Clinical, biologic, and prognostic differences on the basis of primary tumor site in neuroblastoma: a report from the international neuroblastoma risk group project

Evaluation of Minimal Residual Disease in Patients with Neuroblastoma

Neuroblastoma (NB) is a pediatric extracranial solid tumor that accounts for approximately 15% of all pediatric cancer deaths. More than 50% of patients with newly diagnosed NB are classified into a high-risk group with an approximately 50% long-term survival rate. Although most high-risk patients with NB achieve remission, more than half may have minimal residual disease (MRD) that eventually causes relapse. Looking towards an optimal outcome, the accurate evaluation of MRD in patients with NB (NB-MRD) is essential to monitor the treatment response and disease burden. Over the past decades, the quantification of NB-associated messenger RNA (NB-mRNA) by reverse transcriptase-polymerase chain reaction has become widely used to detect NB-MRD, owing to the lack of recurrent genomic aberrations in NB cells. To achieve a more accurate and sensitive detection, the current NB-MRD assays quantify a set of NB-mRNAs to detect NB cells in bone marrow, peripheral blood, and peripheral blood stem cell samples. Among a growing number of NB-MRD assays, several assays quantitating different but overlapping sets of NB-mRNAs are reported to have a significant prognostic value. However, the clinical significance of NB-MRD remains to be established. In this review, we summarize the recent progress in NB-MRD and evaluate its clinical value.

Retrospective analysis of neuroblastoma and pheochromocytoma therapy with I-131 metaiodobenzylguanidine at a reference oncology hospital in Brazil

BACKGROUND

Metaiodobenzylguanidine (MIBG) is a norepinephrine analogue with high affinity and specificity for the norepinephrine transporter. I-131-labeled MIBG (I-131 MIBG) is a therapeutic radiopharmaceutical used in selected cases of refractory or metastatic neuroblastoma and pheochromocytoma, tumors that overexpress the norepinephrine transporter. While the use of I-131 MIBG in neuroblastoma and pheochromocytoma therapy is well-established, the literature shows significant variability in treatment response, regarding the dose of the radiopharmaceutical, previous therapies administered, and the clinical condition of the patients involved in the studies. To contribute to the current literature, this study analyzed the use of I-131 MIBG at a cancer treatment institution in Brazil.

METHODS

Retrospective, observational, single-center study was conducted, with a descriptive and exploratory character, involving patients diagnosed with neuroblastoma and pheochromocytoma treated with I-131 MIBG from 2010 to 2025. Demographic, clinical, and laboratory parameters were collected before and after I-131 MIBG therapy. The outcome was determined through survival analysis.

RESULTS

Thirty-two patients were treated with I-131 MIBG, including 24 patients with neuroblastoma and six patients with pheochromocytoma. Leukocytes and platelets showed a reduction, and aspartate aminotransferase (AST) levels exhibited a significant increase posttherapy in patients with neuroblastoma. Survival rate was 84% in patients with pheochromocytoma and 55% in patients with neuroblastoma in the first year following I-131 MIBG therapy; however, both groups showed a gradual reduction in the cumulative survival rates, reaching 20% after 5 years.

CONCLUSION

I-131 MIBG was primarily used for the treatment of neuroblastoma in pediatric patients, and pheochromocytomas in adults. Anemia, leukopenia, thrombocytopenia, and increased serum AST were the main adverse events, and cumulative survival rates were 20% after 5 years.

MYCN and KAT2A form a feedforward loop to drive an oncogenic transcriptional program in neuroblastoma

The oncoprotein MYCN drives malignancy in various cancer types, including neuroblastoma (NB). However, our understanding of the mechanisms underlying its transcriptional activity and oncogenic function, as well as effective strategies to target it, remains limited. We discovered that MYCN interacts with the transcriptional coactivator KAT2A, and this interaction significantly contributes to MYCN's activity in NB. Our genome-wide analyses indicate MYCN recruits KAT2A to bind to DNA, thereby transcriptionally regulating genes associated with ribosome biogenesis and RNA processing. Moreover, we identified that MYCN directly activates KAT2A transcription, while KAT2A acetylates MYCN, increasing MYCN protein stability. Consequently, MYCN and KAT2A establish a feedforward loop that effectively regulates global gene expression, governing the malignant NB phenotype. Treatment of NB cells with a KAT2A Proteolysis Targeting Chimera (PROTAC) degrader reduces MYCN protein levels, antagonizes MYCN-mediated gene transcription regulation and suppresses cell proliferation. This study highlights the potential of transcriptional cofactors as viable targets for developing anti-MYCN therapies.

Lineage-Selective Dependencies in Pediatric Cancers

The quest for effective cancer therapeutics has traditionally centered on targeting mutated or overexpressed oncogenic proteins. However, challenges arise in cancers with low mutational burden or when the mutated oncogene is not conventionally targetable, which are common situations in childhood cancers. This obstacle has sparked large-scale unbiased screens to identify collateral genetic dependencies crucial for cancer cell growth. These screens have revealed promising targets for therapeutic intervention in the form of lineage-selective dependency genes, which may have an expanded therapeutic window compared to pan-lethal dependencies. Many lineage-selective dependencies regulate gene expression and are closely tied to the developmental origins of pediatric tumors. Placing lineage-selective dependencies in a transcriptional network model is helpful for understanding their roles in driving malignant cell behaviors. Here, we discuss the identification of lineage-selective dependencies and how two transcriptional models, core regulatory circuits and gene regulatory networks, can serve as frameworks for understanding their individual and collective actions, particularly in cancers affecting children and young adults.

Cellular morphometric biomarkers and large language model predict prognosis and treatment response in neuroblastoma patients: A retrospective and double-blind prospective single arm clinical study

BACKGROUND

The heterogeneity of Neuroblastoma (NB) leads to variation in response to treatment and outcomes. The aim of the current study is to discover AI-empowered cellular morphometric biomarkers (CMBs), to establish the corresponding CMB risk score (CMBRS), CMB risk group (CMBRG), large language model driven CMB risk score (CMB-LLM-RS), and large language model driven CMB risk group (CMB-LLM-RG), and to investigate and validate their prognostic and predictive power in NB.

METHODS

In this study, the retrospective cohort enrolled 84 primary NBs between 1/2020 and 12/2021, followed up through 11/22/2024; the prospective cohort enrolled 67 primary NBs between 1/2022 and 7/2023, followed up through 11/22/2024.

RESULTS

We identified 9 CMBs from a retrospective NB cohort, enabling the CMBRS, CMBRG, CMB-LLM-RS, and CMB-LLM-RG. Both CMBRG and CMB-LLM-RG are significantly associated with prognosis (p < 0.0001) and treatment response (p < 0.0001). Furthermore, we double-blindly validated the predictive power of CMBRG and CMB-LLM-RG in a prospective NB cohort, which confirms their potential value in real clinical settings. Importantly, CMBRG provides clinical value independent of the International Neuroblastoma Risk Group (INRG) classification system in both retrospective and prospective NB cohorts (p < 0.05); and the combination of CMBRG and INRG significantly increases prognostic and predictive performance for NB patients.

