to detect infiltration in bone marrow biopsy specimens from patients with disseminated neuroblastoma was assessed by immunohistological and routine histological methods. Frozen cores from 33 staging procedures were tested with UJ13A and UJ127.11. Immunopositive tumour cells were found in 10 of 17 staging procedures in which tumour was detectable by routine histological methods. Positive cells or stromal material were also found in eight of 12 staging procedures in which distorted architecture and fibrosis, but no obvious tumour, had been noted. Paraffin wax embedded cores from 29 of the same staging procedures were tested with antibodies against neurone specific enolase and neurofilament. Only a single core reacted with anti-neurofilament antibody. Neurone specific enolase positive cells or stromal material were found in nine of 15 staging procedures in which obvious tumour was detectable. Although these immunohistochemical techniques proved inferior to routine histology in their ability to detect obvious tumour, the demonstration of immunopositive stromal tissue which was not frankly malignant supports the view that distorted, fibrotic marrow may reflect persistence of neuroectodermal tissue and justifies its distinction from normal marrow when reporting the response to treatment.

Prognostic value of immunocytologic detection of bone marrow metastases in neuroblastoma

BACKGROUND

Morphologic evaluation of bone marrow for neuroblastoma cells is a routine and important component of clinical staging. Specific immunostaining of malignant cells with monoclonal antibodies should be more sensitive, however, and may improve the detection of metastases and provide additional prognostic information.

METHODS

We looked for tumor cells in bone marrow from 197 patients with newly diagnosed neuroblastoma, using immunoperoxidase staining with monoclonal antibodies (immunocytologic analysis) and examination of smears and specimens obtained by trephine biopsy (conventional analysis).

RESULTS

Routine smears and trephine-biopsy specimens were positive for tumor cells in 46 percent of the patients, whereas 67 percent were positive on immunocytologic analysis (P less than 0.0001). Immunocytologic analysis detected bone marrow metastases in 34 percent of patients considered to have only localized or regional disease (Stage I, II, or III). It also identified tumor cells that were not detected by conventional analysis in patients with widespread disease (Stage IV or IVS). Tumor content, as determined by immunocytologic analysis, predicted clinical outcome in relation to the age of the patient at diagnosis. Patients with Stage II or III disease diagnosed after one year of age who did not have occult marrow metastases did well, whereas those with metastases did poorly (P = 0.006). Patients in whom Stage IV disease was diagnosed before they were one year of age did well if bone marrow metastases were few or absent, but had poor survival if the marrow contained more than 0.02 percent tumor cells (P = 0.03).

CONCLUSIONS

Immunocytologic analysis of bone marrow aspirates is more sensitive than conventional analysis in detecting tumor cells and provides prognostic information. The relations among marrow metastases, age at diagnosis, and clinical outcome illustrate the biologic heterogeneity of neuroblastoma.

A simple technique for preparation of bone marrow or peripheral blood buffy coat cells for electron microscopy

A simple and rapid method of processing ethylene-diamine-tetra-acetic acid anticoagulated peripheral blood or aspirated bone marrow for electron microscopy is described. The resultant buffy coat pellet is easily processed into epoxy resin. Semithin sections (1 mu) stained with 1% toluidine blue reveal the various stratified cell layers allowing convenient selection for ultramicrotomy and ultrastructural evaluation.

Bone marrow examination in neuroblastoma patients: a morphologic, immunocytochemical, and immunohistochemical study

Bone marrow examination was performed at the time of diagnosis, before initiation of therapy, and during follow-up of 14 consecutive patients with neuroblastoma who were treated at the National Hospital in Oslo. A total of 30 bone marrow specimens were examined by conventional histology, by immunohistochemistry with selected monoclonal antibodies to neuroblastoma cells (UJ 13A, UJ 167.11, PI 153/3, and A2B5) applied on trephines, and by morphologic evaluation of smears in addition to immunocytochemistry of aspirated bone marrow cells. The study confirmed the value of immunohistochemistry and immunocytochemistry for the detection of bone marrow involvement in neuroblastoma. Immunohistochemistry performed on bone marrow trephines was a slightly better adjunct than immunocytochemistry on aspirated bone marrow cells.

Comparison of radiolabeled monoclonal antibody and magnetic resonance imaging in the detection of metastatic neuroblastoma in bone marrow: preliminary results

Magnetic resonance imaging (MRI) was compared with iodine-131-labeled monoclonal antibody scanning for ability to detect bone marrow metastases in the spine, pelvis, and femurs of children with disseminated neuroblastoma. The five patients in this study had received high-dose chemotherapy and radiation, either with (N = 2) or without (N = 3) bone marrow transplants. MRI disclosed marrow abnormalities at all sites detected with the radiolabeled antibody, which is highly specific for neuroblastoma. However, several diffuse and multifocal marrow changes apparent on MR scans were not present on scintigrams, indicating that MRI is probably less specific than monoclonal antibody imaging. Both methods were more useful than conventional radiography, computed tomography, and 99mTc-MDP bone scans for identifying sites of marrow involvement by neuroblastoma.