Maintaining Outstanding Outcomes Using Response- and Biology-Based Therapy for Intermediate-Risk Neuroblastoma: A Report From the Children's Oncology Group Study ANBL0531

PURPOSE

The primary objective of the Children's Oncology Group study ANBL0531 (ClinicalTrials.gov identifier: NCT00499616) was to reduce therapy for subsets of patients with intermediate-risk neuroblastoma using a biology- and response-based algorithm to assign treatment duration while maintaining a 3-year overall survival (OS) of 95% or more for the entire cohort.

PATIENTS AND METHODS

Children younger than age 12 years with intermediate-risk stage 2A/2B or stage 3 tumors with favorable histology; infants younger than age 365 days with stage 3, 4 or 4S disease; and toddlers from 365 to younger than 547 days with favorable histology, hyperdiploid stage 4, or unfavorable histology stage 3 tumors were eligible. Patients with MYCN-amplified tumors were excluded. Patients were assigned to initially receive two (group 2), four (group 3), or eight (group 4) cycles of chemotherapy with or without surgery on the basis of prognostic markers, including allelic status of chromosomes 1p and 11q; ultimate duration of therapy was determined by overall response.

RESULTS

Between 2007 and 2011, 404 evaluable patients were enrolled. Compared with legacy Children's Oncology Group studies, subsets of patients had a reduction in treatment. The 3-year event-free survival and OS rates were 83.2% (95% CI, 79.4% to 87.0%) and 94.9% (95% CI, 92.7% to 97.2%), respectively. Infants with stage 4 tumors with favorable biology (n = 61) had superior 3-year event-free survival compared with patients with one or more unfavorable biologic features (n = 47; 86.9% [95% CI, 78.3% to 95.4%] v 66.8% [95% CI, 53.1% to 80.6%]; P = .02), with a trend toward OS advantage (95.0% [95% CI, 89.5% to 100%] v 86.7% [95% CI, 76.6% to 96.7%], respectively; P = .08). OS for patients with localized disease was 100%.

CONCLUSION

Excellent survival was achieved with this treatment algorithm, with reduction of therapy for subsets of patients. More-effective treatment strategies still are needed for infants with unfavorable biology stage 4 disease.

Defining Risk Factors for Chemotherapeutic Intervention in Infants With Stage 4S Neuroblastoma: A Report From Children's Oncology Group Study ANBL0531

PURPOSE

Infants with stage 4S neuroblastoma usually have favorable outcomes with observation or minimal chemotherapy. However, young infants with symptoms secondary to massive hepatomegaly or with unfavorable tumor biology are at high risk of death. Our aim was to improve outcomes for patients with symptomatic and/or unfavorable biology 4S neuroblastoma with a uniform treatment approach using a biology- and response-based algorithm.

PATIENTS AND METHODS

The subset of patients with 4S disease with MYCN-not amplified tumors with impaired or impending organ dysfunction, or with unfavorable histology and/or diploid DNA index, were eligible. Patients were assigned to receive two, four, or eight cycles of chemotherapy on the basis of histology, diploid DNA index, chromosome arm 1p or 11q loss of heterozygosity (LOH) status, and symptoms.

RESULTS

Forty-nine eligible patients were enrolled: 41 were symptomatic and 28 had unfavorable biology. Seventeen patients (symptomatic, favorable biology) were assigned two cycles, 21 patients (any unfavorable biologic feature without 1p or 11q LOH) were assigned four cycles, and 11 patients (unfavorable biology including 1p and/or 11q LOH [n = 7] or symptomatic with unknown biology [n = 4]), were assigned eight cycles. The 3-year overall survival was 81.4% ± 5.8%. Eight of nine deaths were in patients younger than 2 months of age at diagnosis (median, 9 days [range, 1 to 68 days]): five acute deaths were a result of hepatomegaly and associated toxicities; two were a result of late relapse in patients with unfavorable biology; and two were a result of treatment complications. No deaths occurred after protocol-mandated pre-emptive treatment of infants younger than 2 months with hepatomegaly, regardless of symptoms. A new scoring algorithm for emergent chemotherapy in patients with 4S disease was developed on the basis of this experience.