CONCLUSIONS

These findings suggest that CMBRG and CMB-LLM-RG have prognostic and predictive value for NB and warrants evaluation in larger multicenter cohorts.

The value of 123I-MIBG xSPECT/CT quantitative parameters in the diagnosis of bone metastasis in pediatric neuroblastoma patients

Background

The diagnostic value of quantitative single-photon emission computed tomography/computed tomography (xSPECT/CT) in the screening of bone metastases of various malignant tumors varies. This study investigated the differential diagnostic value of quantitative parameters of 123I-metaiodobenzylguanidine (123MIBG) xSPECT/CT imaging in the diagnosis of bone metastasis in pediatric neuroblastoma (NB) patients.

Methods

In this retrospective cohort study, the 123I-MIBG xSPECT/CT images of 125 children with NB confirmed by pathology at Beijing Friendship Hospital from March 2022 to December 2023 were assessed. A Spearman correlation analysis was conducted to assess the factors influencing normal bone quantitative parameters, and differences in the standardized uptake values (SUVs), including the maximum standardized uptake value (SUVmax), average standardized uptake value (SUVavg), minimum standardized uptake value (SUVmin), and peak standardized uptake value (SUVpeak), between metastatic bone lesions and normal bone were compared using the Mann-Whitney U test. Receiver operating characteristic (ROC) curves were used to determine the optimal cut-off values of the SUVs in the diagnosis of metastatic bone lesions. The above indexes were compared via a visual analysis, and using the chi-square test. The clinical parameters and semi-quantitative indexes of xSPECT/CT were also analyzed using univariate and multivariate methods.

Results

The study cohort comprised 75 girls and 50 boys with an average age of 5.94 years (0.6-9 years). The SUVs of metastatic bone lesions were significantly higher than those of normal bone (P<0.0001), but there was no statistically significant difference in the SUV values of metastatic bone lesions among the different Curie score subzones (P>0.05). The area under the curve (AUC) values for the SUVmax, SUVavg, SUVmin, and SUVpeak were 0.946 [95% confidence interval (CI): 0.921-0.971], 0.962 (95% CI: 0.939-0.984), 0.953 (95% CI: 0.928-0.978), and 0.959 (95% CI: 0.936-0.982), respectively (P<0.0001). The optimal diagnostic thresholds identified for the SUVmax, SUVavg, SUVmin, and SUVpeak were 0.39, 0.36, 0.19 and 0.35, respectively. The SUVavg was the best index among the different Curie score subzones, and the specificity of the quantitative analysis in diagnosing bone metastasis in NB patients was better than that of the visual analysis. We also showed that tumor stage and neuron specific enolase (NSE) levels are important factors influencing the diagnosis of bone metastasis. There was no statistically significant difference in the SUV values for normal bone among different physical parameters (P>0.05).

Conclusions

A SUVavg above 0.36 g/mL in NB patients had the best efficacy in the diagnosis of bone metastasis in NB patients. Quantitative indexes of xSPECT/CT had better specificity in the diagnosis of bone metastasis in NB patients than the visual analysis. 123I-MIBG xSPECT/CT imaging can increase the diagnostic confidence of bone metastasis in NB.

Identification of Contactin-1 as a Potential Biomarker and Therapeutic Target in Neuroblastoma

BACKGROUND

Neuroblastoma is a common pediatric solid tumor with poor outcomes in high-risk patients. The identification of new therapeutic biomarkers is critical for the treatment of disease.

METHODS

An analysis of large publicly available datasets of tumor gene expression was performed. In vivo studies were performed to elucidate the role of contactin-1 (CNTN1) in tumor progression.

RESULTS

Expression of the glycoprotein CNTN1 is elevated in neuroblastoma compared to other tumor types. CNTN1 expression is higher in stage 1 and non-MYCN-amplified tumors, compared to more aggressive stage 4 and MYCN-amplified tumors. Moreover, high CNTN1 expression is associated with increased overall survival in neuroblastoma patients. In vivo studies demonstrate reduced metastasis in mice xenografted with CNTN1 knockout tumors compared to wildtype.

CONCLUSIONS

The results of this study suggest that CNTN1 is a potential biomarker and therapeutic target in neuroblastoma. Further investigation of CNTN1 could have significant clinical implications for improving neuroblastoma treatment.

Integrating multi-omics data reveals neuroblastoma subtypes in the tumor microenvironment

Neuroblastoma (NB) is a severe pediatric tumor originating from the developing sympathetic nervous system, characterized by diverse clinical outcomes, including spontaneous regression and aggressive metastasis. This variability suggests the existence of different NB subtypes, necessitating accurate classification for effective targeted treatment. In this study, we employed the similarity network fusion (SNF) algorithm and identified three NB subtypes, including mesenchymal-like (MES), MYCN-like (MYCN), and neurogenic-like (Neurogenic). The MES subtype exhibited the highest activation of immune-related pathways. The MYCN subtype demonstrated the worst prognosis, with enrichment in cell growth and proliferation pathways. Conversely, the Neurogenic subtype showed the best prognosis, with enrichment in sympathetic nervous system development processes. Through single-cell RNA sequencing (scRNA-seq) analysis, we examined the tumor microenvironments of these distinct NB subtypes, revealing divergent differentiation trajectories for adrenergic cells within the MYCN and Neurogenic subtypes. We also identified a significant presence of naïve T cells in the MES subtype, as well as mesenchymal cell subtypes associated with the unique plasticity observed in both the MES and MYCN subtypes. Drug sensitivity prediction analysis suggested that the MES subtype may respond favorably to MEK inhibitors, while the MYCN subtype may be susceptible to Bcl-2 inhibitors. Our integrative multi-omics approach enabled precise stratification of NB into biologically distinct subtypes, potentially facilitating the development of subtype-specific therapeutic strategies for improved patient management and survival outcomes.

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.

Ganglioneuroblastoma in the Retropharyngeal Space: A Case Report and Literature Review

Ganglioneuroblastoma is a rare peripheral neuroblastic tumor located anywhere in the sympathetic nervous system but rarely in the retropharyngeal space. Diagnosis can often be difficult based on imaging alone. We describe one case of a child presenting with snoring. The lesion was located in the rare retropharyngeal space, and its histology finally revealed ganglioneuroblastoma. Therefore, clinicians should be aware of pediatric patients with respiratory symptoms indicating cervical ganglioneuroblastoma. To make a definite diagnosis as soon as possible, a core needle biopsy or even immunohistochemistry may need to be performed before surgery.

