Stage 4S Research Articles

Laparoscopic Resection of Abdominal Neuroblastoma

Since indications for laparoscopic adrenalectomy have progressively expanded to pediatric surgery, preliminary reports have studied the laparoscopic approach for abdominal neuroblastoma (NB). We aimed to report on the indications and the results of laparoscopic resection in a large series of abdominal NBs. A retrospective multicenter study included 45 children with abdominal NBs (28 localized, 11 stage 4, 6 stage 4s) and laparoscopic resection of their abdominal primary tumor. Primary site of the tumor was the adrenal gland in 41 cases and retroperitoneal space in 4. The median age at surgery was 12 months (1-122); median tumor size was 37 mm (12-70). Resection was performed through transperitoneal laparoscopy (n = 38) or retroperitoneoscopy (n = 7). Complete macroscopic resection was achieved in 43 of 45 children (96%). The median duration of pneumoperitoneum was 70 min (30-160), and the length of hospital stay was 3 days (2-9). Four procedures (9%) were converted to open surgery, and tumor rupture occurred in three cases. Of the 28 children with localized disease, there was a 96% overall survival (OS) rate after a median follow-up of 28 months (4-94). There was one local relapse in this subgroup, with subsequent complete remission. For the entire 45-children cohort, four children died and three presented a recurrence resulting in OS, disease-free survival, and event-free survival rates of 84% +/- 8.1, 84% +/- 8.2, and 77% +/- 9.1 respectively. Laparoscopic resection of abdominal primary allows effective local control of the disease in a wide range of clinical situations of neuroblastoma, with an acceptable morbidity.

Specific gene expression profiles and unique chromosomal abnormalities are associated with regressing tumors among infants with disseminated neuroblastoma

9501 Background: Among human cancers, neuroblastoma (NB) has the highest incidence of spontaneous remission, especially among the subgroup of stage 4s NB affecting infants. Clinical distinction of stage 4s from lethal stage 4 can be difficult, but critical, since it is the basis for therapeutic decisions. The identification of biological markers that allow a precise distinction of these NB subgroups will aid accurate classification. Methods: Thirty-seven infants with NB were treated at MSKCC from 1987 to 2000. Ten stage 4s and 19 stage 4 were evaluated by allelic and gene expression analyses. Results: All stage 4s patients underwent spontaneous remission while only 69% of newly diagnosed, previously untreated stage 4 patients survived despite combined modality therapy. Among stage 4 tumors, 19/19 were near-diploid/tetraploid, 8/19 MYCN amplified, 50% had LOH at 1p36, 43% had LOH at 1p34-p31 and/or 14q and 37% had LOH at 11q and/or 1p22. Among stage 4s tumors, 7/8 were near-triploid, none MYCN-amplified and LOH was restricted to 11q. Gene expression profiling identified 233 differentially expressed genes between stage 4 and 4s tumors. 25% of these genes with increased expression in stage 4s NB mapped to 1pter-p13, with transcription level correlated with LOH and ploidy. Conclusions: These findings suggest that differential expression of subsets of genes located at specific chromosomal regions play a significant role in the biology of disseminated NB. Besides offering a biological definition of stage 4s, these expression profiles may provide new insights in the genetic control of spontaneous remission in neuroblastoma. No significant financial relationships to disclose.

A phase III trial of biologically-based therapy reduction for intermediate risk neuroblastoma

