Neuroblastoma

Leveraging small voxel with optimal acquisition time for [18F]mFBG total-body PET/CT imaging in pediatric patients with neuroblastoma: a preliminary study

PURPOSE

The advent of total-body PET/CT presents an opportunity for significant advancements in imaging of neuroblastoma with [18F]meta-fluorobenzylguanidine ([18F]mFBG). Small voxel imaging has proven to have better lesion detectability but need enough radioactivity counts. This study aims to balance shortened acquisition times and small voxel reconstruction to keep sufficient image quality and diagnostic confidence on [18F]mFBG total-body PET for neuroblastoma.

METHODS

We retrospectively enrolled 33 pediatric patients with neuroblastoma who underwent 37 [18F]mFBG total-body uEXPLORER PET/CT scans of 10-min duration. PET images were reconstructed with varying acquisition times (0.5-10 min) and three matrix sizes (192 × 192, 512 × 512 and 1024 × 1024). The subjective (scored on a 5-point scale) and objective image quality (signal-to-noise ratio, SNR) of all the sets of reconstructed images were analyzed by nuclear medicine physicians. For indeterminate lesions identified in the group of 192 × 192 matrix with the 10-min scan (G192-10), diagnostic confidence was further evaluated in images reconstructed with the 512 × 512 and 1024 × 1024 matrices (G512 and G1024).

RESULTS

Of the 33 patients with 37 [18F]mFBG PET/CT scans, 17 patients with 20 scans had positive [18F]mFBG PET/CT findings. Sufficient subjective image quality was achieved with at least 2-min acquisition of 192 × 192 matrix and 4-min acquisition of 512 × 512 matrix (with all scores ≥ 3). SNR increased with longer acquisition times for the same voxel size, while decreased as voxel size shrunk. Although the Curie and SIOPEN scores remained consistent across G192, G512, and G1024-10 groups, the G512 groups with at least 2-min acquisition and G1024-10 showed significantly higher confidence scores for characterizing indeterminate lesions on the G192-10 images, with almost all indeterminate lesions being rated as very confident.

CONCLUSIONS

A matrix of 512 × 512 with a minimum of 4-min acquisition on [18F]mFBG total-body PET/CT is recommended for sufficient image quality and improved diagnostic confidence, particularly in detecting indeterminate lesions.

Targeting Pathways in Neuroblastoma: Advances in Treatment Strategies and Clinical Outcomes

Neuroblastoma (NB) is a childhood cancer originating from neural crest cells of the sympathetic nervous system. Despite the advances in multimodal therapy, the treatment of high-risk NB remains challenging. The present review outlines several evidence-related insights into the molecular mechanisms of NB pathogenesis, focusing on genetic drivers (e.g., MYCN amplification) and disrupted signaling pathways (PI3K/Akt/mTOR; Notch; Jak2/STAT3), as well as on the tumor microenvironment's role in progression and resistance. The authors highlight current and emerging therapeutic strategies, including molecularly targeted agents; immunotherapies; and differentiation approaches under investigation. The complexity and heterogeneity of NB underscores the need for continued translational research and for combined strategies aimed at improving outcomes for affected children, highlighting the need for integration of molecular profiling and precision medicine to guide treatment.

Fatty acid metabolism-related risk signature revealing the immune landscape of neuroblastoma and predicting overall survival in pediatric neuroblastoma patients

BACKGROUND

Tumor metabolic reprogramming is a hallmark in cancer cells, wherein fatty acid metabolism assumes a pivotal role in energy supply and the provision of diverse biosynthetic precursors. However, there is a lack of systematic analysis regarding the impact of fatty acid metabolism on prognosis in neuroblastoma (NB) patients and its influence on the immune microenvironment.

METHODS

We acquired RNA expression profiles and corresponding clinical-pathological information for NB patients from the Gene Expression Omnibus, ArrayExpress, and TARGET databases. The GSE49710 cohort was utilized as a training set, whereas E-MTAB-8248 and the TARGET cohorts served as testing sets. Consensus clustering was employed to identify molecular subtypes based on fatty acid metabolism. Independent prognostic genes were pinpointed using LASSO-Cox analysis, which facilitated the development of a novel risk signature that was subsequently validated using the testing sets. We then proceeded to analyze the predictive power of the risk signature for prognosis, its correlation with clinical-pathological features, the immune landscape, and drug sensitivity.

RESULTS

In the consensus clustering analysis, patients in the training set were segregated into two clusters. Cluster 2 exhibiting significantly poorer overall survival (OS) compared to cluster 1. Moreover, cluster 2 was markedly associated with clinical-pathological features indicative of poor prognosis. Following this, univariate Cox regression analysis revealed 207 fatty acid metabolism genes (FMGs) correlated with patient OS. A risk signature based on 35 FMGs was constructed using LASSO-Cox regression analysis, demonstrating significant predictive accuracy and discrimination in both the training and testing sets. The risk signature emerged as an independent prognostic factor and was integrated with multiple clinical-pathological features to develop a nomogram. In the immune landscape analysis, the high-risk group displayed a compromised antigen presentation mechanism, reduced infiltration levels of various immune cells, and escaping of CD8 + T cells and NK cells. Additionally, different risk groups could exhibit different responsiveness to immune checkpoint inhibitors. Lastly, potential chemotherapeutic agents for each risk group were predicted.

CONCLUSION

The novel risk signature, derived from FMGs, demonstrated promising efficacy in predicting the prognosis of NB patients, elucidating their immune landscape, and guiding therapeutic strategies.

RAS gene polymorphisms confer the risk of neuroblastoma in Chinese children from Jiangsu province

INTRODUCTION

To evaluate the potential association between single nucleotide polymorphisms in the RAS gene and neuroblastoma risk, we examined four candidate SNPs within this gene.

METHODS

Our hospital-based case-control study included 402 cases and 473 controls. Four SNPs (rs12587 G > T, rs7973450 A > G, and rs7312175 G > A in KRAS and rs2273267 A > T in NRAS) were genotyped using the TaqMan assay. The association between RAS gene polymorphisms and neuroblastoma susceptibility was assessed through odds ratios and 95% confidence intervals.

RESULTS

None of the four candidate SNPs exhibited a significant attribution to neuroblastoma risk. However, the concurrent presence of 2-3 KRAS risk genotypes significantly conferred an increased susceptibility to neuroblastoma (adjusted odds ratio [AOR] = 2.55, 95% confidence interval [CI] 1.33-4.89; P = 0.005). Further stratified analyses indicated that carriers of the KRAS rs12587 TT genotype tended to be more predisposed to neuroblastoma in males and in the subgroup with tumors originating from other sites. Additionally, the co-occurrence of 2-3 KRAS risk genotypes was found to be linked to an increased neuroblastoma risk in subgroups of individuals older than 18 months, males, tumors originating from retroperitoneum, mediastinum, or other sites, and those with tumors at clinical stage III + IV, respectively.

CONCLUSIONS

In summary, a single KRAS gene polymorphism may be weakly associated with an increased risk of childhood neuroblastoma in Jiangsu province, China, while the presence of more KRAS risk genotypes may increase the contribution to the risk of neuroblastoma.

A non-invasive diagnostic approach for neuroblastoma utilizing preoperative enhanced computed tomography and deep learning techniques

Neuroblastoma presents a wide variety of clinical phenotypes, demonstrating different levels of benignity and malignancy among its subtypes. Early diagnosis is essential for effective patient management. Computed tomography (CT) serves as a significant diagnostic tool for neuroblastoma, utilizing machine vision imaging, which offers advantages over traditional X-ray and ultrasound imaging modalities. However, the high degree of similarity among neuroblastoma subtypes complicates the diagnostic process. In response to these challenges, this study presents a modified version of the You Only Look Once (YOLO) algorithm, called YOLOv8-IE. This revised approach integrates feature fusion and inverse residual attention mechanisms. The aim of YOLO-IE is to improve the detection and classification of neuroblastoma tumors. In light of the image features, we have implemented the inverse residual-based attention structure (iRMB) within the detection network of YOLOv8, thereby enhancing the model's ability to focus on significant features present in the images. Additionally, we have incorporated the centered feature pyramid EVC module. Experimental results show that the proposed detection network, named YOLO-IE, attains a mean Average Precision (mAP) 7.9% higher than the baseline model, YOLO. The individual contributions of iRMB and EVC to the performance improvement are 0.8% and 3.6% above the baseline model, respectively. This study represents a significant advancement in the field, as it not only facilitates the detection and classification of neuroblastoma but also demonstrates the considerable potential of machine learning and artificial intelligence in the realm of medical diagnosis.

ALDOC promotes neuroblastoma progression and modulates sensitivity to chemotherapy drugs by enhancing aerobic glycolysis

Introduction

Neuroblastoma (NB), a malignant extracranial solid tumor originating from the sympathetic nervous system, exhibits poor prognosis in high-risk cases, with a 5-year overall survival rate below 50%. Glycolysis has been implicated in NB pathogenesis, and targeting glycolysis-related pathways shows therapeutic potential. This study investigates the role of the glycolysis-associated gene ALDOC in NB pathogenesis and its impact on chemotherapy sensitivity.

Methods

Transcriptomic data from NB patients were analyzed to identify ALDOC as an independent risk factor for high-risk NB. Protein expression levels of ALDOC were assessed in NB cells versus normal cells using immunoblotting. Functional experiments, including proliferation and migration assays, were conducted in ALDOC-interfered NB cell lines. Glycolytic activity was evaluated by measuring glucose uptake, lactate production, and ATP generation. Additionally, the sensitivity of ALDOC-downregulated NB cells to cisplatin and cyclophosphamide was tested to explore its role in chemotherapy response.

Results

ALDOC was identified as a high-risk prognostic marker in NB, with elevated protein expression in NB cells compared to normal controls. Silencing ALDOC significantly inhibited NB cell proliferation and migration. Glycolytic activity was markedly reduced in ALDOC-downregulated cells, evidenced by decreased glucose uptake, lactate production, and ATP levels. Furthermore, ALDOC suppression enhanced NB cell sensitivity to cisplatin and cyclophosphamide, suggesting a glycolysis-dependent mechanism underlying chemotherapy resistance.