DNA copy number profiles and systems biology connect chromatin remodeling and DNA repair in high-risk neuroblastoma

Neuroblastoma (NB) is a solid tumor that accounts for 15% of all pediatric oncological deaths, and much is due to the low response to therapy in relapsed tumors. High-risk NB may present deletions in chromosome 11q, which may be associated with other chromosomal alterations and a poor response to therapy, but this association is still poorly understood. Using a systems biology network approach, we studied three patients with high-risk NB with deleted 11q stage 4 to highlight the connections between treatment resistance and copy number alterations in distinct cases. We built different protein-protein interaction networks for each patient based on protein-coding genes mapped at the cytobands pre- and post-chemotherapy from distinct copy number alterations data. In the post-chemotherapy networks, we identified five common regulatory nodes corresponding to the gained region located in ch17q:BIRC5, BRCA1, PRKCA, SUMO2, andGPS1. A crosslink between DNA damage and chromatin remodeling proteins was also found - a connection still poorly understood in NB. We identified a potential connection between XPB gain and chemoresistance of NB. The findings help elucidate the molecular profiles of high-risk NB with 11q deletion in pre- and post-chemotherapy tumor samples, which may reflect unique profiles in poor response to treatment.

US Food and Drug Administration Approval Summary: Eflornithine for High-Risk Neuroblastoma After Prior Multiagent, Multimodality Therapy

On December 13, 2023, the US Food and Drug Administration (FDA) approved eflornithine (IWILFIN, US WorldMeds) to reduce the risk of relapse in adult and pediatric patients with high-risk neuroblastoma who have demonstrated at least a partial response to prior multiagent, multimodality therapy including anti-GD2 immunotherapy. The approval was based on an externally controlled trial (ECT) consisting of a single-arm trial, study 3(b), compared with an external control (EC) derived from a National Cancer Institute/Children's Oncology Group-sponsored clinical trial (Study ANBL0032) and supported by confirmatory evidence. In the protocol-specified primary analysis, the event-free survival hazard ratio (HR) was 0.48 (95% CI, 0.27 to 0.85) and overall survival HR was 0.32 (95% CI, 0.15 to 0.70). The most common adverse reactions (≥5%) were hearing loss, otitis media, pyrexia, pneumonia, and diarrhea. Notably, this is the first oncology drug approval which relies on an ECT as the primary clinical data to support substantial evidence of effectiveness. This was made possible by a distinctly high-quality, comparable EC data set with consistent treatment effect estimations demonstrated in multiple sensitivity and supportive analyses. Eflornithine's manageable safety profile and strong nonclinical and mechanistic data provided further support for the approval, and the evidentiary package was evaluated in the context of high unmet need in a rare, life-threatening cancer.

Image-defined risk factors associated with MYCN oncogene amplification in neuroblastoma and their association with overall survival

OBJECTIVE

The MYCN oncogene is a critical factor in the development and progression of neuroblastoma, and image-defined risk factors (IDRFs) are radiological findings used for the preoperative staging of neuroblastoma. This study aimed to investigate the specific categories of IDRFs associated with MYCN amplification in neuroblastoma and their association with overall survival.

METHOD

A retrospective analysis was conducted on a cohort of 280 pediatric patients diagnosed with neuroblastoma, utilizing a combination of clinical and radiological data. MYCN amplification status was ascertained through molecular testing, and the assessment of IDRFs was conducted using either contrast-enhanced computed tomography or magnetic resonance imaging. The specific categories of IDRFs associated with MYCN amplification and their association with overall survival were analyzed.

RESULTS

MYCN amplification was identified in 19.6% (55/280) of patients, with the majority of primary lesions located in the abdomen (53/55, 96.4%). Lesions accompanied by MYCN amplification exhibited significantly larger tumor volume and a greater number of IDRFs compared with those without MYCN amplification (P < 0.001). Both univariate and multivariate analyses revealed that coeliac axis/superior mesenteric artery encasement and infiltration of adjacent organs/structures were independently associated with MYCN amplification in abdominal neuroblastoma (P < 0.05). Patients presenting with more than four IDRFs experienced a worse prognosis (P = 0.017), and infiltration of adjacent organs/structures independently correlated with overall survival in abdominal neuroblastoma (P = 0.009).

CONCLUSION

The IDRFs are closely correlated with the MYCN amplification status and overall survival in neuroblastoma.

Anti-Hu antibody associated paraneoplastic neurological syndrome in a child with ganglioneuroblastoma: A rare case report and literature review

RATIONALE

Paraneoplastic neurological syndrome with anti-Hu antibody (Hu-PNS) is a neurological disorder that occur in patients with malignancy. The syndrome has a wide range of presentations and can present before diagnosis of primary malignancy. Familiarity with these paraneoplastic neurological syndromes can help early recognition and take appropriate regimens.

PATIENTS CONCERNS

Diagnosis and treatment of Hu-PNS.

DIAGNOSES

This is retrospective study that analyzed the clinical data of this case. Through retrospective analysis and targeted antibody screening, serum anti-Hu antibody was detected. Subsequent spinal imaging revealed a mass in the paraspinal region, which was confirmed as ganglioneuroblastoma by pathologic examination.

INTERVENTIONS

The child was treated with a course of intravenous immunoglobulin and radical surgical operation without chemotherapy.

OUTCOMES

The neurological symptoms were gradually improved and no signs indicate disease progression or tumor recurrence.

LESSONS

Hu-PNS has rarely been reported in children with ganglioneuroblastomas. They can mimic non-neoplastic processes, making detection and diagnosis difficult. Serum and/or cerebrospinal fluid onconeural antibody can strongly indicate occult cancers. Early detection of paraneoplastic neurological syndromes can help take appropriate regimens and improve prognosis.

Serum cholesterol level as a predictive biomarker for prognosis of Neuroblastoma

BACKGROUND

Neuroblastoma (NB), a type of solid tumor in children, has a poor prognosis. Few blood biomarkers can accurately predict the prognosis, including recurrence and survival, in children with NB. In this study, we found that the serum total cholesterol (Tchol) level was associated with the prognosis of patients through a retrospective study.

METHODS

Multivariate Cox regression model was used to identify the independent risk factors in the children with NB. Kaplan-Meier method was used to analyze the correlation between the common biomarkers, including the serum Tchol level, and the prognosis of the patients. ROC curves were used to predict the accuracy of the International Neuroblastoma Staging System (INSS) stage and Children's Oncology Group (COG) risk stratification after adding the serum Tchol level.

RESULTS

Compared with the other patients, serum Tchol level was significantly increased in the relapsed and died patients (P < 0.05). Subsequently, serum Tchol level was found as an independent risk factor to affect the outcome of patients (P < 0.05). Finally, we added serum Tchol level into traditional stage and risk classification system to form the new INSS stage and COG risk classification system. It was found that the areas under the ROC curve (AUC) of recurrence-free survival in the new INSS stage and COG risk classification system were increased to 0.691 (95%CI: 0.535-0.847) and 0.748 (95%CI: 0.622-0.874), respectively. Moreover, the AUC areas of overall survival in the new INSS stage and COG risk classification system were increased to 0.722 (95%CI: 0.561-0.883) and 0.668 (95%CI: 0.496-0.819), respectively.