9504 Background: Infants with advanced neuroblastoma (stage 3 and 4) and children >1 year with favorable biology stage 3 disease have had a survival exceeding 80% with aggressive chemotherapy. The primary objective of Childrens Oncology Group A3961 was to maintain a 3-year event-free and overall survival rate above 90% for intermediate risk (IR) neuroblastoma with a reduction in therapy compared to historical trials for similarly defined risk patients. Methods: IR patients were defined by selected clinical (age, INSS stage, histopathology) and biologic (MYCN status and DNA index) factors. All eligible IR patients were MYCN non-amplified and were divided into subcategories defined as favorable or unfavorable biology. Therapy consisted of 2 to 3 agent combinations of carboplatin, etoposide, cyclophosphamide and doxorubicin given every 3 weeks for a total of 4 cycles (favorable biology) or 8 cycles (unfavorable biology). Patients with favorable biology failing to achieve CR/VGPR after 4 cycles and surgery, received 8 cycles. All patients were required to enter a companion neuroblastoma biology study and to enroll on A3961 within 28 days of diagnosis. Results: Between March 1997 and May 2005, 467 eligible patients were enrolled on study. These included 261 stage 3 (105 children; 156 infants), 174 stage 4 infants, and 32 stage 4s infants. 362 (78%) were less than 12 months of age at diagnosis. 330 (71%) patients had favorable and 137 (29%) unfavorable biology. There were 40 (12.1%) of 330 favorable biology patients who went onto cycles 5–8. There were 52 events in 467 cases including 15 deaths and two secondary AML. Conclusions: The primary hypothesis of this study was confirmed and survival rates greater than 90% were maintained for IR neuroblastoma with reduced therapy compared to historical trials. The successor trial will prescribe duration of therapy based, in part, on loss of heterozygosity states at 1p36 and 11q23 as well as initial response to treatment in an endeavor to further reduce therapy for this group of patients. [Table: see text] No significant financial relationships to disclose.

Late complications after surgery in patients with neuroblastoma

Purpose The purpose of this study was 2-fold: to study the complications of neuroblastoma treatment and to establish surgical guidelines. Materials and Methods The medical records of 92 patients with neuroblastoma (stage 1 or 2, n = 33; stage 3, n = 21; stage 4, n = 31; stage 4S, n = 7) who had undergone surgery in our department between 1985 and 2001 were reviewed, with an emphasis on treatments and late complications. Results The disease-free survival rate was 98.3% (58/59) in infantile patients, whereas it was 36.4% (12/33) in advanced patients older than 1 year. The rate was improved up to greater than 50% after the introduction of intensive local therapy with intraoperative radiation (IOR). The treatment-associated morbidity rate was 15.0% in nonadvanced infantile patients, was 42.1% in advanced infantile patients, and was 33.3% in advanced older patients. In the advanced cases, renovascular problems were most frequently seen especially after IOR. Furthermore, pulmonary problems, cardiac problems, and second cancer were highlighted as fatal problems; thyroid dysfunction, vertebral deformity, and growth retardation were also noted. Conclusions Higher incidences of late morbidity and treatment-associated mortality appeared to be more strongly related to disease stage rather than to patient age. Appropriate surgery and IOR with lower doses should be recommended as a surgical strategy for high-risk patients.

The EVI5 TBC domain provides the GTPase-activating protein motif for RAB11

The human EVI5 gene was originally isolated through its involvement with a constitutional chromosome translocation in a patient with stage 4S neuroblastoma. Recently, it has been shown that EVI5 is a centrosomal protein in interphase cells, which relocalizes to the midbody during late phases of mitosis. Disruption of its function leads to incomplete cell division and the formation of multinucleate cells. The EVI5 protein contains a TBC (TRE2/BUB/CDC16 homology) motif located in the N-terminal region. Proteins containing a TBC domain have been shown in some cases to act as GTPase-activating proteins (GAPs) and function through the interaction with Rab-like small G proteins. Despite the identification of over 50 TBC-containing proteins, and over 70 Rab-like proteins, only three combinations have been shown to have Rab/GAP activity to date. In this study, using linear ion trap mass spectroscopy, we have demonstrated that EVI5 exists in a protein complex with Rab11. Further, using a specific Rab-binding assay, we have shown that EVI5 preferentially interacts with the guanosine triphosphate-bound form of Rab11, and in a GAP activity assay, we have confirmed that EVI5 functions as a GAP for the Rab11 GTPase.

