Mass screening for neuroblastoma at 6 months of age: difficult to justify

Neuroblastoma

Neuroblastoma is one of the most common solid tumors in children and has a diverse clinical behavior that largely depends on the tumor biology. Neuroblastoma exhibits unique features, such as early age of onset, high frequency of metastatic disease at diagnosis in patients over 1 year of age and the tendency for spontaneous regression of tumors in infants. The high-risk tumors frequently have amplification of the MYCN oncogene as well as segmental chromosome alterations with poor survival. Recent advanced genomic sequencing technology has revealed that mutation of ALK, which is present in ~10% of primary tumors, often causes familial neuroblastoma with germline mutation. However, the frequency of gene mutations is relatively small and other aberrations, such as epigenetic abnormalities, have also been proposed. The risk-stratified therapy was introduced by the Japan Neuroblastoma Study Group (JNBSG), which is now moving to the Neuroblastoma Committee of Japan Children's Cancer Group (JCCG). Several clinical studies have facilitated the reduction of therapy for children with low-risk neuroblastoma disease and the significant improvement of cure rates for patients with intermediate-risk as well as high-risk disease. Therapy for patients with high-risk disease includes intensive induction chemotherapy and myeloablative chemotherapy, followed by the treatment of minimal residual disease using differentiation therapy and immunotherapy. The JCCG aims for better cures and long-term quality of life for children with cancer by facilitating new approaches targeting novel driver proteins, genetic pathways and the tumor microenvironment.

Divergent Patterns of Incidence in Peripheral Neuroblastic Tumors

BACKGROUND

Prior research on trends in neuroblastoma incidence has conflicted. We aimed to compare how ganglioneuroblastoma and neuroblastoma incidence have changed.

PROCEDURE

Using the Surveillance Epidemiology and End Results (SEER) 9 population-based registry, we identified 2081 malignant peripheral neuroblastic tumors in patients 0 to 14 years from 1973 to 2009. Age-adjusted annual incidence rates were calculated using SEER*Stat, and Joinpoint Regression Program was used to calculate annual percent change (APC) and analyze trends. Data were stratified by histology, age, and stage.

RESULTS

Overall peripheral neuroblastic tumor incidence increased by an APC of 0.47 (P=0.045). However, ganglioneuroblastoma incidence decreased (APC=-1.48; P=0.003), whereas neuroblastoma incidence increased (APC=0.79; P=0.008). When divided by age and stage, locoregional neuroblastoma incidence increased in infants until a significant inflection point in 1996 (APC=4.19; P<0.001) and then decreased sharply (APC=-6.80; P=0.160).

CONCLUSIONS

Ganglioneuroblastoma incidence has decreased, whereas neuroblastoma incidence has increased. These changes could be real, or reflect bias from classification changes or increased detection. Neuroblastoma incidence increased most markedly in infants with locoregional disease only until 1996, then declined, which may reflect changes in tumor ascertainment and folate supplementation.

Effectiveness of nationwide screening program for neuroblastoma in Japan

BACKGROUND

Neuroblastoma (NB) is one of the most malignant neoplasms in childhood. In Japan, while a nationwide screening program at six months of age was introduced in 1985, its efficacy has not been systematically evaluated before or after its introduction. The screening test was changed from a qualitative method to a quantitative method (i.e., high performance liquid chromatography, HPLC) with higher test precision around 1990. However, the Japanese government stopped the program in 2003, after reports which did not show a reduction in mortality from NB. To evaluate the effectiveness of the program, a systematic large-scale epidemiological study was conducted.

METHODS

A retrospective cohort study was carried out to evaluate the effectiveness of the NB screening with HPLC test at 6 months of age in Japan, in comparing mortality and incidence of NB after 6 months of age between screened children and concurrent non-screened children in the same area. The study cohort was defined retrospectively as those children who were born after the introduction of HPLC test, from its earliest introduction of January 1984 to December 31, 1997, in twenty-five prefectures of Japan, which cover approximately half of the newborn population of Japan.

