The association of congenital neuroblastoma and congenital heart disease. Is there a common embryologic basis?

Urorectal Septum Malformation Sequence With Retroperitoneal Neuroblastoma: A Case Report of an Unusual Association

Urorectal septum malformation sequence (URSMS) is an uncommon disease characterized by a failure of the anorectal septum to divide the cloaca and fuse with the cloacal membrane. Complete URSMS is usually lethal in newborn due to severe renal dysfunction and pulmonary hypoplasia. Partial URSMS is compatible with life with a single perineal opening draining a common cloaca with an imperforate anus which amenable to surgical management. Antenatal diagnosis of URSMS is challenging because of multisystem, complex abnormalities involving gastrointestinal, urogenital tract, cardiovascular, and musculoskeletal systems. In this case report, we describe a 15-week male fetus with partial URSMS having a spectrum of multisystem structural anomalies associated with fetal neuroblastoma in retroperitoneal location and adrenal neuroblastoma in situ.

Exploring Shared Susceptibility between Two Neural Crest Cells Originating Conditions: Neuroblastoma and Congenital Heart Disease

In the past years, genome wide association studies (GWAS) have provided evidence that inter-individual susceptibility to diverse pathological conditions can reveal a common genetic architecture. Through the analysis of congenital heart disease (CHD) and neuroblastoma (NB) GWAS data, we aimed to dissect the genetic susceptibility shared between these conditions, which are known to arise from neural crest cell (NCC) migration or development abnormalities, via identification and functional characterization of common regions of association. Two loci (2q35 and 3q25.32) harbor single nucleotide polymorphisms (SNPs) that are associated at a p-value < 10^-3 with conotruncal malformations and ventricular septal defect respectively, as well as with NB. In addition, the lead SNP in 4p16.2 for atrial septal defect and the lead SNP in 3q25.32 for tetralogy of Fallot are less than 250 Kb distant from the lead SNPs for NB at the same genomic regions. Some of these shared susceptibility loci regulate the expression of relevant genes involved in NCC formation and developmental processes (such as BARD1, MSX1, and SHOX2) and are enriched in several epigenetic markers from NB and fetal heart cell lines. Although the clinical correlation between NB and CHD is unclear, our exploration of a possible common genetic basis between NB and a subset of cardiac malformations can help shed light on their shared embryological origin and pathogenetic mechanisms.

Tetralogy of fallot associated with invasive adrenocortical tumor in an adult woman

Migration of cardiac neural crest cells into the pharyngeal arches and the pharyngeal and splanchnic mesoderm contributes to the development of the cardiac outflow tract. The adrenal cortex is derived from the splanchnic mesoderm. Neuroblastoma is more prevalent in patients with congenital heart disease than in the general population, because both originate from embryonal neural crest-derived cells. Similarly, and in light of recent embryological findings, abnormal development or migration of splanchnic mesoderm, possibly due to an underlying genetic defect, could contribute to the association of adrenocortical carcinoma and tetralogy of Fallot. We present the case of a cardiologically asymptomatic 49-year-old woman with total correction of tetralogy of Fallot in the first year of life.

Prevalence of congenital heart defects in neuroblastoma patients: a cohort study and systematic review of literature

Data on the prevalence of congenital heart defects (CHD) in neuroblastoma patients are inconsistent. If CHD are more common in neuroblastoma patients than in the general population, cardiac screening might be warranted. In this study we used echocardiography to determine the prevalence of CHD in a single centre cohort of surviving neuroblastoma patients. In addition, we performed a systematic review of the literature. Echocardiography was performed in 119 of 133 patients (89.5%). Only two patients (1.7%) had CHD. The prevalence of CHD was not significantly different from a previously published control group of 192 leukaemia patients examined by echocardiography (P = 0.49). Literature search revealed 17 studies, showing prevalence rates of CHD in neuroblastoma patients ranging from 0 to 20%. Prevalence was less than 3.6% in the majority of studies. Most studies lacked information on validity. We conclude that current evidence does not support standard cardiac screening in all patients with neuroblastoma.