Discussion

Our findings highlight ALDOC as a critical driver of NB progression through glycolysis acceleration, with implications for therapeutic targeting. The observed increase in chemotherapy sensitivity upon ALDOC inhibition underscores its potential as a biomarker for treatment optimization. However, the complexity of glycolysis regulation, involving multiple genes and pathways, necessitates further mechanistic studies to clarify ALDOC's specific role. Despite this limitation, our work emphasizes the importance of aerobic glycolysis in NB pathogenesis and provides a foundation for developing novel therapeutic strategies targeting ALDOC or associated pathways. Future research should explore interactions between ALDOC and other glycolytic regulators to refine combinatorial treatment approaches.

Identification and verification of international neuroblastoma staging system (INSS) stage-related genes as potential biomarkers for neuroblastoma prognostic models

Background

Neuroblastoma (NB), one of the most common malignant extracranial solid tumors in children, is highly invasive and lethal with limited treatment efficacy. This study aimed to establish a prognostic model of advanced-stage NB.

Methods

Differentially expressed genes were screened and validated using two training datasets and one validation dataset from the Therapeutically Applicable Research to Generate Effective Treatments and Gene Expression Omnibus databases. Protein-protein interaction networks were developed using the MCode plug-in, and the top three key clusters were used to produce candidate genes. We performed gene set enrichment analysis (GSEA), gene ontology analysis (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis, immune cell infiltration, and drug sensitivity analysis to further understand the functions of these candidate genes. Kaplan-Meier (K-M) and receiver operating characteristic (ROC) curves were used to check their prognosis value. Real-time quantitative polymerase chain reaction (qPCR), Western blot (WB), and immunohistochemistry (IHC) were employed to verify the mRNA and protein levels in clinical samples.

Results

A total of 699 differentially expressed genes were identified, including 294 upregulated and 405 downregulated genes. CNR1, PRKACB, CDKN3, and PCLAF were found to significantly affect the overall survival and event-free survival of neuroblastoma patients and were positively correlated with the INSS advanced stages. The functional analysis of these four genes revealed their cancer-promoting effects and correlations with immune-inflammatory, cell cycle, and p53 signaling pathways. After stratifying patients using the established model containing the above four genes, significantly different patterns were observed in terms of infiltrating immune cell proportion, drug sensitivity, and the expression of immune checkpoints. Finally, both the mRNA and protein expression verification assays demonstrated that the CDKN3 and PCLAF were upregulated, while the PRKACB was downregulated in advanced-stage neuroblastoma tissue samples.

Conclusion

The model containing CNR1, PRKACB, CDKN3, and PCLAF can serve as a new prognostic biomarker for predicting the prognosis of patients with neuroblastoma. Findings on immune cell infiltration and immune checkpoints provide novel insights for the immunotherapy of neuroblastoma.

Multiomics Analysis Reveals Neuroblastoma Molecular Signature Predicting Risk Stratification and Tumor Microenvironment Differences

Neuroblastoma (NB) remains associated with high mortality and low initial response rate, especially for high-risk patients, thus warranting exploration of molecular markers for precision risk classifiers. Through integrating multiomics profiling, we identified a range of hub genes involved in cell cycle and associated with dismal prognosis and malignant cells. Single-cell transcriptome sequencing revealed that a subset of malignant cells, subcluster 1, characterized by high proliferation and dedifferentiation, was strongly correlated with the hub gene signature and orchestrated an immunosuppressive tumor microenvironment (TME). Furthermore, we constructed a robust malignant subcluster 1 related signature (MSRS), which was an independent prognostic factor and superior to other clinical characteristics and published signatures. Besides, TME differences conferred remarkably distinct therapeutic responses between high and low MSRS groups. Notably, polo-like kinase-1 (PLK1) was one of the most crucial contributors to MSRS and remarkably correlated with malignant subcluster 1, and PLK1 inhibition was effective for NB treatment as demonstrated by in silico analysis and in vitro experiments. Overall, our study constructs a novel molecular model to further guide the clinical classification and individualized treatment of NB.

Amino Acid Metabolism Subtypes in Neuroblastoma Identifying Distinct Prognosis and Therapeutic Vulnerabilities

Although amino acid (AA) metabolism is linked to tumor progression and could serve as an attractive intervention target, its association with neuroblastoma (NB) is unknown. Based on AA metabolism-related genes, we established three NB subtypes associated with distinct prognoses and specific functions, with C1 and C2 having better outcomes. The C1 displayed enhanced metabolic activity and recruited metabolism-associated cells. The C2 exhibited an activated immune microenvironment and was more vulnerable to immunotherapy. The C3, characterized by cell cycle peculiarity, possessed a dismal prognosis and high frequency of gene mutations and was susceptible to chemotherapy. Furthermore, single-cell RNA sequencing analysis revealed that the C3-associated Scissor+ cell subpopulation was characterized by notorious functional states and orchestrated an immunosuppressive microenvironment. Additionally, we identified that ALK and BIRC5 contributed to the shorter lifespan of C3 and their corresponding inhibitors were potential interventions. In conclusion, we identified three distinct subtypes of NB, which help us foster individualized therapeutic strategies to improve the prognosis of NB.

Giant Adrenal Neuroblastoma in Adults: Surgical Management and Comprehensive Review

Neuroblastoma (NB) is a rare solid tumor of the sympathetic nervous system, primarily occurring in children and rarely in adults. Its extracranial origin stems from the medullary region of the adrenal gland or sympathetic ganglia. We report an 18-year-old female who presented with a 6-month history of abdominal swelling and tenderness. Imaging revealed a large retroperitoneal mass causing significant displacement of adjacent structures. Following multidisciplinary optimization, a huge tumor was successfully resected surgically. Histopathology confirmed the diagnosis of adrenal NB. The patient underwent adjuvant chemotherapy and remained symptom-free with favorable outcomes during a 9-month follow-up. This case underscores the importance of comprehensive diagnostic evaluation and multimodal management in treating rare adult adrenal NB.

Ribosome biogenesis is a therapeutic vulnerability in paediatric neuroblastoma

Background

Neuroblastoma is a heterogeneous malignant paediatric tumor with prognosis depending on patient age and disease stage. Current treatment strategies rely on four key diagnostic criteria: age, histological stage, MYCN gene status, and genomic profile. It has been reported that MYC oncogenic activity depends on ribosome biogenesis, whose hyperactivation in cancer cells supports their high proliferative capacity, and thus represent a potential therapeutic target.

Methods

we utilized the well-established IMR-32 cell line along with a panel of patient-derived neuroblastoma cell lines with varying MYCN status, which we previously established. Additionally, we generated an IMR-32 cell line expressing an shRNA targeting the ribosome biogenesis factor fibrillarin (FBL). Cell growth, apoptosis markers, and cell cycle regulators were analyzed. Expression of ribosome biogenesis factors was assessed using publicly available datasets and RT-qPCR data from an in-house neuroblastoma cohort.

Results

We explored whether ribosome biogenesis represents a vulnerability in neuroblastoma. Our findings demonstrate that inhibition of RNA polymerase I using CX-5461 and BMH-21 suppressed cell proliferation at nanomolar concentrations and induced ribosomal stress, leading to activation of apoptosis and the p21 pathway. Furthermore, we identified FBL as a marker of poor prognosis in neuroblastoma. Consistently, FBL knockdown reduced neuroblastoma cell proliferation, supporting its potential as a therapeutic target.

Conclusion

Our study reinforces the therapeutic potential of ribosome biogenesis inhibition in neuroblastoma and expands the list of potential targets to include rRNA maturation factors. These findings highlight the promise of targeting ribosome biogenesis as a novel approach for neuroblastoma treatment.

Combinatorial immunotherapy with anti-ROR1 CAR NK cells and an IL-21 secreting oncolytic virus against neuroblastoma

Children with recurrent/metastatic neuroblastoma (NB) have a dismal survival (<25%). Novel therapies are desperately needed. Receptor tyrosine kinase-like orphan receptor 1 (ROR1) is highly expressed on NB. C021 is a selective oncolytic herpes simplex virus modified to overexpress human interleukin-21 (hIL-21), a cytokine that enhances natural killer (NK) cell cytotoxicity. In the current study, we successfully engineered ex-vivo-expanded NK cells to express a chimeric antigen receptor (CAR) against ROR1 using mRNA electroporation and investigated the efficacy of anti-ROR1-CAR-NK cells combined with C021 in targeting ROR1+ NB. We found that C021-infected NB cells secreted hIL-21 in vitro and in vivo. Compared to the non-cytokine-secreting parental virus C134, C021 significantly enhanced the in vitro cytotoxicity (p < 0.05) of anti-ROR1-CAR-NK cells with increased interferon (IFN)-γ (p < 0.05), granzyme B (p < 0.05), and perforin (p < 0.05) secretion against NB cells. Furthermore, the combination of C021 and anti-ROR1-CAR-NK cells significantly extended the survival of human NB xenografted NSG mice compared to controls (mock NK, ROR1-CAR-NK, C134, C021, C134+ROR1-CAR-NK, and C021+mock NK). Our results suggest that cytokine-secreting oncolytic virus in combination with CAR-NK cells is a novel, effective immunotherapeutic approach for high-risk NB.

A clinical observational study of dinutuximab beta as first-line maintenance treatment for patients with high-risk neuroblastoma in China

BACKGROUND

High-risk neuroblastoma (HR-NB) is associated with high metastatic and relapse rates that require intensive multimodal treatment. We evaluated the efficacy and safety of dinutuximab beta as first-line maintenance immunotherapy in pediatric patients with HR-NB in real-world clinical settings in China.

METHODS

We retrospectively reviewed the clinical records of pediatric patients with newly diagnosed HR-NB in the hospital from October 2021 to November 2023. Patients treated with dinutuximab beta in combination with granulocyte-macrophage colony-stimulating factor (GM-CSF) and isotretinoin as the first-line maintenance therapy were included in this study. Among patients with residual disease after completing induction and consolidation treatment, those with partial response (PR) or very good partial response (VGPR) except for bone marrow (BM) residue were also administrated vincristine/irinotecan/temozolomide (VIT) chemotherapy.