RESULTS

The study cohort consisted of 4.31 million. We identified 66 NB deaths in the study cohort for the analysis after 6 months. Kaplan-Meier estimate of cumulative mortality of NB per million children at 6 years was 15.33 for the screened group and 32.63 for the non-screened group, respectively. The difference of hazard between the two groups was statistically significant. The age specific mortality rate ratio of NB (95% confidence interval (CI)) was statistically lower at 1 - 3 years [0.415 (0.212 - 0.810)]. The rate ratio of NB incidence (95% CI) at the early stage (i.e., 1, 2 and 4S) between them was statistically higher at 6 months - 1 year [9.56 (4.76 - 19.23)]. That of NB incidence at the advanced stage (i.e., 3 and 4) was statistically lower at 1 - 4 years [0.40 (0.26 - 0.62)].

CONCLUSION

The present study showed the reduction of mortality from NB, as well as the increase of the identification of early stage of NB and the decrease of advanced stage of NB. These findings strongly suggest the effectiveness of the NB screening with HPLC test in Japan. Although there could be several biases inherent to the study design, their possibilities are considered to be relatively low from observational information and theoretical consideration.

Risks and benefits of ending of mass screening for neuroblastoma at 6 months of age in Japan

PURPOSE

The mass screening (MS) for neuroblastoma (NB) at 6 months of age in Japan was discontinued in 2004. This study assessed the risks and benefits of MS based on an analysis of NB detected before or after discontinuation of MS in Japan.

METHODS

The clinical features and Brodeur's genetic type based on MYCN, DNA ploidy, and other genetic aberrations were assessed in 113 NB patients (20 cases after and 93 cases [55 MS cases] before the discontinuation of MS) older than 6 months treated at one institution since 1985.

RESULTS

The 20 patients with NBs detected after MS was discontinued ranged in age from 7 to 67 months, 12 patients were stage 4, and 11 patients would have been detected at 6 months of age if they had undergone MS. The Brodeur's genetic type of these 20 patients showed that 30% (6/20) were type 1 (low risk), 55% (11/20) were type 2A (intermediate risk), and 15% (3/20) were type 2B (high risk). Of 93 patients with NB detected before MS was discontinued, 60% (56/93) were type 1, 18% (17/93) were type 2A, and 22% (20/93) were type 2B. Among the type 2A patients, 82% (9/11) of the patients detected after MS was discontinued showed stage 4, whereas only 50% (9/18) of those diagnosed before MS was discontinued were stage 4. The genetic analysis using single nucleotide polymorphism (SNP) array for type 2A showed that the pattern of genetic aberration was equivalent in those detected either before or after MS was discontinued.

CONCLUSIONS

There was a decrease of type 1 and an increase of type 2A NB in patients after MS was discontinued in Japan. These results suggest that most of the type 1 detected by MS has regressed, and most of the type 2A detected by MS has appeared sporadically as advanced NB in patients older than 1 year.

Secular trends in neuroblastoma mortality before and after the cessation of national mass screening in Japan

Background

In 2003, the Japanese government halted the national mass screening program for neuroblastoma (NB), which had been running since the mid-1980s. It is not known whether the NB mortality rate subsequently increased or decreased.

Methods

Utilizing vital statistics data from 1980 through 2006, we analyzed the secular trends in NB mortality by using cancer of the adrenal gland as a surrogate. We examined the validity of this substitution by comparing the results with data from death certificates. Using a joinpoint regression model, we examined the trends in age-specific mortality rates by calendar year and cumulative mortality rates by birth year. The cumulative mortality rate was analyzed for age under 1 or 2 years for infants born after the cessation of the mass screening program.

Results

The number of deaths from cancer of the adrenal gland was closely correlated with the number of deaths from NB. Significant decreases in the mortality rate were observed from 1980 through 2006 by calendar year for those aged under 1 year, 1 to 4 years, and 5 to 9 years. The cumulative mortality rates by birth year also significantly decreased from the 1980 birth cohort. Although the cumulative mortality rates under the age of 2 appear to have increased after the 2003 birth cohort, the change was not statistically significant.

Conclusions

No significant increase in the NB mortality rate was detected after the cessation of the mass screening program in Japan. However, continuous monitoring is still needed to fully evaluate this health policy decision.

Treatment Complications in Children Diagnosed With Neuroblastoma During a Screening Program

Purpose

The Québec Neuroblastoma Screening Program was put in place to investigate the possibility of decreasing mortality from high-risk neuroblastoma through early screening. We assess treatment complications in the patients diagnosed during this screening program.