Birth-related characteristics, congenital malformation, maternal reproductive history and neuroblastoma: the ESCALE study (SFCE)

Since neuroblastoma occurs very early in children's lives, it has been hypothesized that pre- and perinatal factors may play a role in its etiology. This study investigated the role of birth characteristics, congenital malformation and maternal reproductive history in neuroblastoma. The data used were generated by the national population-based case-control study, ESCALE, conducted in France in 2003-2004. The mothers of 191 neuroblastoma cases and 1,681 controls, frequency-matched by age and gender, were interviewed by telephone, using a standardized questionnaire, on several factors including pregnancy, medical history, lifestyle, childhood medical conditions and exposures. A positive association between congenital malformation and all neuroblastoma cases was observed [Odds ratio (OR) = 2.2, 95% confidence interval (95% CI): 1.1-4.5]. Congenital malformations were highly associated to neuroblastoma in children aged less than 1 year (OR = 16.8, 95% CI: 3.1-90), while no association was observed in children aged 1 year or more (OR = 1.0, 95% CI: 0.3-2.9). A negative association with a maternal history of spontaneous abortions was also found (OR = 0.6, 95% CI: 0.4-0.9). The results strongly support the hypothesis that congenital anomalies may be associated with neuroblastoma, particularly in infant (less than 1 year of age).

Fetal and neonatal neuroblastoma: retrospective review of 271 cases

Neuroblastoma is the foremost malignant neoplasm of the fetus and neonate. The tumor is unique because of its distinctive biologic behavior and many different clinical manifestations. The purpose of this review is to focus on the fetus and neonate to determine the various ways perinatal neuroblastomas differ clinically and morphologically and in their treatment from those found in the older child to show that some forms of the tumor have a better outcome than others. The report attempts to evaluate the influence of site, histology, stage, biologic markers, and treatment on survival.

Abnormal rib number in childhood malignancy: implications for the scoliosis surgeon

STUDY DESIGN

Retrospective review.

OBJECTIVE

To determine if rib anomalies are present in pediatric malignancies in the United States.

SUMMARY OF BACKGROUND DATA

Scoliosis surgeons view radiographs of the entire spine, counting the number of ribs. A European study noted that rib anomalies were more common in certain malignancies. We wished to determine if this is also true in the United States. If so, the potential for screening, early detection of malignancy, and a better understanding of tumor biology is possible.

METHODS

A retrospective review of 218 children with malignancy and a control group of 200 children with polytrauma or suspected child abuse was performed. Chest radiographs were reviewed to determine the number of ribs, and the presence of rib anomalies. 24 ribs was considered normal, <24 or >24 was considered abnormal. P < 0.05 was considered significant.

RESULTS

The average age was 6.8 +/- 5.5 years and number of ribs was 23.8 +/- 0.6. Rib number was normal in 86.8%. There were significant differences between the malignancy and control groups in age (control, 5.7 +/- 5.1 years; malignancy, 7.8 +/- 5.7 years, P = 0.00007), rib number (control, 23.9 +/- 0.5; malignancy, 23.7 +/- 0.7, P = 0.001), and normal/abnormal rib counts (control, 92% normal; malignancy, 82% normal, P = 0.003). In the malignant group, 50% had a lymphoproliferative malignancy, 33% a solid tumor, and 17.0% a neural tumor. Neural malignancies had a higher incidence of rib abnormalities compared with lymphoproliferative or solid malignancies (P = 0.01). Relative to the control group, those with a neural and lymphoproliferative malignancy were 6.23 (95% CI, 2.7-14.5) and 2.0 (95% CI, 1.0-4.1) times more likely to have an abnormal rib count.

CONCLUSIONS

Homeobox genes, important in vertebral and rib sequencing, are abnormally expressed in many different malignancies. This association is a question of great interest. What is the potential for rib number being used as a predictor of childhood malignancy? Can these findings be expanded to adults? These questions require further research. The association noted in this study is interesting but should not yet be used to alarm parents regarding an increased risk of malignancy in their children.

Positive association between congenital anomalies and risk of neuroblastoma

BACKGROUND

Case reports and epidemiological studies have suggested a relationship between congenital anomalies and childhood cancer, but some potential associations remain inconsistent. In this study, we investigated the association between congenital anomalies and neuroblastoma.

PROCEDURE

We used data of a case-control study on neuroblastoma conducted from 1992 to 1994, including 538 children aged 0-19 years with newly diagnosed, histologically confirmed neuroblastoma and 504 controls identified by telephone random-digit dialing and matched to cases on date of birth. Information on congenital anomalies and potential confounding factors was collected through maternal telephone interviews using a structured questionnaire. We estimated odds ratios (OR) and 95% confidence intervals (CI), adjusted for reference age at diagnosis, mother's educational level, mother's race, and household income at birth.

RESULTS

An association between the maternal report of any congenital anomalies and neuroblastoma (OR = 2.58; CI = 1.57-4.25) was observed. Neuroblastoma risk increased with increasing number of anomalies per child (OR = 3.90, CI = 1.27-11.9 for two anomalies or more), and when we restricted analyses to major anomalies (OR = 7.53, CI = 2.23-25.5). Genitourinary anomalies (OR = 5.84, CI = 1.67-20.4) and cardiac anomalies (OR = 4.27, CI = 1.22-15.0) had an elevated, but imprecise neuroblastoma risk.