RESULTS

Fifty-one patients with newly diagnosed HR-NB who achieved at least PR before immunotherapy were evaluated. At the end of immunotherapy, the objective response rate (ORR) in 33 patients with evidence of disease was 60.6% (95% confidence interval (CI), 42.1-77.1%) and the complete response rate (CRR; n = 18) was 54.5% (95% CI, 36.4-71.9%). The 2-year event-free survival (EFS) rate and overall survival (OS) rate were 80.1% (95% CI, 66.2-88.8%) and 97.6% (95% CI, 84.3-99.7%), respectively. The 2-year EFS rate was higher in patients with CR (94.4%; 95% CI, 66.6-99.2%) than in non-CR patients (72.6%; 95% CI, 53.9-84.7%). Dinutuximab beta was well tolerated in patients and had fewer side effects, which decreased over time. Co-treatment of dinutuximab beta with VIT chemotherapy did not require discontinuation in patients undergoing immunochemotherapy.

CONCLUSION

The study showed promising efficacy and safety of dinutuximab beta as the first-line maintenance immunotherapy for pediatric patients with HR-NB. Notably, the combination of dinutuximab beta with GM-CSF and VIT chemotherapy could be used for treating patients who did not achieve CR after previous multimodal therapy.

PHD-2/HIF-1α axis mediates doxorubicin-induced angiogenesis in SH-SY5Y neuroblastoma microenvironment: a potential survival mechanism

The response of neuroblastoma (NB) cells to chemotherapeutics and their influence on NB microenvironment remain incompletely understood. Herein, we examined the underlying molecular mechanism via which Doxorubicin, a chemotherapeutic agent used for NB treatment, promotes proangiogenic response in the SH-SY5Y microenvironment. Doxorubicin treatment at 1 µg/ml reduced SH-SY5Y cell proliferation and primed the apoptosis pathway. Unexpectedly, SH-SY5Y cells treated with doxorubicin upregulated their expression of the pro-angiogenic factors, including vascular endothelial growth factor (VEGF), platelets-derived growth factor (PDGF), and matrix metalloprotease-2 (MMP-2) and secretion of nitric oxide. To assess the functional angiogenesis of SH-SY5Y cells pre-treated with doxorubicin, an indirect co-culture system with human umbilical vein endothelial cells (HUVEC) was established. These HUVECs acquired enhanced proliferation, migration capacity, and tube formation capability and exhibited increased nitric oxide (NO) production, in addition to upregulated α-smooth muscle actin expression, suggesting enhanced contractility. In-ovo studies of the neo-angiogenic response of SH-SY5Y pre-treated with doxorubicin further show their promoted neo-angiogenesis as indicated by the generated blood vessels and histological analysis of CD31 expression. Inhibition of PHD-2 could be a potential target for doxorubicin, as indicated by molecular docking, molecular dynamics (MD) simulation, and MM-GBSA calculations, leading to hypoxia-inducible factor-1 alpha (HIF-1α) stabilization. Bioinformatics analyses and enrichment analyses of RNA-seq data revealed activation of Pi3K pathway which is further validated in-vitro. These results provide evidence of the unexpected pro-angiogenic response of SH-SY5Y cells to doxorubicin treatment and suggest the potential use of multi-modal therapeutic regimens for a more comprehensive approach to NB treatment.

Transcription factor 4 is a key mediator of oncogenesis in neuroblastoma by promoting MYC activity

Super-enhancer-associated transcription factor networks define cell identity in neuroblastoma (NB). Dysregulation of these transcription factors contributes to the initiation and maintenance of NB by enforcing early developmental identity states. We report that the class I basic helix-loop-helix (bHLH) transcription factor 4 (TCF4; also known as E2-2) is a critical NB dependency gene that significantly contributes to these identity states through heterodimerization with cell-identity-specific bHLH transcription factors. Knockdown of TCF4 significantly induces apoptosis in vitro and inhibits tumorigenicity in vivo. We used genome-wide expression profiling, TCF4 chromatin immunoprecipitation sequencing (ChIP-seq) and TCF4 immunoprecipitation-mass spectrometry to determine the role of TCF4 in NB cells. Our results, along with recent findings in NB for the transcription factors T-box transcription factor TBX2, heart- and neural crest derivatives-expressed protein 2 (HAND2) and twist-related protein 1 (TWIST1), propose a role for TCF4 in regulating forkhead box protein M1 (FOXM1)/transcription factor E2F-driven gene regulatory networks that control cell cycle progression in cooperation with N-myc proto-oncogene protein (MYCN), TBX2, and the TCF4 dimerization partners HAND2 and TWIST1. Collectively, we showed that TCF4 promotes cell proliferation through direct transcriptional regulation of the c-MYC/MYCN oncogenic program that drives high-risk NB. Mechanistically, our data suggest the novel finding that TCF4 acts to support MYC activity by recruiting multiple factors known to regulate MYC function to sites of colocalization between critical NB transcription factors, TCF4 and MYC oncoproteins. Many of the TCF4-recruited factors are druggable, giving insight into potential therapies for high-risk NB. This study identifies a new function for class I bHLH transcription factors (e.g., TCF3, TCF4, and TCF12) that are important in cancer and development.

Pharmacologically Targeting Ferroptosis and Cuproptosis in Neuroblastoma

Neuroblastoma is a deadly pediatric cancer that originates from the neural crest and frequently develops in the abdomen or adrenal gland. Although multiple approaches, including chemotherapy, radiotherapy, targeted therapy, and immunotherapy, are recommended for treating neuroblastoma, the tumor will eventually develop resistance, leading to treatment failure and cancer relapse. Therefore, a firm understanding of the molecular mechanisms underlying therapeutic resistance is vital for the development of new effective therapies. Recent research suggests that cancer-specific modifications to multiple subtypes of nonapoptotic regulated cell death (RCD), such as ferroptosis and cuproptosis, contribute to therapeutic resistance in neuroblastoma. Targeting these specific types of RCD may be viable novel targets for future drug discovery in the treatment of neuroblastoma. In this review, we summarize the core mechanisms by which the inability to properly execute ferroptosis and cuproptosis can enhance the pathogenesis of neuroblastoma. Therefore, we focus on emerging therapeutic compounds that can induce ferroptosis or cuproptosis, delineating their beneficial pharmacodynamic effects in neuroblastoma treatment. Cumulatively, we suggest that the pharmacological stimulation of ferroptosis and ferroptosis may be a novel and therapeutically viable strategy to target neuroblastoma.

Safety observations in neuroblastoma patients undergoing 18 F- m FBG PET

OBJECTIVE

Limited safety data have been published on fluorine-18 ( 18 F) meta-fluorobenzylguanidine ( m FBG), a new PET radiopharmaceutical for imaging neural crest and neuroendocrine tumors. As part of a prospective clinical trial, safety data in patients with neuroblastoma were collected and analyzed.

METHODS

Between April 2015 and January 2022, 27 patients with neuroblastoma underwent 18 F- m FBG PET imaging as part of an ongoing single-center phase 1/2 trial (NCT02348749). Pre- and postinjection safety assessments were performed, including vital sign measurement and observation for occurrence of adverse events (AEs).

RESULTS

m FBG administration resulted in no significant changes in measured vital signs. Two subjects had transient, grade 1 facial flushing shortly after the administration, which resolved within a few minutes. Neither subject had a clinically significant change in pulse or blood pressure on postadministration measurements.

CONCLUSION

In this investigation of the potential clinical utility of m FBG PET imaging, no significant adverse safety signals were noted. Two mild, self-limited AEs were observed, without associated changes in vital signs. No grade 2 or higher AEs were noted. The findings are consistent with a favorable safety profile for m FBG in the target population of patients with neuroblastoma.

A pH-Responsive and Guanidinium-Rich Nanoadjuvant Efficiently Delivers STING Agonist for Cancer Immunotherapy

As natural agonists of the stimulator of interferon genes (STING), cyclic dinucleotides (CDNs) have been identified as promising immunotherapies that trigger a potent immune response against tumors. However, the low stability, rapid clearance, inadequate cellular uptake, and inefficient cytosol localization heavily hinder the therapeutic efficacy of the hydrophilic and negatively charged 2', 3'-cyclic-GMP-AMP (cGAMP). How to efficiently deliver cGAMP into the endoplasmic reticulum (ER) to activate STING for immune priming remains challenging. Here, we report a pH-responsive and guanidinium-rich STING nanoagonist (nPGSA) for cytosol delivery of cGAMP. Compared with free cGAMP, nPGSA achieves up to a 37.4-fold enhancement of cellular internalization. The pH-sensitive and guanidinium-functional design facilitates quick release and endosome escape, thus enabling precise ER targeting of cGAMP and 33.9-fold amplification of STING sensibilization. Furthermore, through the modulation of tumor-associated macrophage (TAM) polarization, nPGSA elicits a potent antigen-specific cellular immune response and sustained tumor regression in melanoma- and neuroblastoma-bearing mice. Our study provides a promising strategy for the delivery of cGAMP, and it offers insights into the function of cGAMP in modulating the tumor immune microenvironment for cancer immunotherapy.

CARM1-induced lncRNA NEAT1 synchronously activates MYCN and GalNAcT-I to accelerate the progression of neuroblastoma

PURPOSE

Long non-coding RNAs (lncRNAs) play important roles in progression of neuroblastoma (NB). LncRNA nuclear paraspeckle assembly transcript 1 (NEAT1) has been shown to affect the development of multiple tumors. However, the effect of NEAT1 on NB remain unclear. In this study, the new mechanisms whereby how NEAT1 influences tumor progression in NB was investigated.

METHODS

RT-qPCR, western blot, bioinformatics, cell growth, Transwell, and flow cytometric analyses were performed to determine how NEAT1 synchronously regulates the miR-873-5p/MYCN proto-oncogene(MYCN) and miR-873-5p/polypeptide N-acetylgalactosaminyltransferase 1(GalNAcT-I) axes to accelerate the progression of NB. NB-bearing animal models were established to evaluate the function of NEAT1 in NB. The relationships between transcription factor coactivatorassociated arginine methyltransferase 1 (CARM1) and NEAT1, NEAT1 and miR-873-5p, miR-873-5p and GalNacT-I or MYCN, were verified using luciferase reporter gene assay, respectively.

