Proliferation marker KI-S5 discriminates between favorable and adverse prognosis in advanced stages of neuroblastoma with and withoutMYCN amplification

Adrenal Gland Primary Neuroblastoma in an Adult Patient: A Case Report and Literature Review

Neuroblastoma (NB) is an undifferentiated malignant tumor of the sympathetic ganglia, occurring in children under 5 years of age. However, it is a rare histology in adult patients, occurring once per every 10 million patients per year. We present the case of a 68-year-old male patient presented to our department for right lumbar pain, asthenia, loss of weight and altered general status. The contrast-enhanced abdominal computer tomography revealed bilateral adrenal tumoral masses of 149 mm and 82 mm on the right and left sides, respectively, with invasion of the surrounding organs. The patient underwent right 3D laparoscopic adrenalectomy and right radical nephrectomy. The pathological result concluded that the excised tumor was a neuroblastoma of the adrenal gland. The patient followed adjuvant oncological treatment; however, due to disease progression, he passed away 22 months after the surgery. To our knowledge, less than 100 cases of adrenal NB in adult patients have been published, the eldest case being diagnosed at 75 years of age; meanwhile, the largest reported tumor measured 200 mm, and was excised through open surgery. Minimally invasive techniques have been limited so far to smaller, organ-confined diseases, thus making the present case the largest adrenal NB removed entirely laparoscopically. Neuroblastoma in the adult population is a rare finding, with worse prognosis compared to pediatric patients. The available literature does not provide enough data for standardized, multimodal management, as the patients are treated following adapted pediatric protocols, thus reinforcing the need for international, multidisciplinary boards for rare tumors.

Aurora kinase A is superior to Ki67 as a prognostic indicator of survival in neuroblastoma

AIMS

To compare the expression and prognostic value of the cell cycle markers Aurora kinase A (AURKA) and Ki67 in neuroblastoma, because AURKA expression levels have greater prognostic significance than those of Ki67 in some cancers.

METHODS AND RESULTS

Eighty-eight neuroblastomas were immunostained with anti-AURKA and Ki67 antibodies. Digitally scanned slides were scored using imaging analysis software. Median AURKA and Ki67 proliferation indices (PIs) were 1.5% and 26%, respectively. Higher than median AURKA and Ki67 levels were detected in the neuroblastomas from patients belonging to the high-risk group, those with MYCN amplification, and those with unfavourable pathology, including a high mitosis-karyorrhexis index (MKI). High AURKA and Ki67 levels were significantly associated with shorter overall survival (OS) and event-free survival (EFS) in univariate analyses. In multivariate analyses, high AURKA level was associated with significantly shorter OS and EFS, independently of risk group, and of MYCN amplification and MKI. High Ki67 level was not associated with shorter OS or EFS after adjustment for risk group or MYCN amplification and MKI.

CONCLUSIONS

High AURKA and Ki67 levels were associated with adverse prognostic factors and shorter survival, but AURKA provides more valuable prognostic information than Ki67 in neuroblastoma.

Histological profile of tumours from MYCN transgenic mice

BACKGROUND

MYCN is the most commonly amplified gene in human neuroblastomas. This proto-oncogene has been overexpressed in a mouse model of the disease in order to explore the role of MYCN in this tumour.

AIMS

To report the histopathological features of neuroblastomas from MYCN transgenic mice.

METHODS

27 neuroblastomas from hemizygous transgenic mice and four tumours from homozygous mice were examined histologically; Ki67 and MYCN immunocytochemistry was performed in 24 tumours.

RESULTS

Tumours obtained from MYCN transgenic mice resembled human neuroblastomas, displaying many of the features associated with stroma-poor neuroblastoma, including heterogeneity of differentiation (but no overt ganglionic differentiation was seen), low levels of Schwannian stroma and a high mitosis karyorrhexis index. The tumours had a median Ki67 labelling index of 70%; all tumours expressed MYCN with a median labelling index of 68%. The most striking difference between the murine and human neuroblastomas was the presence of tingible body macrophages in the transgenic mouse tumours reflecting high levels of apoptosis. This has not previously been described in human or other murine neuroblastoma models.

CONCLUSIONS

These studies highlight the histological similarities between tumours from MYCN transgenic mice and human neuroblastomas, and reaffirm their role as a valuable model to study the biology of aggressive human neuroblastoma.

Immunohistochemical expressions of Cap43 and Mina53 proteins in neuroblastoma

BACKGROUND

We studied the expressions of both Mina53, which is a myc target gene and is related to cell proliferation, and Cap43, which is related to metastasis suppression and downregulation of MYCN gene, in neuroblastoma.

METHODS

Forty-eight surgically obtained neuroblastoma specimens were immunohistochemically stained. The Cap43 and Mina53 expression levels were determined, and their relationship to clinical prognostic factors, biological prognostic factors, and the patients' prognosis were examined.

RESULTS

The Cap43 expression score was significantly high in the cases that had one of the good prognostic factors (<1 year old, early stage, mass screening case, no MYCN gene amplification), whereas the Mina53 expression score was high in those with poor prognostic factors. Regarding the MYCN expression site, the Cap43 expression score was significantly high in the cases demonstrating cytoplasm expression, whereas the Mina53 expression score was significantly high in the cases demonstrating nucleus expression. A significant relationship was found between Cap43 and TrkA, between Mina53 and Ki-67, and between Mina53 and TrkA. The prognosis was significantly favorable in the Cap43 high-expression cases, whereas it was significantly poor in the Mina53 high-expression cases.

CONCLUSIONS

Cap43 and Mina53 are both considered to be important biological and prognostic factors in neuroblastoma.