CONCLUSIONS

Our findings support the hypothesis of an association between neuroblastoma and congenital, especially urogenital and cardiac, anomalies.

Congenital heart disease and neuroblastoma: just coincidence?

The clinical history of a neonate with simple transposition of the great arteries in whom a metastatic neuroblastoma was diagnosed incidentally at autopsy is described, and the literature containing all 66 previously reported cases of neuroblastoma associated with congenital cardiac malformations is reviewed. One third of the described cases were classified as in situ neuroblastoma; neural crest derived cardiac lesions were present in 31%. Several possible aetiological mechanisms are discussed, and we conclude that the association of neuroblastoma with congenital cardiac malformations is multifactorial in origin. The described case represents the first reported example in which catecholamine release may have contributed to the fatal outcome of definitive congenital cardiac surgery.

Current aspects of biology, risk assessment, and treatment of neuroblastoma

Neuroblastoma is one of the most intensely studied solid malignancies that affect the pediatric age groups; its clinical presentation, treatment strategies and ultimate prognosis vary greatly. The biologic and genetic character of each tumor has an important impact on disease behavior, and clinical staging now incorporates these factors to generate an overall therapy plan. The clinical presentation of neuroblastoma is related to primary tumor location, production of metabolically active substances, and the presence of metastatic disease. There are also prognostically important associated syndromes including opsoclonus-myoclonus, Horner's syndrome, neurofibromatosis, and a variety of other neurocristopathies. The histologic features of the tumor are of prognostic significance and are utilized in treatment stratification. The International Neuroblastoma Staging System (INSS) has unified classic clinical staging. Features at diagnosis and those determined by initial operation are combined with biologic prognostic factors to achieve risk group assignment for virtually all patients. There are groups of children in which limited therapy is curative and intermediate-risk situations where standard multimodality treatment provides favorable outcomes. Unfortunately, there are many patients with high-risk disease that require intensive strategies, but success is still limited. It is in these most resistant patients that innovative approaches are being undertaken and novel strategies are being investigated.

Simultaneous adrenocortical carcinoma and ganglioneuroblastoma in a child with Turner syndrome and germline p53 mutation

The predisposition to malignancy that is dominantly inherited in Li-Fraumeni syndrome is associated with germline mutations of the tumour suppressor gene p53. Although second malignant neoplasms have been described in children with p53 mutations, the synchronous occurrence of two embryologically different tumours in these children has not been reported. A 20 month old girl with failure to thrive and congenital heart defects was found to have unilateral adrenal masses which, at surgical removal, proved to be an adrenocortical carcinoma and a ganglioneuroblastoma. Further investigation showed a germline p53 mutation and Turner syndrome. It remains to be determined what effect the 45,X chromosomal complement may have on the expression of neoplasms seen in patients with p53 germline mutations.

Neuroblastoma and Poland syndrome in a 15-year-old boy

A 15-year-old boy with neuroblastoma associated with Poland syndrome is presented. He was admitted with a 2-month history of progressive back pain and a 3-day history of weakness of the lower extremities, encopresis and enuresis. On physical examination, in addition to paraplegia, absence of the pectoralis major muscle was diagnosed on the right side of his chest. A large heterogeneous mass in the right side of the thorax was revealed on computerized tomography. Neuroblastoma was diagnosed on histopathological analysis of the mass. To the authors' knowledge this is the first case of neuroblastoma associated with Poland syndrome in the literature.

Intraoperative discovery of neuroblastoma in an infant with pulmonary atresia

There have been 28 previously reported cases of neuroblastoma associated with congenital heart disease. Because many of these have been defects of the conotruncal region, it has been proposed that abnormal neural crest cell migration or maturation may be a factor that links these normally disparate pathologic conditions. Most neuroblastomas in these cases have been detected at autopsy or by radiologic studies conducted in the evaluation of the cardiac anomalies. Recently, we discovered an occult posterior mediastinal neuroblastoma in a patient undergoing a unifocalization procedure for tetralogy of Fallot with pulmonary atresia and major aortopulmonary collaterals. The tumor was resected, and the patient has demonstrated no evidence of residual or metastatic neuroblastoma.