CONCLUSION

We found that serum Tchol level, a clinical biomarker, is a risk factor for recurrence and death among the children with NB. The serum Tchol level could significantly increase the accuracy of the prediction for NB prognosis.

MYCN drives oncogenesis by cooperating with the histone methyltransferase G9a and the WDR5 adaptor to orchestrate global gene transcription

MYCN activates canonical MYC targets involved in ribosome biogenesis, protein synthesis, and represses neuronal differentiation genes to drive oncogenesis in neuroblastoma (NB). How MYCN orchestrates global gene expression remains incompletely understood. Our study finds that MYCN binds promoters to up-regulate canonical MYC targets but binds to both enhancers and promoters to repress differentiation genes. MYCN binding also increases H3K4me3 and H3K27ac on canonical MYC target promoters and decreases H3K27ac on neuronal differentiation gene enhancers and promoters. WDR5 facilitates MYCN promoter binding to activate canonical MYC target genes, whereas MYCN recruits G9a to enhancers to repress neuronal differentiation genes. Targeting both MYCN's active and repressive transcriptional activities using both WDR5 and G9a inhibitors synergistically suppresses NB growth. We demonstrate that MYCN cooperates with WDR5 and G9a to orchestrate global gene transcription. The targeting of both these cofactors is a novel therapeutic strategy to indirectly target the oncogenic activity of MYCN.

Posttreatment complications in pediatric cervical neuroblastoma: A retrospective case series at a tertiary cancer center

BACKGROUND

Neuroblastomas rarely occur as primary tumors in the cervical region. Therefore, very little has been reported regarding treatment strategies, complications, and outcomes of these cervical neuroblastomas. The goal of this study is to review the presentation, management, and outcomes of all primary cervical pediatric neuroblastoma cases at a single tertiary care center.

METHODS

A retrospective cohort review of all neuroblastoma patients treated at a single center were performed. All patients with primary cervical neuroblastoma were reviewed for demographic information, tumor characteristics, treatment, and outcomes.

RESULTS

Thirty (1.8%) patients were found to have undergone treatment for cervical neuroblastoma tumors diagnosed on average at 2.1 years old. Most presented with a swollen neck/palpable mass ± Horner's syndrome. Based on features including tumor staging, N-myc proto-oncogene protein (MYCN) amplification status, histology, most were deemed intermediate or high risk. Treatment strategies centered around chemotherapeutic regimens with surgery when possible as well as various adjuvant treatments including radiation therapy, immunotherapy, bone marrow transplant, and a neuroblastoma vaccine. Ten (33.3%) of patients experienced treatment-related complications and four (13.3%) died as a result of their disease progression. All four patients were high-risk patients, two of which had MYCN amplification.

CONCLUSION

Cervical neuroblastomas generally have favorable outcomes. These tumors can be treated effectively with chemotherapy and surgical intervention with various adjuvant therapies. MYCN amplification and higher stage disease presentation contribute to worse outcomes.

Predicting Bone Marrow Metastasis in Neuroblastoma: An Explainable Machine Learning Approach Using Contrast-Enhanced Computed Tomography Radiomics Features

PURPOSE

To predict bone marrow metastasis in neuroblastoma using contrast-enhanced computed tomography (CECT) radiomics features and explainable machine learning.

METHODS

This cohort study retrospectively included a total of 345 neuroblastoma patients who underwent testing for bone marrow metastatic status. Tumor lesions on CECT images were delineated by two radiologists, and 1409 radiomics features were extracted. Correlation analysis, Least Absolute Shrinkage and Selection Operator regression, and one-way analysis of variance were used to identify radiomics features associated with bone marrow metastasis. A predictive model for bone marrow metastasis was then developed using the support vector machine algorithm based on the selected radiomics features. The performance of the radiomics model was evaluated using the area under the curve (AUC), 95% confidence interval (CI), accuracy, sensitivity, and specificity.

RESULTS

The radiomics model included 16 features, with a predominant focus on texture features (12/16, 75%). In the training set, the model demonstrated an AUC of 0.891 (95% CI: 0.848-0.933), an accuracy of 0.831 (95% CI: 0.829-0.832), a sensitivity of 0.893 (95% CI: 0.840-0.946), and a specificity of 0.757 (95% CI: 0.677-0.837). In the test set, the AUC, accuracy, sensitivity, and specificity were 0.807 (95% CI: 0.720-0.893), 0.767 (95% CI: 0.764-0.770), 0.696 (95% CI: 0.576-0.817), and 0.851 (95% CI: 0.749-0.953), respectively.

CONCLUSION

Radiomics features extracted from CECT images are associated with the presence of bone marrow metastasis in neuroblastoma, providing potential new imaging biomarkers for predicting bone marrow metastasis in this disease.

Correlations between contrast-enhanced CT-measured extracellular volume fraction, histopathological features, and MYCN amplification status in abdominal neuroblastoma: a retrospective study

PURPOSE

To retrospectively investigate the correlations between contrast-enhanced CT (CECT)-measured extracellular volume fraction (fECV) and histopathological features, as well as MYCN amplification status, in abdominal neuroblastoma.

MATERIALS AND METHODS

One hundred and forty-one patients with abdominal neuroblastoma who underwent CECT scanning were retrospectively enrolled. Calculation of fECV involved the measurement of CT values within regions of interest located within the neuroblastoma and aorta on both non-contrast-enhanced CT and equilibrium CECT. The correlations between fECV and various factors, including pathological subtype, mitosis karyorrhexis index (MKI), Shimada classification, MYCN amplification status, International Neuroblastoma Risk Group (INRG) stage, and risk group were analyzed using either the Mann-Whitney U test or Kruskal-Wallis test.

RESULTS

Neuroblastoma and ganglioneuroblastoma exhibited fECV values of 0.349 (0.252, 0.424) and 0.438 (0.327, 0.508), respectively, indicating a statistically significant difference (Z = 2.200, P = 0.028). Additionally, the fECV decreased significantly in neuroblastoma with high MKI (H = 8.314, P = 0.016) or unfavorable histology (Z = 3.880, P < 0.001), as well as in those with MYCN amplification (Z = 5.486, P < 0.001). Notably, a significant variation in fECV was observed among different INRG stages (H = 16.881, P <0.001) and risk groups (H = 29.014, P < 0.001).

CONCLUSION

CECT-derived fECV is associated with histopathological features, MYCN amplification status, INRG stage, and risk stratification of abdominal neuroblastoma, reflecting a potential correlation between the extracellular matrix and the biological behavior of neuroblastoma.

[Peripheral neuroblastic tumors in childhood]

Peripheral neuroblastic tumors represent the fourth-largest group of malignant tumors in childhood. The majority of these tumors are neuroblastomas, which can be classified into undifferentiated, poorly differentiated, and differentiating subtypes. In addition, peripheral neuroblastic tumors include ganglioneuroblastoma, a composite tumor composed of Schwannian cell stroma and neuroblasts as well as benign ganglioneuroma. In this overview, histopathological diagnostic criteria and grading systems, as well as common molecular alterations that are of prognostic and therapeutic significance, are discussed.