RESULTS

Our study revealed elevated levels of NEAT1 expression in NB cells and tissues which was associated with an advanced pathological stage and poor prognostic outcomes. According to in vitro gain- and loss- of function experiments, NEAT1 enhances progression of NB. NEAT1 silencing was found to inhibit NB proliferation in vivo. Mechanistically, to achieve upstream regulation, epigenetic downregulation of NEAT1 was achieved via the inhibition of CARM1. NEAT1 was found to positively regulate MYCN and GalNAcT-I levels as a competitive sponge of miR-873-5p.

CONCLUSION

Activity of the lncRNA NEAT1 can be triggered via CARM1, which synchronously promotes NB development via the miR-873-5p/MYCN and miR-873-5p/GalNAcT-I axes. These findings shed light on the novel molecular mechanisms underlying NB progression.

A Case of Severe Early Childhood Caries Occurring in a Childhood Cancer Patient

BACKGROUND/OBJECTIVES

Childhood cancer is the leading cause of death among children, although medical advances are improving the prognosis. During cancer treatment, nausea or vomiting may occur and eating habits may become irregular; therefore, it is important to prevent the development of oral diseases. We encountered a childhood cancer patient with rapidly progressive multiple dental caries, and this report describes the progress.

METHODS

A boy aged 2 years 9 months was referred for perioperative oral management. No caries were detected in the oral cavity at the initial visit.

RESULTS

As the patient had difficulty eating because of nausea and vomiting during cancer treatment, he began to consume probiotic drinks frequently. At 8-month follow-up, dental caries localized to the primary molars was detected. However, caries had occurred in all erupted teeth by 9 months later, confirming the diagnosis of severe early childhood caries. Dental treatment and long-term oral management contributed to good oral health except for dental abnormalities caused by chemotherapy.

CONCLUSIONS

Childhood cancer patients, particularly at an early age, are at risk of rapid deterioration of oral disease even over a short time period. It is important to cooperate with medical or dental professionals from other hospitals to provide dietary and oral health instruction and continue long-term oral management to improve patients' quality of life.

Approach to the Paediatric Patient With Suspected Pheochromocytoma or Paraganglioma Versus Neuroblastoma

Catecholamine-producing tumors of childhood include neuroblastic tumors, phaeochromocytoma, and paraganglioma (PPGL). PPGL and neuroblastic tumors can arise in similar anatomical locations and clinical presentations can overlap, resulting in diagnostic challenges. Distinguishing between these tumor types is critical as management and long-term surveillance strategies differ depending on the diagnosis. Herein we describe 2 clinical cases and illustrate key considerations in the diagnostic workup of a neuroblastoma vs PPGL for patients presenting with adrenal, pelvic, and retroperitoneal masses in childhood.

Molecular principles underlying aggressive cancers

Aggressive tumors pose ultra-challenges to drug resistance. Anti-cancer treatments are often unsuccessful, and single-cell technologies to rein drug resistance mechanisms are still fruitless. The National Cancer Institute defines aggressive cancers at the tissue level, describing them as those that spread rapidly, despite severe treatment. At the molecular, foundational level, the quantitative biophysics discipline defines aggressive cancers as harboring a large number of (overexpressed, or mutated) crucial signaling proteins in major proliferation pathways populating their active conformations, primed for their signal transduction roles. This comprehensive review explores highly aggressive cancers on the foundational and cell signaling levels, focusing on the differences between highly aggressive cancers and the more treatable ones. It showcases aggressive tumors as harboring massive, cancer-promoting, catalysis-primed oncogenic proteins, especially through certain overexpression scenarios, as predisposed aggressive tumor candidates. Our examples narrate strong activation of ERK1/2, and other oncogenic proteins, through malfunctioning chromatin and crosslinked signaling, and how they activate multiple proliferation pathways. They show the increased cancer heterogeneity, plasticity, and drug resistance. Our review formulates the principles underlying cancer aggressiveness on the molecular level, discusses scenarios, and describes drug regimen (single drugs and drug combinations) for PDAC, NSCLC, CRC, HCC, breast and prostate cancers, glioblastoma, neuroblastoma, and leukemia as examples. All show overexpression scenarios of master transcription factors, transcription factors with gene fusions, copy number alterations, dysregulation of the epigenetic codes and epithelial-to-mesenchymal transitions in aggressive tumors, as well as high mutation loads of vital upstream signaling regulators, such as EGFR, c-MET, and K-Ras, befitting these principles.

Immunogenic Cell Death Inducers in Cancer Immunotherapy to Turn Cold Tumors into Hot Tumors

The combination of chemotherapeutic agents with immune checkpoint inhibitors (ICIs) has revolutionized cancer treatment. However, its success is often limited by insufficient immune priming in certain tumors, including pediatric malignancies. In this report, we explore clinical trials currently investigating the use of immunogenic cell death (ICD)-inducing chemotherapies in combination with ICIs for both adult and pediatric cancers. Given the limited clinical data available for pediatric tumors, we focused on recent preclinical studies evaluating the efficacy of these combinations in neuroblastoma (NB). Finally, to address this gap, we propose an innovative strategy to assess the impact of ICD-inducing chemotherapies on antitumor immune responses in NB. Using tumor spheroids derived from a transgenic NB mouse model, we validated our previous in vivo findings concerning how anthracyclines, specifically mitoxantrone and doxorubicin, significantly enhance MHC class I surface expression, stimulate IFNγ and granzyme B production by CD8+ T cells and NK cells, and promote immune cell recruitment. Importantly, these anthracyclines also upregulated PD-L1 expression on NB spheroids. This screening platform yielded results similar to in vivo findings, demonstrating that mitoxantrone and doxorubicin are the most potent immunomodulatory agents for NB. These data suggest that the creation of libraries of ICD inducers to be tested on tumor spheroids could reduce the number of combinations to be tested in vivo, in line with the principles of the 3Rs. Furthermore, these results highlight the potential of chemo-immunotherapy regimens to counteract the immunosuppressive tumor microenvironment in NB, paving the way for improved therapeutic strategies in pediatric cancers. They provide compelling evidence to support further clinical investigations of these combinations to enhance outcomes for children with malignancies.

The anti-GD2 monoclonal antibody naxitamab plus GM-CSF for relapsed or refractory high-risk neuroblastoma: a phase 2 clinical trial

In this single-arm, non-randomized, phase 2 trial (NCT03363373), 74 patients with relapsed/refractory high-risk neuroblastoma and residual disease in bone/bone marrow (BM) received naxitamab on Days 1, 3, and 5 (3 mg/kg/day) with granulocyte-macrophage colony-stimulating factor (Days -4 to 5) every 4 weeks, until complete response (CR) or partial response (PR) followed by 5 additional cycles every 4 weeks. Primary endpoint in the prespecified interim analysis was overall response (2017 International Neuroblastoma Response Criteria). Among 26 responders (CR + PR) in the efficacy population (N = 52), 58% had refractory disease, and 42% had relapsed disease. Overall response rate (ORR) was 50% (95% CI: 36-64%), and CR and PR were observed in 38% and 12%, respectively. With the 95% CI lower limit for ORR exceeding 20%, the primary endpoint of overall response was met. Patients with evaluable bone disease had a 58% (29/50) bone compartment response (CR, 40%; PR, 18%). BM compartment response was 74% (17/23; CR, 74%). One-year overall survival and progression-free survival (secondary endpoints) were 93% (95% CI: 80-98%) and 35% (95% CI: 16-54%), respectively. Naxitamab-related Grade 3 adverse events included hypotension (58%) and pain (54%). Overall, naxitamab demonstrated clinically meaningful efficacy with manageable safety in patients with residual neuroblastoma in bone/BM.

Targeting MYCN upregulates L1CAM tumor antigen in MYCN-dysregulated neuroblastoma to increase CAR T cell efficacy

Current treatment protocols have limited success against MYCN-amplified neuroblastoma. Adoptive T cell therapy presents an innovative strategy to improve cure rates. However, L1CAM-targeting CAR T cells achieved only limited response against refractory/relapsed neuroblastoma so far. We investigated how oncogenic MYCN levels influence tumor cell response to CAR T cells, as one possible factor limiting clinical success. A MYCN-inducible neuroblastoma cell model was created. L1CAM-CAR T cell effector function was assessed (activation markers, cytokine release, tumor cytotoxicity) after coculture with the model or MYCN-amplified neuroblastoma cell lines. RNA sequencing datasets characterizing the model were compared to publicly available RNA/proteomic datasets. MYCN-directed L1CAM regulation was explored using public ChIP-sequencing datasets. Synergism between CAR T cells and the indirect MYCN inhibitor, MLN8237, was assessed in vitro using the Bliss model and in vivo in an immunocompromised mouse model. Inducing high MYCN levels in the neuroblastoma cell model reduced L1CAM expression and, consequently, L1CAM-CAR T cell effector function in vitro. Primary neuroblastomas possessing high MYCN levels expressed lower levels of both the L1CAM transcript and L1CAM tumor antigen. MLN8237 treatment restored L1CAM tumor expression and L1CAM-CAR T cell effector function. Combining MLN8237 and L1CAM-CAR T cell treatment synergistically enhanced MYCN-overexpressing tumor cytotoxicity in vitro and in vivo concomitant with severe in vivo toxicity. We identify target antigen downregulation as source of resistance against L1CAM-CAR T cells in MYCN-driven neuroblastoma cells. These data suggest that L1CAM-CAR T cell therapy combined with pharmacological MYCN inhibition may benefit patients with MYCN-amplified neuroblastoma.

Global, regional and national burden of neuroblastoma and other peripheral nervous system tumors, 1990 to 2021 and predictions to 2035: visualizing epidemiological characteristics based on GBD 2021

BACKGROUND

Neuroblastoma (NB) is the most common extracranial malignant solid tumor in children, accounting for >15 % of cancer-related deaths in children. We analyzed the epidemiological statistical indicators of neuroblastoma and other peripheral nervous system tumors patients from 1990 to 2021 in Global Burden of Disease (GBD) 2021 database, aiming to provide valuable insights for public health interventions and clinical practices.

METHODS

Based on the GBD 2021 database, this study analyzed the incidence, mortality, prevalence, and Disability-Adjusted Life-Years (DALYs) of neuroblastoma and other peripheral nervous system tumors from 1990 to 2021, stratified by sociodemographic development index (SDI) and geographic regions. Cross-country inequalities analysis was conducted to quantify the SDI-related inequality of disease burden across countries. In addition, the average annual percentage change (AAPC) and Age-Period-Cohort (APC) model were used to evaluate the trend of disease burden, while the global burden of disease to 2035 was predicted by Bayesian Age-Period-Cohort (BAPC) model.