Oligonucleotide array‐based comparative genomic hybridization (aCGH) of 90 neuroblastomas reveals aberration patterns closely associated with relapse pattern and outcome

The study of genomic alterations in neuroblastoma is of particular importance since several cytogenetic markers proved to be closely associated with the clinical phenotype. To disclose patterns of gains and losses, we performed high-resolution oligonucleotide array-based comparative genomic hybridization (aCGH). A total cohort of 90 patients was classified into 6 subsets according to tumor stage and outcome: Stages 1-3+ (with event), Stage 1-3- (no event), Stage 4+/-, and Stage 4S+/-. The aberration patterns in Stages 1-3- and 4S- tumors differed from all other groups as they were predominantly characterized by losses (3, 4, 14, X) and gains (7, 17) of whole chromosomes. However, 59/65 (91%) tumors of Stages 1-3+ or Stage 4 revealed numerous structural copy number alterations (sCNA). While deletions in chromosomes 1, 3, and 11 discriminated outcome in Stage 4, there were no specific sCNA that distinguished tumor stage within the subgroup of unfavorable tumors. sCNA in 1p, 3p, 11q, 17q, or MYCN amplification (MNA) was seen among 22/24 patients who died, 10/12 with metastatic relapses, and 5/9 with local recurrences. Detailed breakpoint analyses on chromosomes 1, 3, 11, and 17 disclosed preferred breaking areas, although breakpoints were not identical. Amplifications were found in 18 patients and involved 2p24 (MYCN) and other segments of chromosome 2, as well as regions on chromosome arms 6q, 12q, and 17q. One single feature in 21q21.1 (BU678720, without known function yet) attracted particular attention since five patients showed a homozygous loss of this sequence.

Spontaneous Regression of Metastases Including Meningeal Metastasis After Gross Resection of Primary Tumor in an Infant With Stage 4 Neuroblastoma

Neuroblastoma is the most common extracranial solid tumor in childhood. Spontaneous regression has been well described in infants, especially in those with stage 4S and those with low-stage neuroblastoma detected by screening. However, neuroblastoma presenting with intracranial metastasis is generally considered to need a postoperative chemotherapy. Here, we report a 3-month-old girl with stage 4 neuroblastoma presenting with spontaneous regression of metastatic tumor including meningeal metastasis after gross resection of primary tumor. Further investigation may be required to detect patients of this kind without the need of postoperative chemotherapy regardless of their stage at diagnosis.

Identification of candidate tumor related genes using comprehensive gene expression analysis of neuroblastic tumors

9051 Background: Neuroblastic tumors (NBTs) represent a heterogeneous and relatively well defined spectrum of neoplastic diseases. We performed gene expression analysis to molecularly characterize the distinct clinicobiological subtypes of NBTs. Methods: Gene expression analysis of 106 NBTs (10 ganglioneuromas, 10 stage 4s, 29 loco-regional (stages 1, 2, 3), and 57 stage 4) and 12 neuroblastoma cell lines was performed using Affymetrix Genechip Human Genome U95 Set Arrays. Differential expression between predefined groups of biological and clinical relevance was determined by differences >3 standard deviations between the means for groups, step-down permutation and false discovery rate methods. Results: Gene expression analysis of clinically defined groups including stage 4 infants versus children, metastatic versus non metastatic, and stroma poor loco-regional versus stage 4, revealed that many differentially expressed genes mapped to chromosomal regions with well described recurrent abnormalities in NBTs (chromosomes 1, 11, 17, 19 and X). Pairwise comparison analysis of biologically defined groups, including triploid versus diploid/tetraploid NBTs, identified significantly discriminating genes that map to the same chromosomal regions. Gene expression analysis of MYCN-amplified versus MYCN non amplified NBTs, confirmed a functional overrepresentation for genes involved in protein biosynthesis. Conclusions: Gene expression profile analysis of clinically and biologically relevant subgroups of NBTs revealed differential expression of genes at specific chromosomal regions known to have strong association between genetic alterations and NBT clinical features. The identification of altered expression helps to define critical chromosomal regions and identify tumor related candidate genes within each region. No significant financial relationships to disclose.

Diagnostic and prognostic impact of urinary catecholamines in neuroblastoma patients

