Long-term follow-up of children with neuroblastoma receiving radiotherapy to metastatic lesions within the German Neuroblastoma Trials NB97 and NB 2004

GPOH Guidelines for Diagnosis and First-line Treatment of Patients with Neuroblastic Tumors, update 2025

The clinical course of neuroblastoma is more heterogeneous than any other malignant disease. Many low-risk patients experience regression after limited or even no chemotherapy. However, more than half of high-risk patients die from disease despite intensive multimodal treatment. Precise disease characterization for each patient at diagnosis is key for risk-adapted treatment. The guidelines presented here incorporate results from national and international clinical trials to produce recommendations for diagnosing and treating neuroblastoma patients in German hospitals outside of clinical trials.

MYCN Impact on High-Risk Neuroblastoma: From Diagnosis and Prognosis to Targeted Treatment

Among childhood cancers, neuroblastoma is the most diffuse solid tumor and the deadliest in children. While to date, the pathology has become progressively manageable with a significant increase in 5-year survival for its less aggressive form, high-risk neuroblastoma (HR-NB) remains a major issue with poor outcome and little survivability of patients. The staging system has also been improved to better fit patient needs and to administer therapies in a more focused manner in consideration of pathology features. New and improved therapies have been developed; nevertheless, low efficacy and high toxicity remain a staple feature of current high-risk neuroblastoma treatment. For this reason, more specific procedures are required, and new therapeutic targets are also needed for a precise medicine approach. In this scenario, MYCN is certainly one of the most interesting targets. Indeed, MYCN is one of the most relevant hallmarks of HR-NB, and many studies has been carried out in recent years to discover potent and specific inhibitors to block its activities and any related oncogenic function. N-Myc protein has been considered an undruggable target for a long time. Thus, many new indirect and direct approaches have been discovered and preclinically evaluated for the interaction with MYCN and its pathways; a few of the most promising approaches are nearing clinical application for the investigation in HR-NB.

[Clinical efficacy of combined therapy in children with stage 4 neuroblastoma]

OBJECTIVES

To study the early clinical efficacy of combined therapy of stage 4 neuroblastoma.

METHODS

A retrospective analysis was performed on the medical data and follow-up data of 14 children with stage 4 neuroblastoma who were diagnosed in Hong Kong University-Shenzhen Hospital from January 2016 to June 2021.

RESULTS

The median age of onset was 3 years and 7.5 months in these 14 children. Among these children, 9 had positive results of bone marrow biopsy, 4 had N-Myc gene amplification, 13 had an increase in neuron-specific enolase, and 7 had an increase in vanilmandelic acid in urine. Based on the results of pathological examination, differentiated type was observed in 6 children, undifferentiated type in one child, mixed type, in one child and poorly differentiated type in 6 children. Of all the children, 10 received chemotherapy with the N7 regimen (including 2 children receiving arsenic trioxide in addition) and 4 received chemotherapy with the Rapid COJEC regimen. Thirteen children underwent surgery, 14 received hematopoietic stem cell transplantation, and 10 received radiotherapy. A total of 8 children received Ch14.18/CHO immunotherapy, among whom 1 child discontinued due to anaphylactic shock during immunotherapy, and the other 7 children completed Ch14.18/CHO treatment without serious adverse events, among whom 1 child was treated with Lu177 Dotatate 3 times after recurrence and is still undergoing chemotherapy at present. The median follow-up time was 45 months for all the 14 children. Four children experienced recurrence within 2 years, and the 2-year overall survival rate was 100%; 4 children experienced recurrence within 3 years, and 7 achieved disease-free survival within 3 years.

CONCLUSIONS

Multidisciplinary combined therapy is recommended for children with stage 4 neuroblastoma and can help them achieve better survival and prognosis.

The application and value of radiotherapy at the primary site in patients with high-risk neuroblastoma

OBJECTIVE

To retrospectively analyze radiotherapy (RT) regimens for patients with high-risk neuroblastoma (HRNB) at the primary site after surgery, and to further analyze the characteristics of patients who would benefit more from RT.

METHODS

98 pediatric patients with HRNB were analyzed for local control (LC), RT dose, extent of excision and prognostic factors. Among them, 69 children received RT.

RESULTS

The 3 year LC rates were 96.9 and 62.1% (p < 0.001) in the RT and non-RT groups, respectively. In the non-RT group, LC was better in patients with complete macroscopic resection (CME) than in those with incomplete macroscopic resection (IME) (p = 0.026), while in the RT group, no significant difference in LC was found (p = 0.985). Among patients with IME, the LC was 100% in patients with RT doses >= 36 Gy and 66.7% in patients with doses <36 Gy.