FINDINGS

This study reported the disease burden of neuroblastoma and other peripheral nervous system tumors in GBD 2021 database for the first time. Globally, the incidence and mortality of neuroblastoma have increased year by year from 1990 to 2021, especially in regions with low SDI, such as South Asia and sub-Saharan Africa, where the burden of disease has increased significantly. Regions with high SDI, such as North America and Western Europe, have seen a reduction in disease burden due to higher levels of medical care and earlier diagnosis. The age distribution shows that children under 5 years of age are mainly affected, especially in low- and middle-income areas. In addition, the incidence is slightly higher in men than in women. The BAPC model predicts that the global incidence, mortality, and DALYs of neuroblastoma will continue to increase until 2035.

INTERPRETATION

Significant regional and population variation in neuroblastoma and other peripheral nervous system tumors worldwide, with a particularly high disease burden in low SDI areas with limited medical resources. This trend highlights the urgent need for global public health interventions and resource allocation, particularly in low-income countries. Future research should focus on improving early diagnosis, risk stratification and target therapy in order to reduce the global burden of disease and improve patients' prognosis.

FUNDING

This study was supported by National Natural Science Foundation of China (No. 82293662, No 82172357 and No 81930066), Key project of Shanghai "Science and Technology Innovation Action Plan (22JC1402304) and Research fund of Shanghai Municipal Health Bureau (No. 2019cxjq03).

Deciphering the secret codes in N7-methylguanosine modification: Context-dependent function of methyltransferase-like 1 in human diseases

N7-methylguanosine (m7G) is one of the most prevalent post-transcriptional modifications of RNA and plays a critical role in RNA translation and stability. As a pivotal m7G regulator, methyltransferase-like 1 (METTL1) is responsible for methyl group transfer during the progression of m7G modification and contributes to the structure and functional regulation of RNA. Accumulating evidence in recent years has revealed that METTL1 plays key roles in various diseases depending on its m7G RNA methyltransferase activity. Elevated levels of METTL1 are typically associated with disease development and adverse consequences. In contrast, METTL1 may act as a disease suppressor in several disorders. While the roles of m7G modifications in disease have been extensively reviewed, the critical functions of METTL1 in various types of disease and the potential targeting of METTL1 for disease treatment have not yet been highlighted. This review describes the various biological functions of METTL1, summarises recent advances in understanding its pathogenic and disease-suppressive functions and discusses the underlying molecular mechanisms. Given that METTL1 can promote or inhibit disease processes, the possibility of applying METTL1 inhibitors and agonists is further discussed, with the goal of providing novel insights for future disease diagnosis and potential intervention targets. KEY POINTS: METTL1-mediated m7G modification is crucial for various biological processes, including RNA stability, maturation and translation. METTL1 has emerged as a critical epigenetic modulator in human illnesses, with its dysregulated expression correlating with multiple diseases progression and presenting opportunities for both diagnostic biomarker development and molecular-targeted therapy. Enormous knowledge gaps persist regarding context-dependent regulatory networks of METTL1 and dynamic m7G modification patterns, necessitating mechanistic interrogation to bridge basic research with clinical translation in precision medicine.

Genetic Risk Profiling Reveals Altered Glycosyltransferase Expression as a Predictor for Patient Outcome in Neuroblastoma

Background/Objectives: Neuroblastoma is a highly aggressive pediatric cancer that arises from immature nerve cells and exhibits a broad spectrum of clinical presentations. While low- and intermediate-risk neuroblastomas often have favorable outcomes, high-risk neuroblastomas are associated with poor prognosis and significant treatment challenges. The complex genetic networks driving these high-risk cases remain poorly understood. This study aims to investigate differences in gene expression patterns that may contribute to disease outcomes. Methods: We employed an in silico approach to analyze a cohort of 493 neuroblastoma tumor samples that underwent mRNA sequencing (GSE49711). This dataset was reanalyzed in depth with a non-hypothesis-driven approach to identify the expression patterns and regulatory mechanisms associated with a poor prognosis. Results: By exploring global gene expression and the integration of clinical parameters, we stratified the samples into two groups with highly distinct gene expression profiles. MYCN amplification emerged as a major driver not only of poor prognosis but also of specific gene regulatory patterns. Notably, tumors with MYCN amplification exhibited the strong regulation of immune response genes and less immune infiltration, suggesting potential immune evasion. However, while we observed only minor changes in immune checkpoint expression, there was a strong modulation of glycosyltransferase genes in MYCN-amplified tumors. Using this information, we were able to construct a risk profile based on 12 glycosylation-related genes, which correlates with the survival outcomes of neuroblastoma patients. Conclusions: This study highlights the role of MYCN amplification in driving a poor prognosis in neuroblastoma through the regulation of immune response and glycosylation-related genes. Based on this finding, we developed a genetic risk profile that correlates with survival outcomes in neuroblastoma patients.

TERT Expression and Clinical Outcome in Pulmonary Carcinoids

PURPOSE

The clinical course of pulmonary carcinoids ranges from indolent to fatal disease, suggesting that specific molecular alterations drive progression toward the fully malignant state. A similar spectrum of clinical phenotypes occurs in pediatric neuroblastoma, in which activation of telomerase reverse transcriptase (TERT) is decisive in determining the course of disease. We therefore investigated whether TERT expression defines the clinical fate of patients with pulmonary carcinoid.

METHODS

TERT expression was examined by RNA sequencing in a test cohort and a validation cohort of pulmonary carcinoids (n = 88 and n = 105, respectively). A natural TERT expression cutoff was determined in the test cohort on the basis of the distribution of TERT expression, and its prognostic value was assessed by Kaplan-Meier survival estimates and multivariable analyses. Telomerase activity was validated by telomere repeat amplification protocol assay.

RESULTS

Similar to neuroblastoma, TERT expression exhibited a bimodal distribution in pulmonary carcinoids, separating tumors into TERT-high and TERT-low subgroups. A natural TERT cutoff discriminated unfavorable from favorable clinical courses with high accuracy both in the test cohort (5-year overall survival [OS], 0.547 ± 0.132 v 1.0; P < .001) and the validation cohort (5-year OS, 0.788 ± 0.063 v 0.913 ± 0.048; P < .001). In line with these findings, telomerase activity was largely absent in TERT-low tumors, whereas it was readily detectable in TERT-high carcinoids. In multivariable analysis considering TERT expression, histology (typical v atypical carcinoid), and stage (≤IIA v ≥IIB), high TERT expression was an independent prognostic marker for poor survival, with a hazard ratio of 5.243 (95% CI, 1.943 to 14.148; P = .001).

CONCLUSION

Our data demonstrate that high TERT expression defines clinically aggressive pulmonary carcinoids with fatal outcome, similar to neuroblastoma, indicating that activation of TERT may be a defining feature of lethal cancers.

Long-Term Outcomes and Quality of Life of High-Risk Neuroblastoma Patients Treated with a Multimodal Treatment Including Anti-GD2 Immunotherapy: A Retrospective Cohort Study

BACKGROUND

The incorporation of anti-GD2 antibodies such as ch14.18/SP2/0 into the multimodal treatment of high-risk neuroblastoma (HR-NB) patients has improved their outcomes. As studies assessing the long-term outcomes, long-term sequelae, and health-related quality of life (HRQoL) of this treatment are limited, this retrospective analysis aimed to explore these.

PATIENTS AND METHODS

Between 1991 and 2002, 65 children received a multimodal treatment, including ch14.18/SP2/0, for primary HR-NB. All received chemotherapy according to the NB90/NB97 trial, 51 received high-dose chemotherapy, and all received ch14.18/SP2/0 treatment. We analyzed the long-term sequelae and HRQoL (EORTC QLQ-C30), and evaluated overall and event-free survival (OS/EFS).

RESULTS

Twenty-five survivors were evaluated for HRQoL and long-term effects. All reported long-term sequelae, including ototoxicity in 16/25 (64%), cardiac toxicity in 6/25 (24%), and endocrine toxicity in 19/25 (76%) patients. Chronic diarrhea was reported in 20% of female patients. Seven patients developed autoimmune diseases. HRQoL scores were better across multiple scales than those of the matched German general population. Twenty-five-year OS and EFS were 50.8% (95% confidence interval: 31-55) and 43% (30.1-55.3), with 33 (50.8%) long-term survivors. Thirty-two patients died: 28 (43.1%) because of progression/relapse and 4 (6.2%) because of secondary neoplasms.

CONCLUSIONS

Multimodal treatment, including ch14.18/SP2/0, can achieve long-term survival in HR-NB patients, with a substantial proportion of survivors reporting better HRQoL compared to the general population. All patients reported long-term side effects mostly attributable to chemotherapy and radiotherapy. The relatively high prevalence of autoimmune diseases and persistent diarrhea warrants additional longitudinal research on individuals treated with anti-GD2 antibodies.

Expression of GD2 and GD3 in peripheral neuroblastic tumors

PURPOSE

The aim of this study was to explore the correlation between the expression of GD2 and GD3 and the histopathological types, risk groups, and chemotherapy in peripheral neuroblastic tumors (pNTs) and provide a theoretical basis for the selection of immunotargeted therapy for pNTs.

MATERIALS AND METHODS

The expression of GD2 and GD3 in samples of pNTs in all 87 cases, including 39 neuroblastomas (NB), 13 ganglion neuroblastomas nodular (GNBn), 19 ganglion neuroblastomas intermixed (GNBi), 16 ganglioneuroma (GN), and 16 paired NB after chemotherapy, were detected by immunohistochemistry (IHC). SPSS 20.0 statistical software was used for statistical analysis, and P < 0.05 was considered statistically significant.

RESULT

The expression of GD2 was higher than that of GD3 ( P < 0.001) in all samples. In NB and GNBn, the expression of GD2 was higher than that of GD3 ( P < 0.001 and P = 0.02, respectively). The expression of GD2 in NB was higher than that in GNBn ( P = 0.015), and GNBn was higher than GNBi ( P < 0.001). The expression of GD2 in the high-risk group was significantly higher than that in the medium-risk group and low-risk group ( P = 0.019). The expression of GD2 before chemotherapy was higher than that after chemotherapy ( P = 0.022). GD2 was expressed in different degrees in tumor-infiltrating lymphocytes.