Image-defined risk factors in localized thoracic neuroblastoma and ganglioneuroma

BACKGROUND

The pretreatment International Neuroblastoma Risk Group Staging System (INRGSS) discriminates localized tumors L1/L2 depending on the absence/presence of image-defined risk factors (IDRFs) at diagnosis. Referring to this new staging system, we assessed initial imaging of localized thoracic neuroblastoma (NB) and ganglioneuroma (GN) and the extent of initial tumor resection.

METHODS

Patients with localized thoracic NB/GN from the German clinical trials NB97 and NB2004 were included. Imaging at diagnosis and operative reports were reviewed retrospectively. IDRFs were assessed centrally and correlated to International Neuroblastoma Staging System (INSS) stage and extent of tumor resection. Additionally, we analyzed data on surgery-related complications.

RESULTS

Imaging series of 88 patients were available for central review. In 18 children, no IDRF was present, 28 exhibited one IDRF, 42 two or more IDRFs, resulting in 70 patients with L2 disease. The most frequently observed IDRF was encasement of any vessel (n = 38). Initial surgical resection was aimed for in 45 patients (L1: n = 11; L2: n = 34). Complete and gross total resection rates were higher children with L2 NB (n = 8/25 L1, n = 17/25 L2 vs. n = 2/15 L1, n = 13/15 L2, respectively). The proportion of surgical complications was very similar between INRGSS L1 and L2 (n = 4/11 vs. n = 17/34). All complications were manageable, and no surgery-related deaths were observed.

CONCLUSION

In this retrospective cohort, the extent of resection and the rate of surgical complications did not differ substantially between patients classified as L1/L2, indicating that INRGSS L2 does not equate unresectability. It appeared that individual IDRFs differ in value. Larger studies are needed to assess the significance and therapeutic/prognostic impact of such findings.

A practical nomogram and risk stratification system for predicting survival outcomes in neuroblastoma patients: a SEER population-based study

BACKGROUND

Neuroblastoma (NB) is a childhood malignancy with marked heterogeneity, resulting in highly variable outcomes among patients. This study aims to establish a novel nomogram and risk stratification system to predict the overall survival (OS) for patients with NB.

METHODS

We analyzed neuroblastoma patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. The nomogram was constructed using independent risk factors for OS, identified through univariate and multivariate Cox regression analyses. The accuracy of this nomogram was evaluated with the concordance index, receiver operating characteristic curve, calibration curve, and decision curve analysis. In addition, we developed a risk stratification system based on the total score of each patient in the nomogram.

RESULTS

A total of 2185 patients were randomly assigned to the training group and the testing group. Six risk factors, including age, chemotherapy, brain metastases, primary site, tumor stage, and tumor size, were identified in the training group. Using these factors, a nomogram was constructed to predict 1-, 3-, and 5-year OS of NB patients. This model exhibited superior accuracy in the training and testing groups, exceeding traditional tumor stage prediction. Subgroup analysis suggested worse prognosis for retroperitoneal origin in the intermediate-risk group and adrenal gland origin in the high-risk group compared to other sites. Additionally, the prognosis for high-risk patients significantly improved after surgery. We also developed a web application to make the nomogram more user-friendly in clinical practices.

CONCLUSION

This nomogram demonstrates excellent accuracy and reliability, offering more precise personalized prognostic predictions to clinical patients.

Nonspecific Gastrointestinal Symptoms as the First Sign of Ganglioneuroblastoma Intermixed-Case Report and Literature Review

Nonspecific gastrointestinal symptoms remain a problem for pediatricians because, out of a thousand trivial cases, there are rare diseases that require in-depth diagnostics and extensive knowledge to identify them. These complaints may be caused by a neoplastic process. We present the case of a 5-year-old boy whose diagnostic pathway lasted about 3 months. He was admitted to hospital due to severe abdominal pain. Physical examination revealed a bloated, hard, and painful abdomen. In the standing X-ray, the features of intestinal obstruction were visualized. An ultrasound examination showed a possible malignant lesion in the location of the left adrenal gland. After the surgical removal of the pathological mass and histopathological examination, the diagnosis of ganglioneuroblastoma intermixed was made. This tumor, along with neuroblastoma, ganglioneuroma, and ganglioneuroblastoma nodular, belongs to neuroblastic tumors (NTs), which originate from primitive cells of the sympathetic nervous system. NTs are quite rare, but they are still the majority of extracranial solid tumors in children, and their symptoms often appear relatively late when the neoplastic process is already advanced. The purpose of this review is to present current information about ganglioneuroblastoma, with a special emphasis on nonspecific gastrointestinal symptoms as first sign of this tumor and its diagnostics.

The molecular basis of tumor metastasis and current approaches to decode targeted migration-promoting events in pediatric neuroblastoma

Cell motility is a crucial biological process that plays a critical role in the development of multicellular organisms and is essential for tissue formation and regeneration. However, uncontrolled cell motility can lead to the development of various diseases, including neoplasms. In this review, we discuss recent advances in the discovery of regulatory mechanisms underlying the metastatic spread of neuroblastoma, a solid pediatric tumor that originates in the embryonic migratory cells of the neural crest. The highly motile phenotype of metastatic neuroblastoma cells requires targeting of intracellular and extracellular processes, that, if affected, would be helpful for the treatment of high-risk patients with neuroblastoma, for whom current therapies remain inadequate. Development of new potentially migration-inhibiting compounds and standardized preclinical approaches for the selection of anti-metastatic drugs in neuroblastoma will also be discussed.

Neuroblastoma of the lumbosacral canal in an adult: a case report and literature review

Neuroblastoma (NB) is a leading cause of death in children. It usually occurs in the adrenal gland and rarely in the spinal canal. Here, we report the case of a 48-year-old male patient with abnormal thickening of the cauda equina nerve as revealed by lumbosacral magnetic resonance imaging. The patient's main clinical manifestations were numbness and pain in both lower limbs. The patient underwent surgical treatment; however, intraoperatively, an unclear border was observed between the cauda equina nerve and the tumor; therefore, the tumor was not forcibly excised. The postoperative pathological results were reported as NB. The disease known as NB, which is extremely rare. We believe that a pathological biopsy is extremely vital for diagnosing NB, and aggressive post-operative radio-chemotherapy could potentially prolong the patient's survival time.