CONCLUSION

The outcome for 4S neuroblastoma can be improved with pre-emptive chemotherapy for evolving hepatomegaly or other baseline comorbidities in infants younger than 2 months of age.

Long-term results for children with high-risk neuroblastoma treated on a randomized trial of myeloablative therapy followed by 13-cis-retinoic acid: a children's oncology group study

PURPOSE We assessed the long-term outcome of patients enrolled on CCG-3891, a high-risk neuroblastoma study in which patients were randomly assigned to undergo autologous purged bone marrow transplantation (ABMT) or to receive chemotherapy, and subsequent treatment with 13-cis-retinoic acid (cis-RA). PATIENTS AND METHODS Patients received the same induction chemotherapy, with random assignment (N = 379) to consolidation with myeloablative chemotherapy, total-body irradiation, and ABMT versus three cycles of intensive chemotherapy. Patients who completed consolidation without disease progression were randomly assigned to receive no further therapy or cis-RA for 6 months. Results The event-free survival (EFS) for patients randomly assigned to ABMT was significantly higher than those randomly assigned to chemotherapy; the 5-year EFS (mean +/- SE) was 30% +/- 4% versus 19% +/- 3%, respectively (P = .04). The 5-year EFS (42% +/- 5% v 31% +/- 5%) from the time of second random assignment was higher for cis-RA than for no further therapy, though it was not significant. Overall survival (OS) was significantly higher for each random assignment by a test of the log(-log(.)) transformation of the survival estimates at 5 years (P < .01). The 5-year OS from the second random assignment of patients who underwent both random assignments and who were assigned to ABMT/cis-RA was 59% +/- 8%; for ABMT/no cis-RA, it was 41% +/- 8% [corrected]; for continuing chemotherapy/cis-RA, it was 38% +/- 7%; and for chemotherapy/no cis-RA, it was 36% +/- 7%.

CONCLUSION

Myeloablative therapy and autologous hematopoietic cell rescue result in significantly better 5-year EFS than nonmyeloablative chemo therapy; neither myeloablative therapy with [corrected] autologous hematopoietic cell rescue nor cis-RA given after consolidation therapy significantly improved OS.

Outcome of high-risk stage 3 neuroblastoma with myeloablative therapy and 13-cis-retinoic acid: a report from the Children's Oncology Group

BACKGROUND

The components of therapy required for patients with INSS Stage 3 neuroblastoma and high-risk features remain controversial.

PROCEDURE

A retrospective cohort design was used to determine if intensive chemoradiotherapy with purged autologous bone marrow rescue (ABMT) and/or 13-cis-retinoic acid (13-cis-RA) improved outcome for patients with high-risk neuroblastoma that was not metastatic to distant sites. We identified 72 patients with INSS Stage 3 neuroblastoma enrolled between 1991 and 1996 on the Phase 3 CCG-3891 randomized trial. Patients were analyzed on an intent-to-treat basis using a log-rank test.

RESULTS

The 5-year event-free survival (EFS) and overall survival (OS) rates for patients with Stage 3 neuroblastoma were 55 +/- 6% and 59 +/- 6%, respectively (n = 72). Patients randomized to ABMT (n = 20) had 5-year EFS of 65 +/- 11% and OS of 65 +/- 11% compared to 41 +/- 11 (P = 0.21) and 46 +/- 11% (P = 0.23) for patients randomized to CC (n = 23), respectively. Patients randomized to 13-cis-RA (n = 23) had 5-year EFS of 70 +/- 10% and OS of 78 +/- 9% compared to 63 +/- 12% (P = 0.67) and 67 +/- 12% (P = 0.55) for those receiving no further therapy (n = 16), respectively. Patients randomized to both ABMT and 13-cis-RA (n = 6) had a 5-year EFS of 80 +/- 11% and OS of 100%.

CONCLUSION

Patients with high-risk Stage 3 neuroblastoma have an overall poor prognosis despite aggressive chemoradiotherapy. Further studies are warranted to determine if myeloablative consolidation followed by 13-cis-RA maintenance therapy statistically significantly improves outcome.