CONCLUSION

GD2 may be better than GD3 as a target of immunotherapy for pNTs, especially in the same pathological type. NB and GNBn may be more suitable for anti-GD2 immunotherapy. The expression of GD2 on tumor-infiltrating lymphocytes may be related to the side effects of anti-GD2 immunotherapy.

Global, regional, and national epidemiology of childhood neuroblastoma (1990-2021): a statistical analysis of incidence, mortality, and DALYs

Background

Neuroblastoma is the most prevalent extracranial solid tumor in pediatric populations worldwide, representing 8-10% of childhood malignancies and contributing to approximately 15% of pediatric cancer-related fatalities. This study aims to report global trends in the incidence, mortality, and disability-adjusted life years (DALYs) of childhood neuroblastoma from 1990 to 2021.

Methods

The study utilized data from the Global Burden of Disease (GBD) database to analyze neuroblastoma incidence, mortality, and DALYs in children aged 0-14 years. Rates for incidence, mortality, and DALYs were calculated per 100,000 population, with 95% uncertainty intervals (UIs). Data from 204 countries and territories were stratified by age, sex, and location. Trends were assessed using Joinpoint regression models to compute the annual percent change (APC) and log-transformed linear regression models to calculate the estimated average annual percentage change (EAPC).

Findings

Globally, the incidence of neuroblastoma in children in 2021 was 5560 cases (95% UI, 3734.21-7560.03), with 1977 deaths (95% UI, 1445.04-2528.54), and 174,186.30 DALYs (95% UI, 127,104.64-223,265.92). From 1990 to 2021, the incidence increased by 30.26% (95% UI, -1.24% to 72.51%), mortality by 20.35% (95% UI, -12.44% to 63.30%), and DALYs by 20.08% (95% UI, -12.89% to 63.27%). The incidence rate rose from 0.25 (95% UI, 0.18-0.33) per 100,000 individuals in 1990 to 0.28 (95% UI, 0.19-0.38) per 100,000 individuals in 2021, an overall increase of 12.60% (95% UI, -14.62% to 49.12%). Among the five Sociodemographic Index (SDI) regions, the highest EAPCs were observed in the low-to-mid SDI regions for incidence (1.87%; 95% CI, 1.64%-2.10%), mortality (1.22%; 95% CI, 1.09%-1.34%), and DALYs (1.36%; 95% CI, 1.15%-1.57%). Regionally, Central Asia exhibited the fastest annual increase in incidence (EAPC = 2.76%; 95% CI, 2.18%-3.34%). At the national level, India had the highest number of neuroblastoma cases globally in 2021, with 685 cases (95% UI, 404.16-1007.67).

Interpretation

The global trends for incidence, mortality, and DALYs related to pediatric neuroblastoma initially increased and then decreased, although an overall increasing trend was observed. However, the burden of disease remains significant in low-, low-middle-, and middle-SDI regions. A comprehensive understanding of the epidemiology of neuroblastoma in children is crucial for enhancing disease prevention and control efforts.

Funding

This research was funded by the Guangxi Natural Science Foundation (Grant No. 2024GXNSFAA010420) and the Youth Science Foundation of Guangxi Medical University (Grant No. GXMUYSF202404).

Regulation and Function of CCL2 and N-Myc in Retinoic Acid-treated Neuroblastoma Cells

BACKGROUND/AIM

Treatment with retinoic acid (RA) often promotes neuroblastoma differentiation and growth inhibition, including the suppression of the expression of the MYCN oncogene. However, RA also targets protumoral chemokines, such as CCL2, which may contribute to the development of resistance. The present study aimed to investigate the regulation and function of CCL2 and N-Myc in RA-treated neuroblastoma cells.

MATERIALS AND METHODS

In Kelly or SH-SY5Y cells, viability was quantified by cell fitness assays. Expression was analyzed using quantitative PCR and the regulation of proteins using enzyme-linked immunoabsorbent assays (ELISA) or western blots.

RESULTS

In MYCN-amplified Kelly cells, endogenous CCL2 levels were significantly lower compared to MYCN non-amplified SH-SY5Y cells. Treatment with 5 μM RA increased CCL2 release in both cell lines, but reduced N-Myc levels and cell numbers in Kelly cells. Over-expression of MYCN enhanced viability in SH-SY5Y cells, but did not affect RA-induced CCL2 release, while supplementation of CCL2 in Kelly cells did not prevent RA-mediated growth reduction. Impaired N-Myc or CCL2 signaling reduced the survival of all RA-treated cells and inhibition of N-Myc also decreased CCL2 levels. However, attenuated survival signaling was not generally associated with reduced levels of N-Myc or CCL2. Co-application of RA and the growth factor receptor inhibitors cediranib or crizotinib decreased N-Myc levels only in Kelly cells, while CCL2 release was dependent on the cell type and stimulus.

CONCLUSION

CCL2 and N-Myc promote the viability of RA-treated cells, although the levels of these mediators were not consistently correlated with cellular outcomes, especially during apoptotic signaling.

HOTTIP rs1859168 C > A polymorphism reduces neuroblastoma susceptibility in Chinese children

Neuroblastoma, " a malignancy originating from neural crest cells, is most commonly diagnosed in children and adolescents. Polymorphisms within the long noncoding RNA (lncRNA) HOXA distal transcript antisense RNA (HOTTIP) are believed to have the capacity to alter an individual's susceptibility to various cancers. This study aimed to investigate the link between HOTTIP gene polymorphisms and neuroblastoma susceptibility. We identified the genotypes of two prevalent polymorphisms (rs3807598 and rs1859168) within the HOTTIP via the TaqMan assay in a cohort comprising 402 individuals diagnosed with neuroblastoma and 473 healthy controls. Logistic regression was used to evaluate the associations between the HOTTIP polymorphisms and the likelihood of neuroblastoma susceptibility. Additionally, the genotype-tissue expression (GTEx) database was used to investigate how these HOTTIP gene variations influence gene expression across different tissues. Our findings demonstrated a significant association between the rs1859168 C > A polymorphism and reduced neuroblastoma susceptibility (CA vs. CC: adjusted odds ratio (OR) = 0.55, 95% confidence interval (CI) = 0.40-0.74, P = 0.0001; CA/AA vs. CC: adjusted OR = 0.69, 95% CI = 0.53-0.91, P = 0.010). The additional stratified analysis revealed that the presence of rs1859168 CA/AA or two protective genotypes was associated with a lower susceptibility in specific subgroups, such as older children and girls. Expression quantitative trait locus (eQTL) analysis revealed that the rs1859168 CC genotype was related to high expression of the HOTTIP gene.

CONCLUSION

We found that HOTTIP gene polymorphisms were associated with a reduced likelihood of neuroblastoma in Chinese children. Further studies with large cohorts and diverse ethnicities are warranted to verify our results.

WHAT IS KNOWN

• Genetic variations can influence neuroblastoma susceptibility. HOTTIP gene polymorphisms may alter an individual's susceptibility to various cancers.

WHAT IS NEW

• HOTTIP gene polymorphisms were associated with a reduced risk of neuroblastoma in Chinese children.

Detection of circulating tumor cells using a microfluidic chip for diagnostics and therapeutic prediction in mediastinal neuroblastoma

Circulating tumor cells (CTCs) have served as noninvasive tumor biomarkers in many types of cancer. Here, we detected CTCs in mediastinal neuroblastoma (mNB) patients for use as diagnostic and treatment response predictive biomarkers. We employed a cascaded filter deterministic lateral displacement microfluidic chip (CFD-Chip) to enrich CTCs in peripheral blood from 32 mNB patients and 7 healthy children. CTCs were identified by immunofluorescence staining and integrated neoplastic cell morphology. In total, 66.67% of newly diagnosed mNB patients were positive for CTCs while no CTCs were detected in healthy children. Moreover, CTC count differed significantly across different International Neuroblastoma Staging System, International Neuroblastoma Risk Group staging system, and risk stratifications. CTC count was also significantly higher in children with metastasis than those without metastasis. Additionally, CTC demonstrated a significant difference among patients with different clinical responses to therapy. CTC count decreased or fluctuated at low levels in patients with complete and partial response, compared to considerably increased in patients with stable and progressive diseases.Conclusion: CTCs may serve as non-invasive indicators for mNB diagnosis, staging, and metastasis prediction, and demonstrate promising potential as a liquid biopsy biomarker for the dynamic monitoring of therapeutic efficacy.

Restoring Mitochondrial Quantity and Quality to Reverse Warburg Effect and Drive Tumor Differentiation

Reduced mitochondrial quality and quantity in tumors is associated with dedifferentiation and increased malignancy. However, it remains unclear how to restore mitochondrial quantity and quality in tumors, and whether mitochondrial restoration can drive tumor differentiation. Our study shows that restoring mitochondrial function using retinoic acid (RA) to boost mitochondrial biogenesis and a mitochondrial uncoupler to enhance respiration synergistically drives neuroblastoma differentiation and inhibits proliferation. U-13C-glucose/glutamine isotope tracing revealed a metabolic shift from the pentose phosphate pathway to oxidative phosphorylation, accelerating the TCA cycle and switching substrate preference from glutamine to glucose. These effects were reversed by ETC inhibitors or in ρ0 cells lacking mtDNA, emphasizing the necessity of mitochondrial function for differentiation. Dietary RA and uncoupler treatment promoted tumor differentiation in an orthotopic neuroblastoma xenograft model, evidenced by neuropil production and Schwann cell recruitment. Single-cell RNA sequencing analysis of the orthotopic xenografts revealed that this strategy effectively eliminated the stem cell population, promoted differentiation, and increased mitochondrial gene signatures along the differentiation trajectory, which could potentially significantly improve patient outcomes. Collectively, our findings establish a mitochondria-centric therapeutic strategy for inducing tumor differentiation, suggesting that maintaining/driving differentiation in tumor requires not only ATP production but also continuous ATP consumption and sustained ETC activity.

Neuroblastoma response to RAS-MAPK inhibitors and APR-246 (eprenetapopt) co-treatment is dependent on SLC7A11

Background

We previously demonstrated that APR-246 (eprenetapopt) could be an efficient treatment option against neuroblastoma (NB), the most common pediatric extracranial solid tumor. APR-246's mechanism of action is not completely understood and can differ between cell types. Here we investigate the involvement of well-known oncogenic pathways in NB's response to APR-246.