Patients and Methods

A total of 476,603 patients born during the screening period were eligible. Parents of 425,838 children (89%) agreed to participate in the 3-week screening, and 73% agreed to participate in the 6-month screening. Forty-five patients had neuroblastoma. We reviewed the medical and research charts for all patients diagnosed by screening. Follow-up was available from 8 to 13 years after screening.

Results

Forty-five patients were diagnosed by screening. All patients were treated according to the Pediatric Oncology Group recommendations of the time. All patients had surgery, and 29 patients received chemotherapy. No patient died from neuroblastoma. Eleven patients suffered complications from treatment. Two patients had life-threatening complications.

Conclusion

In view of the lack of impact of screening programs on neuroblastoma mortality, evidence that many of the tumors detected through screening can be observed without treatment and the serious complications that may arise from therapy, we do not support neuroblastoma screening programs for children.

Diagnostic precision and accuracy in interpretation of specimens from cancer screening programs

Few areas in modern medicine provide a better example of evidence-based data than the anatomic pathologists' classification of fully developed malignancies. Beginning with the Papanicolaou (Pap) smear, morphologic tools also were applied to specimens obtained in cancer screening programs directed at large, asymptomatic patient populations. The Papanicolaou test was quickly responsible for a reduction in the incidence of invasive squamous cell carcinoma of the cervix, proving the concept that screening could interdict the development of advanced malignancy. Other screening programs followed the Papanicolaou test initiative, producing a revolutionary change in the specimens submitted to pathologists. Cancer screening generates specimens containing morphologic deviations from normal that are thought to put currently healthy patients at risk of future malignancy. However, translating morphologic findings in such samples into risk estimates raises a number of statistical and ethical problems. When diagnostic thresholds are set to favor specificity, unwanted false-negative results accrue. Conversely, aiming at sensitivity over specificity is associated with biologically false-positive results, which are likewise undesirable. Pathologists interpreting these specimens find themselves facing a screening paradox. These screening programs attempt to discover the very earliest changes of neoplastic transformation, but these same earliest changes are inherently the most difficult to identify with precision and accuracy. This paper discusses these challenges.

Neuroblastoma Mass Screening in Late Infancy: Insights Into the Biology of Neuroblastic Tumors

Purpose: Neuroblastoma screening in early infancy has detected predominantly “favorable” tumors. We postponed screening to an age between 7 and 12 months to test whether this shift of screening age might influence the detection rate of genetically/clinically unfavorable tumors.

Patients and Methods: In a 10-year period, 313,860 infants were screened by analysis of urine catecholamines. When a neuroblastoma was diagnosed, at least two different areas from every tumor were analyzed for genetic features (MYCN amplification, 1p status, ploidy). Furthermore, neuroblastoma incidence and mortality of the screened group and the cohort of 572,483 children not participating in the screening program were compared.

Results: Forty-six neuroblastomas were detected by mass screening. In 17 tumors (37%) at least one of the biologic features was “unfavorable.” In 10 of 17 patients, one or more of these alterations were only focally present (tumor heterogeneity). In the screened cohort, neuroblastoma incidence was significantly higher when compared with unscreened children (18.2 v 11.2/100,000 births), while there was a trend towards lower incidence of stage 4 over 1 year (2.2 v 3.8). Mortality was not significantly different (0.96 v 1.57).

Conclusion: In contrast to other neuroblastoma screening programs, more than one-third of patients were found with unfavorable genetic markers in our study. The high proportion of focal alterations suggests that biologically young neuroblastomas may consist of genetically favorable and unfavorable parts/areas/clones. We conclude that at least one-third of neuroblastomas detected by screening in late infancy are anticipated cases. This, however, does not result in significantly reduced mortality.

Children may not benefit from neuroblastoma screening at 1 year of age. Updated results of the population based controlled trial in Germany

Neuroblastoma is the second most frequent malignancy in childhood. We investigated whether screening for neuroblastoma at 1 year of age reduces the incidence of metastatic disease or mortality. Screening was offered in 6 of the 16 German states from 1995 to 2000 with the remaining states serving as controls. We studied 2,581,188 children in the screening area born between 1994 and 1999 and 2,117,600 in the control area. We compared mortality from neuroblastoma and the incidence of disseminated disease in the two groups. The screened group and the control group had similar rates of stage 4 neuroblastoma and mortality due to neuroblastoma. Comparison of the screened group and the control area revealed substantial over diagnosis in the screened participants. The present findings provide no support for mass screening for neuroblastoma at 1 year of age.