Treatment of Colon Conduit Redundancy in a Child with Esophageal Atresia

We recently revised a redundant colon conduit in a boy who was born with isolated esophageal atresia. In view of the paucity of reports dealing with correction of this common complication of esophageal replacement, it seemed appropriate to report our experience. Because of effective medical therapy of acid peptic disease, patients who formerly required conduit replacement may now be candidates for revision; however, the medical literature does not specify when conduit revision, as opposed to conduit replacement, is indicated; also, no guidance is provided regarding what constitutes effective operative revision. Innovative techniques that stretch and elongate the atretic esophagus will likely lessen the use of conduits in esophageal atresia; nevertheless, colon conduits are useful in many other clinical situations and will remain an essential part of the armamentarium of pediatric, general, and thoracic surgeons. This report highlights the DeMeester and Tannuri technique, whereby a colon conduit is prepared like a Roux limb. The mesentery is divided only once; the conduit's blood supply is not severed from the distal mesocolon. This innovation improves a conduit's blood supply and lessens its attendant complications. Lastly, we describe a muscle splitting, posterolateral thoracotomy technique that is simpler than the alternatives and is useful in a variety of clinical situations.

Treatment of colon conduit redundancy in a child with esophageal atresia

We recently revised a redundant colon conduit in a boy who was born with isolated esophageal atresia. In view of the paucity of reports dealing with correction of this common complication of esophageal replacement, it seemed appropriate to report our experience. Because of effective medical therapy of acid peptic disease, patients who formerly required conduit replacement may now be candidates for revision; however, the medical literature does not specify when conduit revision, as opposed to conduit replacement, is indicated; also, no guidance is provided regarding what constitutes effective operative revision. Innovative techniques that stretch and elongate the atretic esophagus will likely lessen the use of conduits in esophageal atresia; nevertheless, colon conduits are useful in many other clinical situations and will remain an essential part of the armamentarium of pediatric, general, and thoracic surgeons. This report highlights the DeMeester and Tannuri technique, whereby a colon conduit is prepared like a Roux limb. The mesentery is divided only once; the conduit's blood supply is not severed from the distal mesocolon. This innovation improves a conduit's blood supply and lessens its attendant complications. Lastly, we describe a muscle splitting, posterolateral thoracotomy technique that is simpler than the alternatives and is useful in a variety of clinical situations.

Communicating bronchopulmonary foregut malformation: a case report

CBPFM is a rare finding associated with GERD in infancy. To our knowledge this case represents the twenty-fifth reported case in a child and the one-hundred and thirty first reported case in the literature overall. This case serves to remind the practitioner that children with symptoms of GER may not be just one of the endless number of happy spitters.

Efficacy of complete resection for high-risk neuroblastoma: a Children's Cancer Group study

BACKGROUND/PURPOSE

Previous reports indicate that complete resection of high-risk neuroblastoma improves outcome but may entail high surgical complication rates. The authors evaluated the effect of complete primary site resection on event-free survival (EFS), overall survival (OS), and complication rates in patients entered on a high-risk neuroblastoma treatment protocol.

METHODS

A total of 539 eligible patients with high-risk neuroblastoma were entered on protocol CCG-3891. Patients were assigned randomly to continuation chemotherapy or autologous bone marrow transplantation. Surgical resection was performed at diagnosis or after induction chemotherapy. Surgeons assessed resection as complete (CR), minimal residual (<5%, MR), or partial (PR). Incomplete resections received secondary resection or 10 Gy of external beam radiation. Patients were evaluated for EFS, OS, and complications of surgery based on completeness of overall best resection.

RESULTS

The proportion of patients resectable at diagnosis was 27% for CR and 14% for MR. This improved after chemotherapy to 45% and 25%. Complication rates based on completeness of resection were 29%, 38%, and 36% for CR, MR, and PR, respectively. Estimated 5-year EFS rate was 30% +/- 3% for patients who achieved CR (n = 210) compared with 25% +/- 3% (P =.1010) for those with less than CR (n = 258).

CONCLUSIONS

Resectability improved after neoadjuvant chemotherapy. Complete resection did not increase complications. There was a small survival benefit for complete resection. This study suggests that complete resection may still be important in the current era of intense chemotherapy and transplant.