Urinary catecholamine metabolites are well-known to be elevated in patients with neuroblastoma. Some investigators have described different patterns in favorable and unfavorable cases. However, extended studies have not been published. We investigated urinary catecholamine patterns and their correlation to stage, biological features, and outcome in 114 consecutively clinically diagnosed neuroblastoma patients. Sensitivity of vanillylmandelic acid (VMA), homovanillic acid (HVA), and dopamine (DA) was 80.7, 71.9, and 61.3%, respectively. In 91.2% of patients at least one parameter was above normal. High VMA levels were associated with favorable biological features, high DA levels were predominantly found in biologically unfavorable disease. Whereas patients with normal HVA levels had a significant better outcome, the other parameters showed no significant association with prognosis. For disseminated neuroblastoma of infancy, DA/VMA ratio proved to be helpful for the discrimination of stage 4 versus stage 4s. Urinary catecholamines appear to be useful to give a first but important hint about the biological behavior and thus the prognosis of the underlying disease. Particularly DA/VMA ratio may serve as a tool for "biological grading"-especially in disseminated disease of infancy. In addition, it may be speculated that HVA negativity and low DA/VMA ratio may be helpful for the decision of a "wait and see" strategy in selected neuroblastoma patients with localized disease.

Successful treatment of MYCN amplified, progressive stage 4S neuroblastoma in a neonate with hepatic artery embolization in addition to multimodality treatment

Stage 4S metastatic neuroblastoma (NB) has a favorable prognosis due to a high rate of spontaneous regression. Young infants risk lethal complications arising from hepatomegaly, which can develop rapidly despite treatment. MYCN oncogene amplification confers a significantly worse prognosis. We describe a 4-week-old neonate with MYCN-amplified stage 4S NB complicated by gross hepatomegaly causing rapidly progressive respiratory, hepatic, and renal failure. The child remains in remission 3 years after hepatic artery embolization, radiotherapy, standard, and high-dose chemotherapy. Embolization of the hepatic artery, with classical treatment, is feasible and safe at this age and may contribute substantially to the management of high-risk patients.

Neuroblastoma stage 4S with 123I‐MIBG‐positive bone marrow involvement

Neuroblastoma stage 4S with ¹²³I‐MIBG‐positive bone marrow involvement

Liver involvement in neuroblastoma: The memorial Sloan‐Kettering experience supports treatment reduction in young patients

We reviewed clinical and biologic findings in a series of infants with neuroblastoma (NB) in liver. The aim was to gain insights into improving therapy. Among 19 newly or recently diagnosed infants with NB in liver, 1987-2002, those with stage 4 involving bone received chemotherapy, while those without bone or extensive bone marrow (BM) involvement were observed or received limited treatment if NB caused life-threatening symptoms. We assessed results in the context of NB treatment risk stratification, which is based on age, stage, and selected biologic features (MYCN, ploidy, histology). Six of eight infants with bone involvement became long-term event-free survivors including 1/2 with MYCN amplification and four who received only 4-6 cycles of chemotherapy; at the end of treatment, four infants had abnormalities in liver +/- the primary site, but these resolved. All 11 infants without bone lesions became long-term survivors with either no cytotoxic therapy or only one cycle of chemotherapy (+/- radiotherapy to liver), including four who had stage 4 and one stage 4S patient who still had NB in BM at age 15 months. Treatment reduction should be considered for subsets of infants with non-MYCN-amplified widespread NB: stage 4 without bone or extensive BM involvement may not require cytotoxic therapy, stage 4S with symptomatic hepatomegaly may not require multiple cycles of chemotherapy, and classic stage 4 may do well with limited chemotherapy. Persistent liver abnormalities post-treatment may not require continued therapy to achieve a radiologic complete remission.

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

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

Late Presentation of Opsoclonus-Myoclonus-Ataxia Syndrome in a Child With Stage 4S Neuroblastoma

Opsoclonus-myoclonus-ataxia syndrome (OMA) in children is most commonly associated with occult neuroblastoma (NB). Although children with OMA and NB have decreased mortality, they suffer from increased neurologic morbidity. The pathogenesis of OMA in NB is not well understood, but current research and treatments support an immune-mediated process. The authors describe an unusual presentation of OMA occurring following 6 months of chemotherapy in a child with stage 4S NB who presented with partial Horner syndrome. Histopathologic examination of his primary cervical tumor showed NB maturation, which may have played a role in precipitating OMA syndrome. Further study of unusual cases of OMA in NB may provide better understanding of the syndrome and additional treatment options for these children.