Methods

A proteome profiler kinase assays and western blot analysis were used to identify the molecular pathways involved in the responses to APR-246. Bulk ATP levels were used to determine the viability of cells and the IC50 for APR-246. Cystine-FITC was used to measure the cellular uptake of cysteine. PmRNA5 was used to activate ERK1/2 and pshRNA1 was used to silence HSP27. An IMR-32 xenograft zebrafish embryo model was used to assess APR-246 and sulfasalazine efficacy in vivo.

Results

After APR-246 treatment, the most deregulated signaling protein identified was ERK1/2, an end-point kinase of the RAS-MAPK pathway. Induction of phospho-ERK1/2 resulted in increased glutathione (GSH) levels, increased cystine uptake, and increased resistance of NB cells to APR-246. Using ERK1/2 inhibitors in combination with APR-246, we were able to categorize cells into synergistic and antagonistic groups. After co-treatment, these two groups differ by their levels of SLC7A11 and Hsp27 phosphorylation, cystine uptake, and BIM expression. Using erastin and sulfasalazine, both inhibitors of SLC7A11 and activators of ferroptosis, we were able to reverse the antagonistic effects of ERK1/2 inhibitors and demonstrate a strong synergistic action in vitro and in vivo in zebrafish models.

Conclusions

These results demonstrated a pivotal role of the RAS-MAPK pathway in the NB cellular response to APR-246 via the modulation of intracellular concentrations of GSH and the transport of cystine through SLC7A11, phosphorylation of Hsp27, and programmed cell death. Combining APR-246 with RAS-MAPK pathway inhibitors can, in some cases, lead to antagonistic action, which can be reversed by combining APR-246 with the clinically approved drug sulfasalazine.

Defining neuroblastoma: From origin to precision medicine

Neuroblastoma (NB), a heterogenous pediatric tumor of the sympathetic nervous system, is the most common and deadly extracranial solid malignancy diagnosed in infants. Numerous efforts have been invested in understanding its origin and in development of novel curative targeted therapies. Here, we summarize the recent advances in the identification of the cell of origin and the genetic alterations occurring during development that contribute to NB. We discuss current treatment regimens, present and future directions for the identification of novel therapeutic metabolic targets, differentiation agents, as well as personalized combinatory therapies as potential approaches for improving the survival and quality of life of children with NB.

Exercise and tumor proteome: insights from a neuroblastoma model

The impact of exercise on pediatric tumor biology is essentially unknown. We explored the effects of regular exercise on tumor proteome profile (as assessed with liquid chromatography with tandem mass spectrometry) in a mouse model of one of the most aggressive childhood malignancies, high-risk neuroblastoma (HR-NB). Tumor samples of 14 male mice (aged 6-8 wk) that were randomly allocated into an exercise (5-wk combined aerobic and resistance training) or nonexercise control group (6 and 8 mice/group, respectively) were analyzed. The Search Tool for the Retrieval of Interacting Genes/Proteins database was used to generate a protein-protein interaction (PPI) network and enrichment analyses. The Systems Biology Triangle (SBT) algorithm was applied for analyses at the functional category level. Tumors of exercised mice showed a higher and lower abundance of 101 and 150 proteins, respectively, than controls [false discovery rate (FDR) < 0.05]. These proteins were enriched in metabolic pathways, amino acid metabolism, regulation of hormone levels, and peroxisome proliferator-activated receptor signaling (FDR < 0.05). The SBT algorithm indicated that 184 and 126 categories showed a lower and higher abundance, respectively, in the tumors of exercised mice (FDR < 0.01). Categories with lower abundance were involved in energy production, whereas those with higher abundance were related to transcription/translation, apoptosis, and tumor suppression. Regular exercise altered the abundance of hundreds of intratumoral proteins and molecular pathways, particularly those involved in energy metabolism, apoptosis, and tumor suppression. These findings provide preliminary evidence of the molecular mechanisms underlying the potential effects of exercise in HR-NB.NEW & NOTEWORTHY We used liquid chromatography with tandem mass spectrometry to explore the impact of a 5-wk exercise intervention on the tumor proteome profile in a mouse model of one of the most aggressive childhood malignancies, high-risk neuroblastoma. Exercise altered the abundance of hundreds of proteins and pathways, particularly those involved in energy metabolism and tumor suppression. These molecular changes could mediate, at least partly, the potential antitumorigenic effects of exercise.

Antiproliferative effects of cadmium sulfide nanoparticles obtained from walnut shells by green synthesis method on SH-SY5Y cell line

Nanoparticles are attracting attention for their potential therapeutic applications, particularly in cancer therapy, underscoring their importance in medicine. Cadmium sulfide nanoparticles, known for their robust catalytic and optical properties, are classified as chalcogenides and show promise for cancer diagnosis and treatment. Neuroblastoma, a common solid tumor in childhood, poses a significant health threat with different outcomes depending on its biological subtype. This study evaluated the antiproliferative effects of cadmium sulfide nanoparticles on the SY-SH5Y cell line. Walnut shell extract and Na2S were used to facilitate the synthesis of cadmium sulfide nanoparticles by green synthesis. Characterization of the synthesized cadmium sulfide nanoparticles was performed by Fourier transform infrared spectroscopy, scanning electron microscopy, and x-ray diffraction analyses. The SH-SY5Y cell line was cultured in a standard cell culture medium and then exposed to different cadmium sulfide nanoparticles (10-25-50-75-100 µg/mL) for 24 hours. Cell viability, oxidant, and antioxidant levels were then assessed using a 3-(4,5-dimetiltiyazol-2-il)-2,5-difeniltetrazolyum bromür, total antioxidant, and total oxidant assays. The data showed that applying 100 μg/mL cadmium sulfide nanoparticles resulted in a significant decrease in cancer cell viability of up to 40.96 % (p<0.05). The cadmium sulfide nanoparticles had a dose-dependent effect on the SH-SY5Y cell line. Furthermore, cadmium sulfide nanoparticles increased oxidative activity in neuroblastoma cells, which was consistent with the results of the 3-(4,5-dimetiltiyazol-2-il)-2,5-difeniltetrazolyum bromür assay. In conclusion, cadmium sulfide nanoparticles exhibited potent activity against the neuroblastoma cell. This study highlights the antiproliferative efficacy of green-synthesized cadmium sulfide nanoparticles with walnut shell extract on relevant cancer cell lines.

Jaundice as a Rare Presentation of Neuroblastoma in a Pediatric Patient

ABSTRACT

Neuroblastoma presenting as obstructive jaundice due to compression of the extrahepatic bile duct is very rare. An 11-month-old girl had sudden onset of jaundice. Initial imaging suggested a dilated biliary system caused by hepatic hilum mass. 18 F-FDG PET/CT showed a lesion with increased 18 F-FDG accumulation associated with surrounding enlarged lymph nodes. Surgical pathology confirmed the diagnosis of a poorly differentiated neuroblastoma associated with multiple lymph node metastases.

Advances in the approaches used to repurpose drugs for neuroblastoma

INTRODUCTION

Neuroblastoma (NB) remains a challenging pediatric malignancy with limited treatment options, particularly for high-risk cases. Drug repurposing offers a convenient and cost-effective strategy for treating rare diseases like NB. Using existing drugs with known safety profiles accelerates the availability of new treatments, reduces development costs, and mitigates risks, offering hope for improved patient outcomes in challenging conditions.

AREAS COVERED

This review provides an overview of the advances in approaches used to repurpose drugs for NB therapy. The authors discuss strategies employed in drug repurposing, including computational and experimental methods, and rational drug design, highlighting key examples of repurposed drugs with promising clinical results. Additionally, the authors examine the challenges and opportunities associated with drug repurposing in NB and discuss future directions and potential areas for further research.

EXPERT OPINION

The fact that only one new drug has been approved in the last 30 years for the treatment of neuroblastoma plus a significant proportion of high-risk NB patients that remain uncurable, evidences the need for new fast and cost-effective alternatives. Drug repurposing may accelerate the treatment development process while reducing expenses and risks. This approach can swiftly bring effective NB therapies to market, enhancing survival rates and patient quality of life.

Spliceosomal vulnerability of MYCN-amplified neuroblastoma is contingent on PRMT5-mediated regulation of epitranscriptomic and metabolomic pathways

Approximately 50 % of poor prognosis neuroblastomas arise due to MYCN over-expression. We previously demonstrated that MYCN and PRMT5 proteins interact and PRMT5 knockdown led to apoptosis of MYCN-amplified (MNA) neuroblastoma. Here we evaluate the highly selective first-in-class PRMT5 inhibitor GSK3203591 and its in vivo analogue GSK3326593 as targeted therapeutics for MNA neuroblastoma. Cell-line analyses show MYCN-dependent growth inhibition and apoptosis, with approximately 200-fold greater sensitivity of MNA neuroblastoma lines. RNA sequencing of three MNA neuroblastoma lines treated with GSK3203591 reveal deregulated MYCN transcriptional programmes and altered mRNA splicing, converging on key regulatory pathways such as DNA damage response, epitranscriptomics and cellular metabolism. Stable isotope labelling experiments in the same cell lines demonstrate that glutamine metabolism is impeded following GSK3203591 treatment, linking with disruption of the MLX/Mondo nutrient sensors via intron retention of MLX mRNA. Interestingly, glutaminase (GLS) protein decreases after GSK3203591 treatment despite unchanged transcript levels. We demonstrate that the RNA methyltransferase METTL3 and cognate reader YTHDF3 proteins are lowered following their mRNAs undergoing GSK3203591-induced splicing alterations, indicating epitranscriptomic regulation of GLS; accordingly, we observe decreases of GLS mRNA m6A methylation following GSK3203591 treatment, and decreased GLS protein following YTHDF3 knockdown. In vivo efficacy of GSK3326593 is confirmed by increased survival of Th-MYCN mice, with drug treatment triggering splicing events and protein decreases consistent with in vitro data. Together our study demonstrates the PRMT5-dependent spliceosomal vulnerability of MNA neuroblastoma and identifies the epitranscriptome and glutamine metabolism as critical determinants of this sensitivity.