Cost-effective imaging approach to the nonbilious vomiting infant

OBJECTIVE

To develop a cost- and time-effective algorithm for differentiating hypertrophic pyloric stenosis (HPS) from other medical causes of emesis in infants referred from community-based pediatricians and family practitioners to the imaging department of a tertiary children's care facility.

METHODS

Eighty-nine vomiting infants (22 females, 67 males) between the ages of 11 and 120 days (mean, 43.5 days) had received nothing by mouth for at least 1 hour before the study. Each child was assessed for duration of vomiting, status of body weight, time and volume of last ingestion, and time of last emesis. A #8 French (Sherwood Medical, St Louis, MO) nasogastric feeding tube was placed in the child's stomach. The contents were aspirated and measured to determine likelihood of HPS. An aspirated volume >/=5 mL implicated gastric outlet obstruction, and ultrasonography (US) was performed. If this study was positive for HPS, the patient was referred for surgery. If US was negative, an upper gastrointestinal series (UGI) was performed. An aspirated stomach contents volume <5 mL suggested a medical cause for the emesis, and UGI was performed. Pediatric surgeons with no knowledge of the volume results palpated the abdomens of 73 of 89 infants (82%).

RESULTS

Twenty-three of 89 patients (25%) had HPS. The aspirate criteria for HPS had a sensitivity of 91%, a specificity of 88%, and an accuracy of 89%. Of the false-positive studies (total = 8), six were related to recent significant ingestion (within 2 hours of the study), and two were attributable to antral dysmotility. The surgeons palpated the mass in 10 of 19 patients (53%). Sensitivity and specificity were 53% and 93%, respectively. Only 6 of 89 infants (7%) required both US and UGI to determine the etiology of the nonbilious vomiting. By performing the UGI in 66 patients, it was also found that 14% had slow gastric emptying and 79% had gastroesophageal reflux. Eighty-one percent of the gastroesophageal reflux was significant.

CONCLUSION

The volumetric method of determining the proper imaging study is cost- and time-effective in the evaluation of the nonbilious vomiting infant for pyloric stenosis. If US was performed initially in all patients referred for imaging, two studies would have been performed in 68 of 89 patients (76%) to define the etiology of the emesis. Because we used the volumetric method, 62 fewer imaging studies were performed, representing a savings of $4464 and 30 hours of physician time. If children are given nothing by mouth for 3 to 4 hours before gastric aspiration, the specificity of the volumetric method improves to 94%, and the accuracy improves to 96%.

Evaluation of contrast media for bronchography

BACKGROUND

Bronchography is occasionally needed for the evaluation and management of some congenital pulmonary anomalies as well as some acquired diseases, usually of the tracheo- bronchial tree. There is currently no effective, approved contrast agent for this imaging techniq ue.

OBJECTIVE

We evaluated five agents (barium sulfate, iohexol, propyliodone oily, propyliodone aqueous, and perflubron) in terms of image quality, histologic changes, and effects on hemodynamics, blood gases, and standard laboratory tests in New Zealand White rabbits.

MATERIALS AND METHODS

Animals were anesthetized and intubated. Each contrast agent (0.25 ml/kg) was administered intratracheally. Three animals in each group had intravenous lines placed for blood sampling and blood pressure monitoring and were sacrificed at 1 h. An additional three animals for each agent were sacrificed at 24 h and 1 week after imaging. Blood samples were taken immediately before contrast instillation and at 1 h postbronchography. Fluoroscopic images were recorded on standard VHS video tape and evaluated in blind fashion. Segments of lung tissue and bronchi were obtained for histologic examination.

RESULTS

Necrosis and/or inflammatory infiltrates were noted in 78 % of the bronchograms performed with propyliodone aqueous, 67 % with propyliodone oily, 55 % with perflubron, and 33 % with iohexol 120, 240 and 350. No histologic damage was observed with barium. The propyliodones gave the best-quality imaging results and the most histologic changes. Iohexol, in any concentration, gave the least acceptable images and a moderate number of histologic changes. Barium sulfate demonstrated acceptable images with virtually no histologic changes.