Neuroblastoma trends in Osaka, Japan, and Great Britain 1970-1994, in relation to screening

Japan pioneered and has maintained a nationwide mass screening programme for neuroblastoma since 1985 without prior evaluation among a target population. Convincing population-based evaluation of the ongoing programme has also been very limited because a population-based registry for childhood cancer has not been in operation. This report describes trends in incidence of and mortality from neuroblastoma in Osaka Prefecture, Japan, using Great Britain as an external control, between 1970 and 1994. Incidence and mortality rates were comparable between the 2 areas before the beginning of screening in Osaka. However, incidence rates were markedly increased in Osaka, especially among children younger than 1 year, from 25.9 per million children during 1970-1979 to 240.2 during 1991-1994, while age-standardized incidence rates for metastatic tumours among children aged 1 year or above did not decrease after introduction of the programme. Age-standardized mortality rates per million were unchanged at 3.9 (1970-1979) and 4.1 (1991-1994) in Osaka and 5.7 (1971-1979) and 5.0 (1991-1994) in Great Britain. Cumulative incidence rates among those up to 15 years old progressively increased from 103.4 per million (1970-1979) to 350.0 (1991-1994) in Osaka, though cumulative mortality rates did not decrease: 52.0 and 57.5, respectively. Corresponding figures in Great Britain were 101.0, 115.1, 78.6 and 70.1, respectively. The present findings show little beneficial effect of the screening programme.

Expression of the periostin mRNA level in neuroblastoma

BACKGROUND

Neuroblastoma is the most common malignant solid tumor in early childhood. Whether neuroblastoma is diagnosed by mass screening or by clinical symptom, it has been reported to be correlated with prognosis of the disease. The periostin protein shares structural and sequence homology with fasciclin I, which is an insect adhesion molecule.

METHODS

Expression of periostin messenger RNAs were evaluated by real-time reverse transcription polymerase chain reaction (RT-PCR) assay in 24 tumor samples from neuroblastoma using LightCycler. The data were analyzed in reference to clinicopathologic factors.

RESULTS

There was a tendency for higher periostin transcripts levels in the tumor samples from stage IV when compared with the stage I (P =.0845). The periostin mRNA level was higher in the group with disease diagnosed by symptom than in the group with disease diagnosed by mass screening (P =.0266). The periostin mRNA level also was higher in the group with disease diagnosed after 1 year of age than in the group with disease diagnosed before 1 year of age (P =.0059).

CONCLUSION

Because the groups with disease diagnosed by symptom or after 1 year of age were reported to be the worse prognosis, the periostin mRNA expression levels were correlated with tumor progression or prognosis of neuroblastoma.

Stephen L. Gans overseas lecture. Mass screening for neuroblastoma in Japan: lessons learned and future directions

BACKGROUND/PURPOSE

Since 1985, a nationwide mass screening program (MS) for neuroblastoma has been conducted for 6-month-old infants throughout Japan, resulting in the detection of more than 1,900 cases of neuroblastoma. The outcome of these patients has been excellent: more than 97% of them are alive. Yet, several reports suggest that the number of advanced-stage neuroblastoma patients over 1 year of age has not changed substantially. The current report focuses on the 15-year experience with MS of the Kyushu Pediatric Oncology Study Group.

METHODS

The clinical and biological features of neuroblastoms detected (n = 320) and not detected by MS (n = 245) were compared. Regional and national statistics for neuroblastoma before and after 1985 were analyzed using standard epidemiologic measures for the occurrence of disease.

RESULTS

The majority of the MS-positive cases were biologically favorable and had an excellent outcome. In contrast, the majority of non-MS patients in whom neuroblastoma later developed had advanced-stage, unfavorable-prognosis tumors. The overall mortality rate of neuroblastoma in the Kyushu area was not improved by MS.