Identification of the molecular subtypes and construction of risk models in neuroblastoma

The heterogeneity of neuroblastoma directly affects the prognosis of patients. Individualization of patient treatment to improve prognosis is a clinical challenge at this stage and the aim of this study is to characterize different patient populations. To achieve this, immune-related cell cycle genes, identified in the GSE45547 dataset using WGCNA, were used to classify cases from multiple datasets (GSE45547, GSE49710, GSE73517, GES120559, E-MTAB-8248, and TARGET) into subgroups by consensus clustering. ESTIMATES, CIBERSORT and ssGSEA were used to assess the immune status of the patients. And a 7-gene risk model was constructed based on differentially expressed genes between subtypes using randomForestSRC and LASSO. Enrichment analysis was used to demonstrate the biological characteristics between different groups. Key genes were screened using randomForest to construct neural network and validated. Finally, drug sensitivity was assessed in the GSCA and CellMiner databases. We classified the 1811 patients into two subtypes based on immune-related cell cycle genes. The two subtypes (Cluster1 and Cluster2) exhibited distinct clinical features, immune levels, chromosomal instability and prognosis. The same significant differences were demonstrated between the high-risk and low-risk groups. Through our analysis, we identified neuroblastoma subtypes with unique characteristics and established risk models which will improve our understanding of neuroblastoma heterogeneity.

MYCN driven oncogenesis involves cooperation with WDR5 to activate canonical MYC targets and G9a to repress differentiation genes

MYCN activates canonical MYC targets involved in ribosome biogenesis, protein synthesis and represses neuronal differentiation genes to drive oncogenesis in neuroblastoma (NB). How MYCN orchestrates global gene expression remains incompletely understood. Our study finds that MYCN binds promoters to up-regulate canonical MYC targets but binds to both enhancers and promoters to repress differentiation genes. MYCN-binding also increases H3K4me3 and H3K27ac on canonical MYC target promoters and decreases H3K27ac on neuronal differentiation gene enhancers and promoters. WDR5 is needed to facilitate MYCN promoter binding to activate canonical MYC target genes, whereas MYCN recruits G9a to enhancers to repress neuronal differentiation genes. Targeting both MYCN's active and repressive transcriptional activities using both WDR5 and G9a inhibitors synergistically suppresses NB growth. We demonstrate that MYCN cooperates with WDR5 and G9a to orchestrate global gene transcription. The targeting of both these cofactors is a novel therapeutic strategy to indirectly target the oncogenic activity of MYCN.

Neural crest-related NXPH1/α-NRXN signaling opposes neuroblastoma malignancy by inhibiting organotropic metastasis

Neuroblastoma is a pediatric cancer that can present as low- or high-risk tumors (LR-NBs and HR-NBs), the latter group showing poor prognosis due to metastasis and strong resistance to current therapy. Whether LR-NBs and HR-NBs differ in the way they exploit the transcriptional program underlying their neural crest, sympatho-adrenal origin remains unclear. Here, we identified the transcriptional signature distinguishing LR-NBs from HR-NBs, which consists mainly of genes that belong to the core sympatho-adrenal developmental program and are associated with favorable patient prognosis and with diminished disease progression. Gain- and loss-of-function experiments revealed that the top candidate gene of this signature, Neurexophilin-1 (NXPH1), has a dual impact on NB cell behavior in vivo: whereas NXPH1 and its receptor α-NRXN1 promote NB tumor growth by stimulating cell proliferation, they conversely inhibit organotropic colonization and metastasis. As suggested by RNA-seq analyses, these effects might result from the ability of NXPH1/α-NRXN signalling to restrain the conversion of NB cells from an adrenergic state to a mesenchymal one. Our findings thus uncover a transcriptional module of the sympatho-adrenal program that opposes neuroblastoma malignancy by impeding metastasis, and pinpoint NXPH1/α-NRXN signaling as a promising target to treat HR-NBs.

HIF and MYC signaling in adrenal neoplasms of the neural crest: implications for pediatrics

Pediatric neural crest-derived adrenal neoplasms include neuroblastoma and pheochromocytoma. Both entities are associated with a high degree of clinical heterogeneity, varying from spontaneous regression to malignant disease with poor outcome. Increased expression and stabilization of HIF2α appears to contribute to a more aggressive and undifferentiated phenotype in both adrenal neoplasms, whereas MYCN amplification is a valuable prognostic marker in neuroblastoma. The present review focuses on HIF- and MYC signaling in both neoplasms and discusses the interaction of associated pathways during neural crest and adrenal development as well as potential consequences on tumorigenesis. Emerging single-cell methods together with epigenetic and transcriptomic analyses provide further insights into the importance of a tight regulation of HIF and MYC signaling pathways during adrenal development and tumorigenesis. In this context, increased attention to HIF-MYC/MAX interactions may also provide new therapeutic options for these pediatric adrenal neoplasms.

Metastasis pattern and prognosis in children with neuroblastoma

BACKGROUND

We aimed to investigate the different metastases and prognoses of neuroblastoma (NB) and determine the risk factors of metastasis.

METHOD

Data of 1224 patients with NB were obtained from the Surveillance, Epidemiology and End Results database (2010-2018). Pearson's chi-square test, Kaplan-Meier analysis, multivariable logistic regression and Cox regression analysis were used to determine the factors associated with prognosis.

RESULTS

The overall incidence of NB was an age-adjusted rate of 8.2 patients per 1,000,000 children. In total, 1224 patients were included in our study, with 599 patients (48.9%) exhibiting distant metastases. Compared to patients with non-metastatic NB, a greater proportion of patients with metastatic NB were under 1 year, male, had an adrenal primary site, unilateral tumour, a tumour size > 10 cm, neuroblastoma-not otherwise specified (NB-NOS), second malignant neoplasms and were more likely to choose radiotherapy and chemotherapy. Multivariate Cox regression showed that metastasis was an independent risk factor for overall survival (OS) and cancer-specific survival (CSS). The survival rate of non-metastatic patients with NB was better than those with metastasis (OS: hazard ratio (HR): 0.248, P < 0.001; CSS: HR: 0.267, P < 0.001). The bone and liver were the two most common isolated metastatic sites in NB. However, no statistical difference was observed in OS and CSS between the only bone metastasis group, only liver metastasis group and bone metastasis combined with liver metastasis group (all P > 0.05). Additionally, age at diagnosis > 1 year (odds ratio (OR): 3.295, P < 0 .001), grades III-IV (OR: 26.228, P < 0 .001) and 5-10 cm tumours (OR: 1.781, P < 0 .001) increased the risk of bone metastasis of NB. Moreover, no surgical treatment (OR: 2.441, P < 0 .001) increased the risk of liver metastasis of NB.

CONCLUSION

Metastatic NB has unique clinicopathological features, with the bone and liver as the most common single metastatic sites of NB. Therefore, more aggressive treatment is recommended for high-risk children with NB displaying distant metastases.