Risk factors for scoliosis in children with neuroblastoma

To determine the risk factors for scoliosis in children treated for neuroblastoma. From 1957 to 1997, 58 children with neuroblastoma were treated at one institution and have survived a minimum of 5 years. There were 35 boys and 23 girls with a median age of 6 months (range, 2 weeks to 15 years) at initial diagnosis. Primary site was located in the adrenal gland in 25 (43.1%), abdominal/nonadrenal in 16 (27.6%), thoracic in 12 (20.7%), cervical in 3 (5.3%), and pelvic region in 2 (3.5%). The International Neuroblastoma Staging System (INSS) stage was Stage 1 in 10 (17.2%), Stage 2A in 7 (12.1%), Stage 2B in 5 (8.6%), Stage 3 in 22 (37.9%), Stage 4 in 4 (6.9%), and Stage 4S in 10 (17.2%). Thirty-three (56.9%) received chemotherapy whereas 5 (8.6%) had a laminectomy as part of the surgical procedure. Twenty-seven (46.6%) received radiotherapy (RT). Beam energy was 1.25 MV in 11 (41%), 250 kV in 10 (37%), 4 MV in 4 (15%), and 6-MV photons in 1 patient. One patient received 300 cGy in 1 fraction total skin RT using 6-MeV electrons. For the remaining patients, fraction size was 100 cGy in 6 (22%), 150-180 cGy in 11 (41%), 200 cGy in 4 (15%), and 250-300 cGy in 3. Three patients had total body irradiation at 333 cGy for 3 fractions. For all children who received RT, median total dose was 2000 cGy (range, 300-3900 cGy). Patients who were treated with RT had plain films of the irradiated area every 1 to 2 years until at least the age of puberty. Median follow-up was 10 years (range, 5-46 years). The overall 5-, 10-, and 15-year scoliosis-free rates were 87.6%, 79.0%, and 76.0% respectively. Twelve (21%) developed scoliosis at a median time of 51 months (range, 8-137 months). The degree of scoliosis was mild (< or =20 degrees ) in 8 (67%). Four had scoliosis ranging from 30 degrees to 66 degrees ; 3 of these patients required surgical intervention, whereas 1 had an underlying Duchenne muscular dystrophy which manifested itself 8 years after diagnosis of neuroblastoma. Median time to scoliosis was 23 months (range, 8-54 months) in children who had a laminectomy. On multivariate analysis, both history of laminectomy (p = 0.0005) and use of RT (p = 0.0284) were found to be risk factors for development of scoliosis. Gender, age at diagnosis, INSS stage, primary site, and use of chemotherapy were not found to be significant. Both RT fraction size and beam energy were also not significant, but increasing total RT dose was found to be significant (p = 0.0039). The 15-year scoliosis-free rates were 20% for children who had a laminectomy and 81.3% for those who did not have a laminectomy. The 15-year scoliosis-free rates for children treated with RT doses 0 cGy, 1-1750 cGy, 1751-2300 cGy, and >2300 cGy were 91.7%, 87.5%, 51.4%, and 44.4% respectively. Treatment-related factors, namely laminectomy and radiotherapy, were found to increase the risk of scoliosis in patients with neuroblastoma. Children who had a laminectomy were more likely to manifest scoliosis earlier. Increasing RT dose was found to impact adversely on the development of scoliosis.

Low occurrence of familial neuroblastomas and ganglioneuromas in five consecutive GPOH neuroblastoma treatment studies

Familial neuroblastoma is of special interest in view of the oncogenesis of this tumour with its early manifestation in childhood. The inheritance seems to follow an autosomal-dominant Mendelian trait with incomplete penetrance. Familial neuroblastomas and ganglioneuromas have not been reported in detail within large treatment studies. A retrospective clinicopathological survey of patients reported to the German neuroblastoma treatment studies over 24 years was performed. Among 2863 patients (2752 neuroblastomas, 111 ganglioneuromas) included in five consecutive trials, only 22 hereditary cases in ten families were observed. Neuroblastomas were found in 18 patients and ganglioneuromas in four, accounting for less than one percent of all cases. Six patients with neuroblastomas had localised disease, seven had stage 4, three had stage 4S, and stage was unknown in two patients. In four families, two generations were affected, with ganglioneuromas occurring in the parental generation in two families. Two families had three affected patients. Contrary to previous reports, age distribution and number of primary tumours in patients with familial tumours were not significantly different from patients with sporadic tumours. The outcome of both groups was comparable. These data confirm the low prevalence of familial neuroblastoma and may help in counselling the affected families.