CONCLUSION

RT is valuable, provides patients with excellent LC, and is safe in the short term. RT had a complementary therapeutic effect on incompletely resected tumors, thus bringing their LC to the level of patients with CME. For patients with IME, RT at a dose of not less than 36 Gy may improve LC.

ADVANCES IN KNOWLEDGE

This study analysed the role of radiotherapy in HRNB, investigated the dose of RT depending on the degree of resection, and explored the characteristics of patients who would benefit more from RT.

Risk Factors Associated with Metastatic Site Failure in Patients with High-Risk Neuroblastoma

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We observed an increased hazard for failure at metastatic sites which remain persistently avid on MIBG following systemic therapy.

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-Limited response to induction therapy described by Curie and SIOPEN score selects patients at greater risk for poly-metastatic site failure.

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-The low proportion of metastatic sites treated with radiotherapy precluded definitive testing of its impact on the hazard for metastatic site failure.

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-Patients who are unable to undergo transplant, and/or have extensive disease at diagnosis (lung metastases) may be poor candidates for consolidative metastatic site directed radiotherapy given the high competing risk of failure at a new metastatic site.

Purpose

This retrospective study sought to identify predictors of metastatic site failure (MSF) at new and/or original (present at diagnosis) sites in high-risk neuroblastoma patients.

Methods and materials

Seventy-six high-risk neuroblastoma patients treated on four institutional prospective trials from 1997 to 2014 with induction chemotherapy, surgery, myeloablative chemotherapy, stem-cell rescue, and were eligible for consolidative primary and metastatic site (MS) radiotherapy were eligible for study inclusion. Computed-tomography and I­123 MIBG scans were used to assess disease response and Curie scores at diagnosis, post-induction, post-transplant, and treatment failure. Outcomes were described using the Kaplan–Meier estimator. Cox proportional hazards frailty (cphfR) and CPH regression (CPHr) were used to identify covariates predictive of MSF at a site identified either at diagnosis or later.

Results

MSF occurred in 42 patients (55%). Consolidative MS RT was applied to 30 MSs in 10 patients. Original-MSF occurred in 146 of 383 (38%) non­irradiated and 18 of 30 (60%) irradiated MSs (p = 0.018). Original- MSF occurred in post­induction MIBG-avid MSs in 68 of 81 (84%) non­irradiated and 12 of 14 (85%) radiated MSs (p = 0.867). The median overall and progression-free survival rates were 61 months (95% CI 42.6­Not Reached) and 24.1 months (95% CI 16.5­38.7), respectively. Multivariate CPHr identified inability to undergo transplant (HR 32.4 95%CI 9.3­96.8, p < 0.001) and/or maintenance chemotherapy (HR 5.2, 95%CI 1.7­16.2, p = 0.005), and the presence of lung metastases at diagnosis (HR 4.4 95%CI 1.7­11.1, p = 0.002) as predictors of new MSF. The new MSF-free survival rate at 3 years was 25% and 87% in patients with and without high-risk factors.

Conclusions

Incremental improvements in systemic therapy influence the patterns and type of metastatic site failure in neuroblastoma. Persistence of MIBG-avidity following induction chemotherapy and transplant at MSs increased the hazard for MSF.

Evaluation of treatment-associated eye toxicity after irradiation in childhood and adolescence-results from the Registry of the Evaluation of Side Effects after Radiotherapy in Childhood and Adolescence (RiSK)

Purpose

The aim of the study is to evaluate treatment-related acute and late eye toxicity associated with radiation therapy in childhood and adolescence as correlated with RT (radiotherapy) doses.

Methods

From 2001 to 2016, a total of 1725 children and adolescents undergoing radiation therapy were prospectively documented in the Registry of the Evaluation of Side Effects after Radiotherapy in Childhood and Adolescence (RiSK). The RTOG/EORTC criteria were used to classify ocular acute and late effects. Uni- and multivariate analyses were carried out to evaluate the impact of patient age, pre-existing impairments, and radiation dose on ocular toxicity.

Results

Of all documented patients, 593 received dose to the eye and formed the basis of this analysis. In 435 patients, information on acute reaction was available and graded 1, 2, 3, and 4 in 49, 17, 0, and 2 patients, respectively. Information on late toxicity was available in 268 patients and graded 1, 2, 3, and 4 in 15, 11, 11, and 5 patients, respectively. The acute toxicity rate was significantly higher in children who received a maximum dose > 50 Gy to the eye (p < 0.001) and who had a pre-existing eye impairment (p < 0.001 in multivariate analysis). The development of late toxicity was significantly higher for patients experiencing acute toxicity and having received a radiation dose > 50 Gy.

Conclusion

Acute and late toxicity both correlate with high radiation dose to the eye (> 50 Gy) and acute toxicity additionally with pre-existing eye impairments.