Excess of congenital abnormalities in French-Canadian children with neuroblastoma: a case series study from Montréal

Neuroblastoma is one of the most common cancers of childhood. Some studies have shown an excess of congenital abnormalities in children who have been diagnosed with neuroblastoma. In this study we examined the medical records of all children with neuroblastoma seen at St. Justine Children's Hospital between the years 1977 and 1993. A total of 141 children (131 of French-Canadian ancestry) were included in this study. Twelve children (8.5%) had 21 defined congenital abnormalities (1,490 per 10,000 children). This compared with a rate of 444.3 children with abnormalities per 10,000 live births (4.44%) for all congenital abnormalities in the British Columbia Health Surveillance Registry, 1979-1988 (relative risk = 1.91, P = 0.03). Six of the 12 children had cardiovascular malformations. These and previous results suggest that there may be a common developmental origin to neuroblastoma and to some congenital malformations. Genes that control development may be worthy of further study in these children.

Homeobox genes: molecular link between congenital anomalies and cancer

Homeobox-containing genes play a major role in the control of segmental identity during embryonic development in Drosophila. Abnormalities of these genes have been shown to produce a wide variety of congenital anomalies in invertebrates and in vertebrates. Many transgenic mice, which are mutant for homeobox genes, show a specific skeletal abnormality, similar to the human cervical rib. In humans, a relationship exists between malformations and tumours. Human cervical rib has been shown to be associated with an increased incidence of malignancy. Recent evidence indicates that homeobox genes might also play a role in carcinogenesis. In this article, we explore the possibility that alterations of homeobox genes might be the basic underlying aetiology for the association between congenital malformations and tumours, at least in a proportion of cases. We provide evidence in support of this argument and suggest areas of further research which would confirm this concept.

[Cardiomyopathy induced by catecholamines in neuroblastoma]

BACKGROUND

Cardiovascular disorders associated with neural crest tumors are congenital malformations rather than cardiomyopathies.

CASE REPORT

A 18 month-old girl developed heart failure one week after discovery of an adrenal neuroblastoma with excessive secretion of catecholamines. Investigation showed dilated cardiomyopathy without myocardial hypertrophy. Besides chemotherapy, the patient was given nitrous derivatives, diuretics and converting enzyme inhibitor. His cardiac condition gradually improved so that partial resection of the tumor was possible 2 years later.

CONCLUSIONS

The cardiomyopathy presented by this patient is possibly catecholamine-induced even though catecholamines usually results in myocardial hypertrophy rather than dilated cardiomyopathy. The reason why such a cardiomyopathy has never been reported in patients with neuroblastoma remains unclear.

Intestinal ganglioneuroblastoma in a 22-week fetus

The clinical history and autopsy findings of a 22-week fetus with intestinal ganglioneuroblastoma, cardiac anomalies, omphalocele, and ileal atresia are presented. Ganglioneuroblastoma was confined to the large intestine and was not suspected prenatally despite ultrasonographic examination. Although enteric ganglia share neural crest lineage with other sites of congenital neuroblastoma, this is the first report of a primary intestinal ganglioneuroblastoma in a fetus or child. Various hypotheses are discussed to explain the coexistence of cardiac malformation and congenital neuroblastoma in this fetus and other cases in the literature. It is hypothesized that other malformations evident in this fetus were caused by the tumor, possibly as teratogenic effects of neuroblastoma-derived catecholamines during embryogenesis.

Association of rib anomalies and malignancy in childhood

A relationship exists between tumours and malformations both generally and in particular combinations. This is also valid for minor errors of morphogenesis suggesting that embryonic tumours are an expression of aberrant intra-uterine morphogenesis. We speculated that these minor aberrations might also manifest in other morphological defects, especially in minor anomalies and malformations of the ribs. We reviewed chest roentgenographs of 1000 children with malignancies for rib anomalies and compared them to 200 patients with mainly infectious diseases. We found 242 rib anomalies in 218 children with tumours (21.8%) and 11 (5.5%) in children without malignancy. This difference was statistically highly significant (P less than 0.001). A high incidence of cervical ribs was found in neuroblastoma (33%), brain tumour (27.4%), leukaemia (26.8%), soft tissue sarcoma (24.5%), Wilms tumour (23.5%) and Ewing sarcoma (17.1%). Only neuroblastoma showed a high incidence of rib bifurcation (4.5%). The increased incidence of these mesenchymal defects in children with malignancies may be another clue for an altered morphogenesis in tumour origin. In neuroblastoma the rib anomaly may be another expression of neurocristopathy as proposed for the association of congenital heart disease and neuroblastoma.

Percutaneous biopsy of thoracic lesions in children

Over the last 6 years, 15 percutaneous thoracic biopsies have been performed in 15 children. The peripheral nature of most of the lesions allowed ultrasound guidance in ten and needles larger than 21 gauge in ten. No pneumothorax developed. Of the 15, 12 biopsies were sufficient for final diagnosis; 3 required surgical biopsy for more definitive tissue typing.