Risk factors for scoliosis in children treated for neuroblastoma

To determine the risk factors for scoliosis in children treated for neuroblastoma. From 1957 to 1997, 58 children with neuroblastoma were treated at 1 institution and have survived a minimum of 5 years. There were 35 boys and 23 girls with a median age of 6 months (range, 2 weeks to 15 years) at initial diagnosis. Primary site was located in the adrenal gland in 25 (43.1%), abdominal /non-adrenal in 16 (27.6%), thoracic in 12 (20.7%), cervical in 3 (5.3%) and pelvic region in 2 (3.5%). The International Neuroblastoma Staging System (INSS) stage was Stage 1 in 10 (17.2%), Stage 2A in 7 (12.1%), Stage 2B in 5 (8.6%), Stage 3 in 22 (37.9%), Stage 4 in 4 (6.9%) and Stage 4S in 10 (17.2%) children. Thirty-three (56.9%) received chemotherapy while 5 (8.6%) had a laminectomy as part of surgical procedure. Twenty-seven (46.6%) received radiotherapy (RT). Beam energy was 1.25 MV in 11 (41%), 250 KV in 10 (37%), 4 MV in 4 (15%) and 6 MV photons in 1 patient. One patient received 300cGy in 1 fraction total skin RT using 6 MeV electrons. For the remaining patients, fraction size was 100 cGy in 6 (22%), 150–180 cGy in 11 (41%), 200 cGy in 4 (15%) and 250–300 cGy in 3. Three patients had total body irradiation at 333cGy for 3 fractions. For all children who received RT, median total dose was 2000 cGy (range, 300–3900 cGy). Patients who had RT had plain films of the irradiated area every 1 to 2 years until at least the age of puberty. Median follow-up was 10 years (range 5–46 years). The overall 5-, 10- and 15-year scoliosis-free rates were 87.6%, 79.0% and 76.0% respectively. Twelve (21%) developed scoliosis at a median time of 51 months (range, 8–137 months) from initial diagnosis. The degree of scoliosis was mild (less than or equal to 20 degrees) in 8 (67%). Four patients had scoliosis ranging from 30 to 66 degrees; three of these patients required orthopedic intervention, while 1 had an underlying Duchenne muscular dystrophy which manifested itself 8 years after diagnosis. Median time to scoliosis was 23 months in children who had a laminectomy (range 8–54 months). On multivariate analysis, both history of laminectomy (p = .0005) and use of RT (p = .0284) were found to be risk factors for development of scoliosis. Gender, age at diagnosis, INSS stage, primary site and use of chemotherapy were not found to be significant. Both fraction size and beam energy were also not significant, but increasing total RT dose was found to be significant on logistic regression analysis (p = 0.0017).The 15-year scoliosis-free rates were 20% for children who had a laminectomy and 81.3% for those who did not have laminectomy. The 15-year scoliosis-free rates for children treated with RT doses 0 cGy, 1–1750 cGy, 1751–2300 cGy and greater than 2300 cGy were 91.7%, 87.5%, 51.4% and 44.4% respectively (p = .0039,log-rank). Treatment-related factors, namely laminectomy and radiotherapy, were found to increase the risk of scoliosis in patients with neuroblastoma. Children who had a laminectomy were more likely to manifest scoliosis earlier. Increasing RT dose was found to impact adversely on the development of scoliosis.

Clustering of gene hypermethylation associated with clinical risk groups in neuroblastoma.