Updates on liquid biopsies in neuroblastoma for treatment response, relapse and recurrence assessment

Neuroblastoma is a paediatric malignancy of the sympathoadrenal or Schwann cells derived from the neural crest. Risk stratification in neuroblastoma is informed by MYCN amplification, age, stage, ploidy, and segmental chromosomal alterations. High-risk cases bear dismal overall survival. A panel of pathology and imaging modalities are utilised for diagnosis, while treatment strategies depend on the risk group. Despite this, relapse can occur in 50% of high-risk neuroblastoma patients in remission post-treatment. Liquid biopsies typically comprise the sampling of the peripheral blood and are attractive since they are less invasive than surgical tumour tissue biopsies. Liquid biopsies retrieve circulating tumour DNA and circulating tumour RNA released by tumours in addition to circulating tumour cells. These biological materials can be utilised to analyse tumour genetic alterations. Monitoring tumour-derived molecular information can assist diagnostics, targeted therapy selection, and treatment while reflecting minimal residual disease, relapse, and recurrence. This study aims to review the latest research on liquid biopsies for disease diagnosis, assessing treatment efficacy, minimal residual disease, relapse, and recurrence in neuroblastoma. A deeper understanding of the application of liquid biopsies could inform future prospective clinical trials, and in time, facilitate their routine implementation in clinical practice.

Neuroblastoma Masquerading as Constipation: Reducing Diagnostic Error With the Pediatric Abdominal Point-of-Care Ultrasound Survey

Abdominal pain is a common pediatric complaint in the emergency department and other clinical settings. While most causes are benign, dangerous and time-sensitive conditions may be present. Point-of-care ultrasound (POCUS) is a diagnostic modality that can help more thoroughly explore the differential diagnosis at a relatively low cost, without exposure to ionizing radiation, and in a timely manner.  This report presents the case of a three-year-old male with three weeks of abdominal pain, constipation, poor appetite, and weight loss that were evaluated multiple times for presumed constipation. POCUS at a rural critical access emergency department revealed an echogenic mass encasing the aorta and causing hydronephrosis, later confirmed as neuroblastoma on CT and biopsy. Comprehensive oncologic care was initiated at a tertiary care center. Neuroblastoma, one of the more common forms of childhood cancer, particularly in the first year of life, often presents with non-specific symptoms that can delay diagnosis. This case report highlights the role of POCUS, and the authors introduce the incorporation of the PAPS exam (pediatric abdominal POCUS survey) in the evaluation of vague pediatric abdominal pain to improve diagnostic accuracy and reduce errors.

Unveiling Tumorigenesis Mechanisms and Drug Therapy in Neuroblastoma by Mass Spectrometry Based Proteomics

Neuroblastoma (NB) is the most common type of extracranial solid tumors in children. Despite the advancements in treatment strategies over the past years, the overall survival rate in patients within the high-risk NB group remains less than 50%. Therefore, new treatment options are urgently needed for this group of patients. Compared with genomic aberrations, proteomic alterations are more dynamic and complex, as well as more directly related to pathological phenotypes and external perturbations such as environmental changes and drug treatments. This review focuses on specific examples of proteomics application in various fundamental aspects of NB research, including tumorigenesis, drug treatment, drug resistance, and highlights potential protein signatures and related signaling pathways with translational values for clinical practice. Moreover, emerging cutting-edge proteomic techniques, such as single cell and spatial proteomics, as well as mass spectrometry imaging, are discussed for their potentials to probe intratumor heterogeneity of NB.

Combining ERAP1 silencing and entinostat therapy to overcome resistance to cancer immunotherapy in neuroblastoma

BACKGROUND

Checkpoint immunotherapy unleashes tumor control by T cells, but it is undermined in non-immunogenic tumors, e.g. with low MHC class I expression and low neoantigen burden, such as neuroblastoma (NB). Endoplasmic reticulum aminopeptidase 1 (ERAP1) is an enzyme that trims peptides before loading on MHC class I molecules. Inhibition of ERAP1 results in the generation of new antigens able of inducing potent anti-tumor immune responses. Here, we identify a novel non-toxic combinatorial strategy based on genetic inhibition of ERAP1 and administration of the HDAC inhibitor (HDACi) entinostat that increase the immunogenicity of NB, making it responsive to PD-1 therapy.

METHODS

CRISPR/Cas9-mediated gene editing was used to knockout (KO) the ERAP1 gene in 9464D NB cells derived from spontaneous tumors of TH-MYCN transgenic mice. The expression of MHC class I and PD-L1 was evaluated by flow cytometry (FC). The immunopeptidome of these cells was studied by mass spectrometry. Cocultures of splenocytes derived from 9464D bearing mice and tumor cells allowed the assessment of the effect of ERAP1 inhibition on the secretion of inflammatory cytokines and activation and migration of immune cells towards ERAP1 KO cells by FC. Tumor cell killing was evaluated by Caspase 3/7 assay and flow cytometry analysis. The effect of ERAP1 inhibition on the immune content of tumors was analyzed by FC, immunohistochemistry and multiple immunofluorescence.

RESULTS

We found that inhibition of ERAP1 makes 9464D cells more susceptible to immune cell-mediated killing by increasing both the recall and activation of CD4+ and CD8+ T cells and NK cells. Treatment with entinostat induces the expression of MHC class I and PD-L1 molecules in 9464D both in vitro and in vivo. This results in pronounced changes in the immunopeptidome induced by ERAP1 inhibition, but also restrains the growth of ERAP1 KO tumors in vivo by remodelling the tumor-infiltrating T-cell compartment. Interestingly, the absence of ERAP1 in combination with entinostat and PD-1 blockade overcomes resistance to PD-1 immunotherapy and increases host survival.

CONCLUSIONS

These findings demonstrate that ERAP1 inhibition combined with HDACi entinostat treatment and PD-1 blockade remodels the immune landscape of a non-immunogenic tumor such as NB, making it responsive to checkpoint immunotherapy.

Early evolutionary branching across spatial domains predisposes to clonal replacement under chemotherapy in neuroblastoma

Neuroblastoma (NB) is one of the most lethal childhood cancers due to its propensity to become treatment resistant. By spatial mapping of subclone geographies before and after chemotherapy across 89 tumor regions from 12 NBs, we find that densely packed territories of closely related subclones present at diagnosis are replaced under effective treatment by islands of distantly related survivor subclones, originating from a different most recent ancestor compared to lineages dominating before treatment. Conversely, in tumors that progressed under treatment, ancestors of subclones dominating later in disease are present already at diagnosis. Chemotherapy treated xenografts and cell culture models replicate these two contrasting scenarios and show branching evolution to be a constant feature of proliferating NB cells. Phylogenies based on whole genome sequencing of 505 individual NB cells indicate that a rich repertoire of parallel subclones emerges already with the first oncogenic mutations and lays the foundation for clonal replacement under treatment.

Event-free survival in neuroblastoma with MYCN amplification and deletion of 1p or 11q may be associated with altered immune status

BACKGROUND

Neuroblastoma exhibits substantial heterogeneity, which is intricately linked to various genetic alterations. We aimed to explore immune status in the peripheral blood and prognosis of patients with neuroblastoma with different genetic characteristics.

METHODS

We enrolled 31 patients with neuroblastoma and collected samples to detect three genetic characteristics. Peripheral blood samples were tested for immune cells and cytokines by fluorescent microspheres conjugated with antibodies and flow cytometry. Event-free survival (EFS) was analyzed using the Kaplan‒Meier method.

RESULTS

Twenty-two patients had genetic aberrations, including MYCN amplification in 6 patients, chromosome 1p deletion in 9 patients, and chromosome 11q deletion in 14 patients. Two genetic alterations were present in seven patients. The EFS was worse in patients with MYCN amplification or 1p deletion than in the corresponding group, whereas 11q deletion was a prognostic factor only in patients with unamplified MYCN. Changes in immune status revealed a decrease in the proportion of T cells in blood, and an increase in regulatory T cells and immunosuppression-related cytokines such as interleukin (IL)-10. The EFS of the IL-10 high-level group was lower than that of the low-level group. Patients with concomitant genetic alterations and a high level of IL-10 had worse EFS than other patients.

CONCLUSIONS

Patients with neuroblastoma characterized by these genetic characteristics often have suppressed T cell response and an overabundance of immunosuppressive cells and cytokines in the peripheral blood. This imbalance is significantly associated with poor EFS. Moreover, if these patients show an elevated levels of immunosuppressive cytokines such as IL-10, the prognosis will be worse.

Combination of Losartan and Platinum Nanoparticles with Photothermal Therapy Induces Immunogenic Cell Death Effective Against Neuroblastoma

Introduction

Photothermal therapy (PTT) is a promising therapeutic procedure with minimal side effects, which can not only kill tumor directly but also cause immunogenic cell death (ICD). However, most solid tumors, including neuroblastoma, are abundant in fibroblasts, which limit the penetration and delivery of nanoparticles. Losartan is an antihypertensive drug approved by the FDA, and it has been proved to have the effect of breaking down excessive ECM network.

Methods

In this study, we investigated the application and potential mechanism of the combination of mesoporous platinum nanoparticles (MPNs) and losartan in the PTT of neuroblastoma by establishing neuroblastoma models in vitro and in vivo.

Results

Compared to the MPNs group without 808 nm laser irradiation, Neuro-2a cells pretreated with PTT and losartan showed lower survival rates, increased surface calreticulin, and higher release of HMGB1 and ATP. The group also exhibited the highest anti-tumor efficacy in vivo, with a tumor suppression ratio of approximately 80%. Meanwhile, we found that CD3+ T cells, CD4+ T cells and CD8+ T cells from the peripheral blood of experimental group mice were significantly higher than control groups, and CD8+PD-1+ cells were significantly lower than those in MPNs + Los group and Los + laser group. And the expression of PD-1 and α-SMA in Neuro-2a tumors tissue was reduced. Furthermore, losartan could reduce damage of liver function caused by MPNs and laser treatment.

Conclusion

This study demonstrated that losartan-induced fibroblasts ablation increased the penetration of MPNs into tumors. Enhanced penetration allowed PTT to kill more tumor cells and synergistically activate immune cells, leading to ICD, indicating the great promise of the strategy for treating neuroblastoma in vivo.