Ophthalmologic Manifestations of Neuroblastoma: A Systemic Review

Neuroblastoma (NBL) is the most common extracranial solid tumor found in pediatric patients. It develops from the sympathetic tract tissue. Although the symptoms are associated with tumor localization, sometimes NBL is manifested as ophthalmologic disorders. In this paper, we describe their incidence and the correlation with the prognosis. We searched 2 databases (PubMed and Web of Science) for papers published before April 2022, and concerned pediatric patients with NBL, which caused ophthalmologic changes. We collected 7 papers assessing the occurrence of ophthalmologic findings in the NBL patients, as well as 68 case reports presenting children with orbital changes and NBL, or with other tumors stemming from the sympathetic ganglia. The statistical analysis was performed to synthetize the data. The ophthalmologic signs occurred in 17.89% of the NBL cases; however, they were observed on presentation in 10.68%. The isolated ocular presentation was found in 2.56% of patients, whereas Horner syndrome was most frequent. The ophthalmologic symptoms correlated with patients' age, primary tumor site, and survival rate. NBL may be challenging to diagnose in cases with isolated ophthalmologic manifestations. Numerous possible ocular signs can be observed, which emphasize the need for multidisciplinary care with regard to the NBL patients.

Long-Term Survival of Neuroblastoma Patients Receiving Surgery, Chemotherapy, and Radiotherapy: A Propensity Score Matching Study

Neuroblastoma is the most common extracranial solid malignancy in children. This study was undertaken to determine the long-term survival of neuroblastoma patients receiving conventional therapeutics (surgery, chemotherapy, and radiotherapy). The neuroblastoma patients examined were registered in the Surveillance, Epidemiology and End Results (SEER) database (1975-2016). Using propensity score matching analysis, the patients were paired by record depending on whether they received surgery, chemotherapy, or radiotherapy. Univariate and multivariate analyses of the disease-specific survival of the paired patients were performed by the log-rank test and Cox regression assay. A total of 4568 neuroblastoma patients were included in this study. During 1975-2016, the proportion of histopathological grade III/IV cases receiving surgery gradually increased, while the number of patients with tumors of grade I to IV undergoing chemotherapy or radiotherapy was stable or even decreased. After propensity score analysis, for Grade I + II and Grade III tumors, surgery obviously improved the disease-specific survival of patients, while chemotherapy was unfavorable for patient prognosis, and radiotherapy exerted no obvious effect on the patients. However, no matter what treatment was chosen, the patients with advanced-histopathological-grade tumors had a poor prognosis. Meanwhile, for all histopathological grades, the patients receiving surgery and subsequent chemotherapy or radiotherapy suffered from worsen disease-specific survival than those simply undergoing surgery. Fortunately, the negative effects of surgery, chemotherapy, or radiotherapy improved gradually over time. Surgery improved the long-term survival of the neuroblastoma patients, while chemotherapy and radiotherapy exerted an unfavorable impact on patient outcome. These results provide an important reference for the clinical treatment of neuroblastoma.

A single-center study of thoracoscopic surgery in the treatment of pediatric mediastinal neurogenic tumors

OBJECTIVE

To study the feasibility, safety, and efficacy of thoracoscopic surgery in the treatment of pediatric mediastinal neurogenic tumors, and summarize the treatment experiences and surgical skills.

METHODS

A single-center retrospective analysis of 37 patients with pediatric mediastinal neurogenic tumors was conducted. Clinical charactersistics and postoperative complications were all analyzed.

RESULTS

All the operations were successfully completed. There was no statistically significant difference in tumor diameter between the two groups (p > 0.05). The open surgery group had an average operation time of 96.5 ± 32.38 min, while the thoracoscopic surgery group had an average operation time of 78.3 ± 24.51 min (p < 0.05). The thoracoscopic surgery group had significantly lower intraoperative blood loss than the open surgery group (p < 0.05). In addition, the duration of the postoperative thoracic drainage tube was 5.43 ± 0.76 days in the open surgery group, which was longer than the 2.38 ± 0.87 days in the thoracoscopic surgery group (p < 0.05). Furthermore, the postoperative length of hospital stay was an average of 10.23 ± 1.43 days for the open surgery group, longer than for the thoracoscopic surgery group (4.36 ± 0.87 days) (p < 0.05).

CONCLUSIONS

Thoracoscopic surgery has several advantages in the treatment of pediatric mediastinal neurogenic tumors and is worthy of clinical popularization and application. For giant mediastinal malignant neurogenic tumors, puncture biopsy and adjuvant chemotherapy can be performed before surgery to lessen the tumor volume and enlarge the operation space, which would reduce bleeding and complications.

Clinical and surgical outcome differences on the basis of pathology category in cervical neuroblastic tumors

BACKGROUND

Cervical neuroblastic tumors (NTs) are rare but less aggressive cancer with an above-average survival rate. Little has been published regarding the management and surgical outcomes of patients with cervical NTs based on pathology category. This study compared and identified the preoperative characteristics of cervical NTs in different pathology categories and evaluated the outcomes of patients undergoing surgical resection.

MATERIALS AND METHODS

Upon the institutional review board's approval, a retrospective chart review was performed at Beijing Children's Hospital from April 2013 to August 2020. Demographics of patients, imaging data, lab test results, operation details and outcomes were recorded and analyzed.

RESULTS

Of 32 cervical NTs, 24(80%) were classified as neuroblastoma (NB) /ganglioneuroblastoma-nodular (GNBn) and 8(20%) as ganglioneuroblastoma-intermixed (GNBi)/ ganglioneuroma (GN). Patients with GNBi/GN were older than those with NB/GNBn (44.5 months (IQR 16-81) vs 9 months (IQR 1-47); P = 0.001). GNBi/GN patients presented more frequently with stage 1 disease compared with NB/GNBn patients (100% vs. 29.2%, P = 0.001), less frequently with tumor-related symptoms (0% vs. 70.8%, P = 0.001), artery encased tumor (0% vs. 41.7%, P = 0.035), and surgical complications (25% vs. 70.8%, P = 0.038). GNBi/GN patients were also less likely to show elevated neuron specific enolase (NSE) (12.5% vs. 79.2%, P = 0.002).

CONCLUSIONS

Cervical NB/GNBn and GNBi/GN patients had distinct characteristic clinical presentations and surgical outcomes. For children with features suggestive of benign disease (older age, asymptomatic, normal serum tumor markers) and no artery image-defined risk factors (IDRFs), upfront resection can be considered.

Characteristics and karyotype analysis of a patient with turner syndrome complicated with multiple-site tumors: A case report

Turner syndrome (TS) is a congenital chromosomal abnormality that affects approximately 1 in 2,500 people. Both in China and abroad, few studies exist on the incidence of tumors in patients with TS. Most reported cases are complicated with gonadal germ cell tumors, and extragonadal tumors are rare, with the latter not yet being reported in China. Through chromosome karyotype analysis and surgical exploration, a pediatric patent was diagnosed with TS complicated with gonadoblastoma and adrenal neuroblastoma. The patient was short in stature and had a facial deformity. After admission, adrenal computed tomography was conducted, and a right adrenal mass was identified as a neurogenic tumor. After surgical resection and gonadal exploration, the pathological results revealed left gonadoblastoma, right gonadal stromal cell hyperplasia, and ganglion neuroblastoma (mixed type) in the right adrenal gland. Pediatric patients with TS have an increased likelihood of developing neuroblastoma and adrenal-related tumors, and changes in adrenal hormone levels and clinical manifestations are often not obvious when combined with adrenal-related tumors. To avoid missed diagnosis and delayed treatment, screening for adrenal tumors is therefore recommended for patients with TS before the initiation of growth hormone treatment.