CONCLUSIONS

The optimal time for screening is the point at which neuroblastomas regressing spontaneously can no longer be detected, but more aggressive disease can be found. A birth cohort study could determine the optimal timing for a second screening. Identification of other new prognostic factors may be required.

Screening of infants and mortality due to neuroblastoma

BACKGROUND

Neuroblastoma, the most common extracranial solid tumor that occurs in early childhood, can be identified in the preclinical stages by the detection of catecholamines in the urine. However, it is unknown whether routine screening for neuroblastoma reduces mortality due to this disease.

METHODS

Through their parents, we offered screening for neuroblastoma at three weeks and six months of age to all 476,654 children born in the province of Quebec, Canada, during a five-year period (May 1, 1989, through April 30, 1994). The participation rate was 92 percent. The rate of death due to neuroblastoma was determined and compared with the rates in several unscreened control populations born during the same period.

RESULTS

Among children younger than eight years of age in the Quebec cohort, there were 22 deaths due to neuroblastoma; the cumulative (+/-SE) mortality rate due to neuroblastoma was 4.78+/-1.14 per 100,000 children over a period of nine years. The standardized incidence ratios for death due to neuroblastoma for the Quebec cohort were 1.11 (95 percent confidence interval, 0.64 to 1.92) as compared with a control group in Ontario, Canada; 0.90 (95 percent confidence interval, 0.48 to 1.70) as compared with a control group in Minnesota; 1.40 (95 percent confidence interval, 0.81 to 2.41) as compared with a control group in Florida; and 0.96 (95 percent confidence interval, 0.56 to 1.66) as compared with a control group in the Greater Delaware Valley. The standardized mortality ratio for the Quebec cohort as compared with the rest of Canada was 1.39 (95 percent confidence interval, 0.85 to 2.30); the odds ratio for the comparison with a cohort born in Quebec before the screening program began was 0.98 (95 percent confidence interval, 0.54 to 1.77).

CONCLUSIONS

Screening infants for neuroblastoma does not appear to reduce mortality due to this disease.

Marginal decrease in mortality and marked increase in incidence as a result of neuroblastoma screening at 6 months of age: cohort study in seven prefectures in Japan

PURPOSE

To determine the usefulness of 6-month screening for neuroblastoma.

PATIENTS AND METHODS

The cumulative incidence rates (IRs) and cumulative mortality rates (MRs) of neuroblastoma in children younger than 60 months of age were analyzed for control (n = 713,025), qualitative screening (Qual Screen, n = 1,142,519), and quantitative screening (Quan Screen, n = 550,331) cohorts, and for Screened and Unscreened subgroups within screening cohorts.

RESULTS

IRs (per 100,000) for infants aged 6 to 11 months were 1.12 in Control, 5.69 in Qual Screen (P <.0001), and 17.81 in Quan Screen (P <.0001); IRs for children aged 12 to 59 months were 7.29 in Control, 5.86 in Qual Screen (P =.28), and 6.36 in Quan Screen (P =.60). IRs for children aged 12 to 59 months in Unscreened or Screened subgroups remained at the same level. When patients diagnosed at younger than 6 months of age were excluded, the MR (per 100,000) under 60 months for Control was 4.21; those in Unscreened and Screened subgroups were 3.84 and 2.53 in Qual Screen (P =.30), and 3.20 and 1.97 in Quan Screen (P =.73), respectively; MRs between Control and Unscreened subgroups revealed no significant differences (P =.89 in Qual Screen, P =.85 in Quan Screen).

CONCLUSION

Six-month screening resulted in a marked increase in incidence for infants with no significant decrease in incidence for children older than 1 year of age. A decrease in mortality was observed, but it was not significant. The usefulness of screening is questionable, because the decrease of mortality should be balanced against the adverse effect of overdiagnosis and the psychological burden on parents and children.

Clinical and biologic characteristics for recurring neuroblastoma at mass screening cases in Japan

BACKGROUND

It is said that most cases detected by neuroblastoma mass screening at 6 months of age tend to have a favorable clinical course after a surgical resection either with or without mild chemotherapy. However, a few cases have an unfavorable outcome. In the current study, the authors analyzed the clinical and biologic characteristics for recurring neuroblastoma in mass screening cases.

