Isolated CNS relapse in neuroblastoma

Involvement of the central nervous system in neuroblastomas: A potential direct pathway

Although frequently disseminated to other anatomical sites, neuroblastoma (NB) is rarely reported as involving the central nervous system (CNS), which may reflect insufficient research in poorly controlled systemic disease. Here we demonstrate the involvement of the CNS in patients with NB over 18 months of age at diagnosis of extensive systemic disease. Meningeal metastases were observed even in the presence of complete systemic control. Although no improvement in patient's survival was observed, radiotherapy was effective in preventing CNS recurrence after observation of actual or previous dural disease. In conclusion, this study uncovered the uncommon pathologic involvement of the CNS in children with advanced NB and underscores the meningeal surface as a potential pathway for this to occur.

Imaging findings of patients with metastatic neuroblastoma to the brain

RATIONALE AND OBJECTIVES

Metastatic involvement of brain is rare in neuroblastoma (NB). We retrospectively evaluated conventional and advanced imaging and clinical findings of seven patients with secondary intra-axial brain NB metastases.

MATERIALS AND METHODS

Magnetic resonance imaging and computed tomography examinations of patients with metastatic brain NB were reviewed. Recent iodine-123 metaiodobenzylguanidine ((123)I-MIBG) scans were also reviewed. A medical record review was performed for relevant clinical, laboratory, histopathologic, and genetic data.

RESULTS

Mean age at the time of primary tumor diagnosis was 35 months, and all were considered high-risk NB at diagnosis. Mean time interval between diagnosis and brain involvement was 23.2 months. Extensive prior extra-central nervous system (CNS) disease was present in all patients, but concomitant extra-CNS disease at the time of brain involvement was absent in three (43%) patients. Various forms of disease, including intraparenchymal, intraventricular, and leptomeningeal lesions were detected. Most intraparenchymal lesions were supratentorial and hemorrhagic; however, hemorrhage was absent in multiple leptomeningeal nodules in one patient. Contrast enhancement of lesions was present on all contrast-enhanced studies. Restricted diffusion of lesions was present in two patients. Arterial spin labeling (ASL) perfusion in two patients also revealed increased cerebral blood flow. Recent (123)I-MIBG scans were available in four patients and showed lesions in two patients with larger metastases but failed to demonstrate lesions in another two patients with smaller lesions.

CONCLUSIONS

Brain metastases of NB are often supratentorial and hemorrhagic and demonstrate contrast enhancement. Diffusion-weighted imaging can show restricted diffusion. ASL images may reveal increased perfusion. MIBG scans may not show smaller brain metastases.

Detection of MYCN DNA in the cerebrospinal fluid for diagnosing isolated central nervous system relapse in neuroblastoma

We present the case of a 1-year-old female with stage-4 neuroblastoma with MYCN amplification; she was treated with five chemotherapy courses, resulting in normalization of elevated serum levels of tumor markers. Complete remission was achieved after allogeneic hematopoietic stem-cell transplantation with reduced-intensity conditioning. Nine months later, however, the tumor relapsed in the central nervous system (CNS). The serum and cerebrospinal fluid (CSF) levels of the tumor markers were normal, but the MYCN copy number was high only in the CSF DNA, suggesting an isolated CNS recurrence. The MYCN copy number in the CSF DNA was reflective of response to treatment.

Isolated central nervous system recurrence in a child with stage IV neuroblastoma

Neuroblastoma is the most common extracranial solid tumor in children. Survival rates have improved due to advances in treatment with aggressive chemotherapy and autologous bone marrow transplantation. Usual sites of recurrence include the site of primary tumor, residual gross disease, bone, bone narrow, liver, and lungs. The authors describe a 16-month-old boy with stage IV extracerebral primary neuroblastoma who died because of an isolated central nervous system (CNS) relapse. The CNS is a rare site of relapse that is, however, increasingly diagnosed due to prolonged survival. Criteria to identify patients at increased risk of CNS relapse are urgently needed. High-risk patients should be followed-up with brain and spine magnetic resonance imaging (MRI) for timely detection of metastases and appropriate management.

Imaging of metastatic CNS neuroblastoma

OBJECTIVE

Although neuroblastoma is a common childhood malignancy, which frequently metastasizes, involvement of the CNS is rarely reported in the literature. However, over the past several years, we have encountered an increasing number of cases of metastatic neuroblastoma to the CNS. This metastatic potential and changing metastatic pattern may, in part, be due to advances in medical treatment, leading to prolonged survival. This article will review the common and uncommon manifestations of metastatic neuroblastoma with an emphasis on the skull, dura, brain, ventricles, and leptomeninges.

CONCLUSION

Neuroblastoma has diverse manifestations including masquerading as primary neurologic disease. This disease must be considered in a child with any unexplained neurologic disorder. Realizing that neuroblastoma may represent the cause of neurologic disease in a child will lead to earlier diagnosis.

Whole neuraxis irradiation to address central nervous system relapse in high-risk neuroblastoma

BACKGROUND

As systemic control of high-risk neuroblastoma (NB) has improved, relapse in the central nervous system (CNS) is an increasingly recognized entity that carries a grim prognosis. This study describes the use of craniospinal irradiation (CSI) for CNS relapse and compares outcomes to patients who received focal radiotherapy (RT).

METHODS

A retrospective query identified 29 children with NB treated at Memorial Sloan-Kettering Cancer Center since 1987 who received RT for CNS relapse. At CNS relapse, 16 patients received CSI (median dose, 2160cGy), and 13 received focal RT. Of those who underwent CSI, 14 (88%) received intra-Ommaya (IO) radioimmunotherapy (RIT); one patient in the non-CSI cohort received IO-RIT.

RESULTS

Patient characteristics were similar between the groups. Time to CNS relapse was 20 and 17 months for the CSI and non-CSI cohorts, respectively. At a median follow-up of 28 months, 12 patients (75%) in the CSI group are alive without CNS disease, including two patients with isolated skeletal relapse. Another patient is alive without disease after a brain relapse was retreated with RT. Three patients died-one with no NB at autopsy, one of CNS disease, and one of systemic disease. The two patients who died of NB did not receive IO-RIT. All 13 patients in the non-CSI cohort died at a median of 8.8 months.

CONCLUSIONS

Low-dose CSI together with IO-RIT provides durable CNS remissions and improved survival compared with focal RT and conventional therapies. Further evaluation of long-term NB survivors after CSI is warranted to determine the treatment consequences for this cohort.