Neuroblastoma is the most common extracranial solid malignancy in infancy and childhood, but the biological factors involved in its development and progression are still unclear. Transcriptional silencing of tumor suppressor genes mediated by hypermethylation of promoter CpG islands is a hallmark of human tumors. We addressed the clinical relevance of promoter hypermethylation in neuroblastoma. We examined the methylation status of 45 candidate genes representative of many cellular pathways in 10 neuroblastoma cell lines and of 10 of these genes in 145 tumor samples (118 of them were primary neuroblastomas). We used Fisher's exact test to examine the association of CpG island methylation and clinical subgroups and Kaplan-Meier analysis to determine the association between methylation and survival in primary tumors. Cluster analysis was used to group cell lines and tumors by gene methylation status. Bonferroni-corrected statistical tests were two-sided. Clustering of neuroblastoma cell lines on the basis of hypermethylation distinguished lines with MYCN amplification (a negative prognostic factor) from those without it (P =.012). Promoter hypermethylation of the developmental gene HOXA9 was associated with mortality in noninfant patients (P =.04) and in tumors lacking MYCN amplification (P =.023). Hypermethylation of the proapoptotic gene TMS1 and the cell cycle gene CCND2 was associated with stage 4-progressing tumors (P<.001), but the genes were never methylated in stage 4S tumors, which undergo spontaneous regression. Hypermethylation of the differentiation gene RARbeta2 was associated with patient survival (P =.032). Unsupervised hierarchical cluster analysis of all tumors based on methylation of the 10 genes separated several clinically relevant groups of tumors. Profiling the status of CpG island hypermethylation in human primary neuroblastomas may have clinicopathologic value.

4S neuroblastoma: the long-term outcome.

Stage 4S neuroblastoma is associated with a high rate of spontaneous maturation and involution, with survival rates of 70-90%. There is little long-term follow-up data describing the disease status or late effects. The aim of this study was to assess the clinical outcome and imaging findings in long-term survivors of 4S neuroblastoma. The patient population was identified from a single centre over 26 years. Twenty-five of 31 consecutive patients were long-term survivors. Five died from disease progression and one from cerebral palsy related complications. All survivors underwent clinical examination. Abdominal ultrasound scanning, liver function tests, hepatitis viral screen, and urinary catecholamines were performed. The mean age at diagnosis was 8 +/- 9 weeks with a mean age when studied of 11 years and 10 months +/- 8 years. Twenty of 25 had no significant clinical findings, three had disease associated clinical abnormalities (neurological, multiple subcutaneous nodules). Three patients had treatment related effects (small testes, urethral stricture, radiation induced soft tissue hypoplasia, post-surgical Horners syndrome). Persistant adrenal enlargement and calcification was noted in three patients. Twelve patients had abnormal liver ultrasound findings ranging from mildly coarse echotexture to structural changes without evidence of hepatic dysfunction or infection. Treatment did not correlate with abnormal hepatic ultrasound findings. The majority of long-term survivors of stage 4S neuroblastoma have no clinically or radiologically significant sequelae but do have residual abnormalities. These findings have implications for subsequent management of unrelated medical conditions in this patient group.

Promoter methylation in esophageal squamous carcinomas

Aberrant hypermethylation occurs in tumour cell CpG islands and is an important pathway for the repression of gene transcription in cancers. We investigated aberrant hypermethylation of 11 genes by methylation-specific polymerase chain reaction (PCR), after treatment of the DNA with bisulphite, and correlated the findings with MYCN amplification and allelic status at 1p in a series of 44 neuroblastic tumours. This tumour series includes five ganglioneuromas (G), one ganglioneuroblastoma (GN) and 38 neuroblastomas (six stage 1 tumours; five stage 2 tumours; six stage 3 cases; 19 stage 4 tumours, and two stage 4S cases). Aberrant methylation of at least one of the 11 genes studied was detected in 95% (42 of 44) of the cases. The frequencies of aberrant methylation were: 64% for thrombospondin-1 (THBS1); 30% for tissue inhibitor of metalloproteinase 3 (TIMP-3); 27% for O6-methylguanine-DNA methyltransferase (MGMT); 25% for p73; 18% for RB1; 14% for death-associated protein kinase (DAPK), p14ARF, p16INK4a and caspase 8, and 0% for TP53 and glutathione S-transferase P1 (GSTP1). No aberrant methylation was observed in four control normal tissue samples (brain and adrenal medulla). MYCN amplification was found in 11 cases (all stage 4 neuroblastomas), whereas allelic loss at 1p was identified in 16 samples (13 stage 4 and two stage 3 neuroblastomas, and one ganglioneuroma). All but one case with caspase 8 methylation also displayed MYCN amplification. Our results suggest that promoter hypermethylation is a frequent epigenetic event in the tumorigenesis of neuroblastic tumours, but no specific pattern of hypermethylated genes could be demonstrated.