METHODS

In 245 cases detected through mass screening in the Kyushu area in Japan, the clinical data and biologic features (N-myc status, DNA ploidy, Shimada histology, neuron-specific enolase (NSE), ferritin) were investigated, whereas, in particular, the data for recurring cases also were analyzed.

RESULTS

Of 245 cases, 28 tumors had one or more biologically unfavorable prognostic factors, and 6 patients experienced recurrence. Three of the six patients with recurring disease underwent a complete resection of the primary tumor, whereas three cases had undergone an incomplete resection of the tumor. Regarding the initial chemotherapy, three cases received mild chemotherapy, two cases received no chemotherapy, and one case had high-dose multidrug chemotherapy. Regarding biologic prognostic factors, four of six cases with recurring disease had one or more unfavorable factors, whereas two cases had no unfavorable factors. Regarding the outcome after recurrence, four cases are CR, one case has a stable residual tumor, and one case died of disease with N-myc amplification.

CONCLUSIONS

Most neuroblastomas detected by mass screening at 6 months of age have biologically favorable factors. However, approximately 10% of the cases had one or more unfavorable factors and thus might have a higher risk of recurrence than the patients with no unfavorable factors. Conversely, some cases with recurring disease had no unfavorable factors; however, the reason for this is still unclear. A long-term follow-up for mass screening cases is important, and it also might be necessary to research the established biologic factors and identify other new prognostic factors.

Prenatally detected tumor mass in the adrenal gland

BACKGROUND/PURPOSE

Screening programs using urinary vanillylmandelic acid have detected neuroblastomas in early infancy with some success. With the widespread use of ultrasonography in modern obstetric practice, use of ultrasonography to screen for fetal neuroblastoma seems to be reasonable and practical.

METHODS

Seven fetuses had suprarenal masses detected by maternal ultrasound scan at 32 to 37 weeks' gestation between 1993 and 1998. They were delivered normally if the pregnancy was uncomplicated, especially if it was without maternal preeclampsia or fetal hydrops. Each mass was further confirmed by ultrasound scan, computed tomography, or magnetic resonance imaging in the neonatal period. Tumor excision was performed at the age of 6 to 38 days of life.

RESULTS

The size of the masses measured ranged from 2.0x2.0 cm to 4.5x4.5 cm. The diagnosis was adrenal hemorrhage in 1 neonate, Evan's stage I neuroblastoma in 3, and stage IV-S neuroblastoma in 3. All of the specimens with a diagnosis of neuroblastoma showed a favorable histology by the Shimada classification system. Infants with stage I disease were treated with tumor excision only, and they had survived without disease by 14, 18, and 25 months of follow-up. One infant with stage IV-S neuroblastoma was treated further with minimal chemotherapy and has survived without disease at the 66-month follow-up examination. Another child with stage IV-S neuroblastoma has survived with local recurrence and increasing liver metastasis and was still on chemotherapy at the 2-month follow-up examination. The third child with stage IV-S disease presented with massive hepatomegaly and bone marrow involvement, and disseminated intravascular coagulopathy had developed. The patient died on the 5th day of life without surgical intervention.

CONCLUSIONS

The increasing use of obstetric ultrasonography has made the prenatal screening of neuroblastomas possible. The prognosis of infants with a suprarenal mass may be improved with this early detection and early surgical intervention.

The position and size of radiological nephrogram in Japanese preschool children

The early detection of retroperitoneal masses in children, such as neuroblastoma, Wilm's tumor, hydronephrosis and cystic renal diseases, has a great clinical importance for the improvement of their prognosis. The kidney is often affected in its size or position by these lesions, and occasionally allows clinicians to find a clue to reach the correct diagnosis before the patient become symptomatic. Since we had no clinically available nomogram on the position and the size of the kidney in Japanese children, we measured the size and position of the kidneys on plain abdominal x-rays in 347 Japanese children in preschool years with a special attention to their relationship with the spine. As a result, the nomogram showed age dependent growth of the kidneys keeping almost the same ratio with the spine, while the distance between the upper pole of the kidney and the spine remained less than 10 mm in all age groups. Our nomogram may be useful not only for picking up the malposition of the kidneys but also for the follow up of the patients with chronic renal diseases affecting the growth of the kidneys.