Chromogenic in situ hybridization-detected hotspot MYCN amplification associates with Ki-67 expression and inversely with nestin expression in neuroblastomas

Since neuroblastomas are intratumorally heterogeneous, the analysis of genetic and biologic features of randomly selected tumor specimen spots may lead to erroneous conclusions. Our purpose was therefore to construct an easily assessable and strictly defined strategy to unify the detection of various molecular markers in paraffin-embedded neuroblastoma samples. We selected tumor specimen spots of highest proliferation activity, that is, hotspots, for the analysis of MYCN amplification status and proliferation-associated molecular markers, such as nestin, which role in neuroblastoma specimens was evaluated for the first time. Using a chromogenic in situ hybridization (CISH) technique, we showed that patients with a MYCN copy number higher than six in anti-Ki-67-detected hotspots have significantly worse overall survival prognosis than patients with low MYCN copy numbers (P = 0.0006). The chosen cutoff value of six was shown to dichotomize MYCN-amplified neuroblastomas at least as specifically as Southern blot hybridization, in which amplification was defined by a copy number of > or = 10. Interestingly, we also detected without difficulty MYCN-amplified neuroblastic cells in bone marrow samples using the CISH technique. The proliferation activity, assessed with an anti-Ki-67-based proliferation index, was significantly higher in MYCN-amplified than in nonamplified hotspots. The proliferation indices of the hotspots had also a significant correlation with the prognosis (International Classification) and histological type, whereas the proliferation accelerator Id2 did not associate with any of the mentioned parameters. The expression of nestin associated inversely with MYCN amplification (P = 0.018), which challenges a previously suggested role of nestin in neuroblastomas. In summary, hotspot focusing provides a means of analyzing proliferation-associated markers in neuroblastomas, and together with the CISH detection of the MYCN copy number enables an easy and reliable examination of MYCN status in neuroblastomas.

Metastatic Adrenal Neuroblastoma in an Adult

BACKGROUND

Neuroblastoma (NB) is a common malignancy in children, but rarely occurs in adults. Accepted unfavourable prognostic factors include age > 1 year, low histologic grade and advanced stage, MYCN amplification, chromosomal aberrations, elevations of neuron specific enolase and lactate dehydrogenase, and increased catecholamine metabolites in urine or serum. In adults, abdomen/retroperitoneum are the primary sites and in children the adrenal gland.

CASE REPORT

A 51- year-old man was admitted to our hospital with hypertension and a large right retroperitoneal mass. Clinically, phaeochromocytoma was suspected. Tumour resection revealed adrenal NB grade III. Chemotherapy according to the paediatric German Neuroblastoma Trial (NB97) was started. Follow-up computed tomography showed regression of the enlarged mediastinal and retroperitoneal lymph nodes. Because of local and systemic progression palliative radiochemotherapy was started. The patient died 9 months after diagnosis.

CONCLUSION

To the best of our knowledge this is the oldest NB patient registered so far in Germany. Currently there are no standard treatment guidelines for patients with NB in adulthood. Collection and evaluation of data in adult patients with this tumour are warranted in order to optimise treatment strategies.

Expression of the c-kit receptor characterizes a subset of neuroblastomas with favorable prognosis

Expression of the c-kit proto-oncogene product in neuroblastomas has been reported, but its clinical relevance is unclear. We determined the expression of c-kit by immunohistochemistry in a series of 155 neuroblastomas with long-term follow-up. The specificity of the reaction was verified by Western blot analysis and quantitative RT-PCR, and exon 11 of the kit gene was screened for mutations by PCR and capillary electrophoresis. No mutations were detected, and transcription of the kit gene correlated with protein expression. c-kit expression was associated with lower tumor stages and a low rate of MYCN amplification. More importantly, it coincided with tumor differentiation (P<0.0001), and portended a favorable outcome with a relative risk of 0.18 (P<0.0001). In a multivariate analysis of event-free survival, loss of c-kit (relative risk 4.25, P<0.0001) was an independent prognostic factor next to INSS stage 4 and before MYCN amplification. It is concluded that c-kit is transcriptionally regulated in neuroblastomas. Its expression likely identifies a subset of neuroblastomas with conserved capacity for differentiation, which may represent the embryonal variety of the disease. Assessment of c-kit may improve prognostic models for neuroblastoma and provide a basis for new therapy concepts.

Repp86 expression and outcome in patients with neuroblastoma

PURPOSE

Given the well-known challenges of neuroblastoma prognosis, we investigated whether the expression of restrictedly expressed proliferation-associated protein of 86 kDa theoretical molecular mass (repp86), a proliferation-associated protein expressed in S, G2, and M phases of the cell cycle, correlates with the clinical outcome in patients with neuroblastoma.

PATIENTS AND METHODS

161 children with different stages of neuroblastoma were studied; the median follow-up time was 72.8 months. The patients were staged according to the International Neuroblastoma Staging System, and histologic grading of the tumors was performed according to the criteria of Hughes and those of the International Neuroblastoma Pathology Classification. The MYCN gene copy number was determined by Southern blot analysis or fluorescence in situ-hybridization, and repp86 expression was assessed immunohistochemically by means of monoclonal antibody Ki-S2 on paraffin sections from archival tumor samples.

RESULTS

A repp86 labeling index (RI) of more than 10% positive tumor cells significantly predicted a shortened disease-free interval and an increased tumor mortality (both P <.0001). Moreover, the RI allowed the identification of patients with favorable and adverse prognosis in subsets defined by stage, grade, age, and MYCN status. In a multivariate analysis, the RI emerged as the most important predictor of event-free and disease-specific survival with hazard ratios of 11.7 and 10.5, respectively (both P <.0001).

CONCLUSION

It seems that repp86 expression is closely associated with the biologic behavior of neuroblastoma. Assessment of the RI might, therefore, considerably refine prognostic models.