CONCLUSION

From the histologic and imaging results, barium is the best available contrast material for bronchography.

Surgical correction of hydrothorax from diaphragmatic eventration in children on peritoneal dialysis

Continuous ambulatory peritoneal dialysis (CAPD) is frequently used in the pediatric age group for reversible and end-stage renal failure. Most pediatric patients tolerate this therapy with few complications. Approximately 2% of children, however, develop massive unilateral hydrothorax. This major complication usually results in the discontinuation of peritoneal dialysis in all forms and the institution of hemodialysis. Occult diaphragmatic defects account for most adult and pediatric patients who develop this complication. Three pediatric patients receiving CAPD complicated by massive hydrothorax are described. All patients were successfully treated by thoracotomy and repair of the diaphragmatic eventration with an immediate return to CAPD. This is the first report of successful therapy of this kind in children. A review of the cause, diagnosis, and treatment of massive hydrothorax developing during CAPD therapy is presented.

Triglyceride absorption in transperitoneal alimentation

In 17 fasted rabbits, a 20% solution of Intralipid was administered into the peritoneal cavity. Oral and intravenous feedings were not provided. Eight of the rabbits underwent resection of 50% of the intestine. Serial samples of serum and peritoneal fluid showed that half of the triglyceride was absorbed within 1 hour in rabbits with intact viscera, but not until 2 hours in rabbits with intestinal resection. The caval-arterial gradient for triglycerides was consistently positive in rabbits with intact intestine, whereas it was smaller and erratic after intestinal resection. The portal-arterial gradient was never significantly different from zero. These data indicate that the major triglyceride absorption occurred across the visceral peritoneum through lymphatic vessels, with little portal venous absorption. Transperitoneal absorption of triglycerides occurred to a sufficient degree to provide substantial nutritional supplementation in rabbits with intact intestine; absorption was less in rabbits with intestinal resection.

Morphologic effects of orchiopexy or orchiectomy on the contralateral testis in experimental unilateral cryptorchidism

For evaluation of the effects of orchiopexy and orchiectomy on the contralateral descended testis, unilateral cryptorchidism was produced in 60 21-day-old mice by suturing of the left testis to the inner abdominal wall. A sham operation was performed on the left testis of 20 control mice (S). After creation of unilateral cryptorchidism, orchiopexy (P) or orchiectomy (O) was performed on the left testis at 2 (group I) and 10 (group II) weeks (ten mice each). All testes were removed for examination 2 weeks after orchiopexy or orchiectomy. In both groups the mean values of testicular weight, seminiferous tubular diameter, and tubular biopsy score of contralateral O testes were always statistically similar to the values of contralateral S testes (p greater than 0.01). The difference between TBS values of contralateral P and S testes was not significant in group I (p greater than 0.01), but it was significant in group II (p less than 0.01). The data from this murine experiment suggest that orchiectomy for unilateral cryptorchid testis is almost always helpful in improving contralateral morphology; however, orchiopexy can be helpful if it is not performed late in the period of maturation.

Morphologic effects of unilateral cryptorchidism on the contralateral descended testis

Unilateral cryptorchidism is frequently accompanied by infertility. Uncertainty exists as to whether the infertility is a genetic effect or is related to an autoimmune reaction to the elevated testis. The effects of unilateral cryptorchidism were evaluated in 50 mice by surgically elevating the left testicle of 21-day-old mice into the abdomen (AT). A sham operation was performed on the left testicle of 50 control mice (SHT). The temperature of the abdominal testes measured 2.5 degrees C higher than the scrotal testes. The testes were removed from both sides at 1, 2, 3, 4 and 6 weeks postoperation. After testicular weights were recorded, seminiferous tubule diameters were measured, and germinal epithelium maturity was graded histologically using a modified Johnson testicular biopsy score. Progressive abnormal changes were seen in the contralateral descended testicles of AT as compared to SHT. By 3 weeks, though testicular weight changes were similar, mean seminiferous tubule diameter was smaller (P less than .001), and the germinal epithelium was less mature (P less than .001). These changes persisted through the sixth week. By changing the physiologic environment of one testicle, we have induced alterations in the histologic appearance of the contralateral testicle during the period of normal maturation.