Tumour Hidden behind Thoracic Spine Pain: A Rare Case of Neuroblastoma in a Young Mother-A Case Report

BACKGROUND

Neuroblastoma (NB) is the most common form of paediatric malignancy, responsible for up to 15% of cancer deaths in children, whereas in adults, its onset is a rarer event, despite being characterized by greater lethality. The purpose of this case report was to describe the clinical presentation, physical examination, and clinical decision-making process in a patient with Neuroblastoma mimicking thoracic spine pain of musculoskeletal origin.

METHODS

a thirty-two-year-old mother complained of thoracic spine pain on her left vertebral side and in her left periscapular muscles; her pain was constant, deep, and worse at night; she also experienced pain during physical exertion of her upper limbs; the patient also reported pain in her left breast.

RESULTS

the physiotherapist's anamnesis and physical examination led him to suspect the need for an extra-expertise pathology and to refer his patient to another medical specialist; the subsequent investigations revealed a poorly differentiated Neuroblastoma ALK + (IIC) in the posterior mediastinum on the left; the patient underwent surgery excision after 4 months.

CONCLUSIONS

differential screening should be a physiotherapist's fundamental skill in their patients' clinical management, especially in direct access cases; the physiotherapist has an ethical and moral duty to conduct differential screening, in order to rule out extra-expertise pathologies-both when patients self-refer for rehabilitation assessment, and when they are referred by other practitioners.

The Extracellular Matrix and Neuroblastoma Cell Communication-A Complex Interplay and Its Therapeutic Implications

Neuroblastoma (NB) is a pediatric neuroendocrine neoplasm. It arises from the sympatho-adrenal lineage of neural-crest-derived multipotent progenitor cells that fail to differentiate. NB is the most common extracranial tumor in children, and it manifests undisputed heterogeneity. Unsatisfactory outcomes of high-risk (HR) NB patients call for more research to further inter-relate treatment and molecular features of the disease. In this regard, it is well established that in the tumor microenvironment (TME), malignant cells are engaged in complex and dynamic interactions with the extracellular matrix (ECM) and stromal cells. The ECM can be a source of both pro- and anti-tumorigenic factors to regulate tumor cell fate, such as survival, proliferation, and resistance to therapy. Moreover, the ECM composition, organization, and resulting signaling networks are vastly remodeled during tumor progression and metastasis. This review mainly focuses on the molecular mechanisms and effects of interactions of selected ECM components with their receptors on neuroblastoma cells. Additionally, it describes roles of enzymes modifying and degrading ECM in NB. Finally, the article gives examples on how the knowledge is exploited for prognosis and to yield new treatment options for NB patients.

Changes in image-defined risk factors with neoadjuvant chemotherapy in pediatric abdominal neuroblastoma

PURPOSE

To observe the changes in image-defined risk factors (IDRFs) with neoadjuvant chemotherapy in pediatric abdominal neuroblastoma and to investigate the correlations between IDRF changes and histopathological features. In addition, this study also investigated the correlations between residual IDRFs after neoadjuvant chemotherapy and intraoperative complications.

METHODS

Forty-three patients with abdominal neuroblastoma who received neoadjuvant chemotherapy in our hospital from January 2015 to September 2021 were enrolled. Intraoperative records, histopathological features, and CT images at initial diagnosis and after neoadjuvant chemotherapy of all patients were retrospectively collected and analyzed.

RESULTS

A total of 245 IDRFs were found at initial diagnosis, with a median of 6 [5, 7] IDRFs per patient. After neoadjuvant chemotherapy, IDRFs significantly decreased to 156 (p < 0.001), with a median of 4 [3, 5] IDRFs remaining per patient. The majority of IDRFs (6/8, 75.00%) were significantly improved after neoadjuvant chemotherapy (p < 0.05), while tumor invasion of renal pedicles (p > 0.05) and adjacent structures (p > 0.05) was the least responsive IDRF. IDRFs in different types of neuroblastoma decreased significantly after neoadjuvant chemotherapy (p < 0.05), while they were not significant in neuroblastoma with low and intermediate mitosis-karyorrhexis indices (p > 0.05). The number of residual IDRFs correlated positively with the volumes of intraoperative blood loss (r = 0.399, p = 0.008), but not with the presence of intraoperative complications (r = 0.111, p = 0.478).

CONCLUSIONS

IDRFs in different types of neuroblastoma can be significantly improved after neoadjuvant chemotherapy, while IDRFs in neuroblastoma with low and intermediate mitosis-karyorrhexis indices might not be easily improved. At the same time, the number of residual IDRFs after neoadjuvant chemotherapy might not correlate with the occurrence of intraoperative complications in abdominal neuroblastoma.

Tumoral heterogeneity in neuroblastoma

Neuroblastoma is a solid, neuroendocrine tumor with divergent clinical behavior ranging from asymptomatic to fatal. The diverse clinical presentations of neuroblastoma are directly linked to the high intra- and inter-tumoral heterogeneity it presents. This heterogeneity is strongly associated with therapeutic resistance and continuous relapses, often leading to fatal outcomes. The development of successful risk assessment and tailored treatment strategies lies in evaluating the extent of heterogeneity via the accurate genetic and epigenetic profiling of distinct cell subpopulations present in the tumor. Recent studies have focused on understanding the molecular mechanisms that drive tumoral heterogeneity in pursuing better therapeutic and diagnostic approaches. This review describes the cellular, genetic, and epigenetic aspects of neuroblastoma heterogeneity. In addition, we summarize the recent findings on three crucial factors that can lead to heterogeneity in solid tumors: the inherent diversity of the progenitor cells, the presence of cancer stem cells, and the influence of the tumor microenvironment.

Phosphoserine phosphatase as an indicator for survival through potentially influencing the infiltration levels of immune cells in neuroblastoma

Introduction: Metabolic deregulation, a hallmark of cancer, fuels cancer cell growth and metastasis. Phosphoserine phosphatase (PSPH), an enzyme of the serine metabolism pathway, has been shown to affect patients’ prognosis in many cancers but its significance in neuroblastoma remains unknown. Here, we show that the functional role and potential mechanism of PSPH and it is correlated with survival of neuroblastoma patients.

Patients and Methods: The TARGET dataset (n = 151) and our hospital-based cases (n = 55) were used for assessing the expression level of PSPH associated with survival in neuroblastoma patients, respectively. Then, in vitro experiments were performed to define the role of PSPH in neuroblastoma. The ESTIMATE and TIMER algorithms were utilized to examine the correlation between PSPH expression level and abundance of immune cells. Further, Kaplan-Meier survival analysis was performed to evaluate the effect of both PSPH and immune cells on patients’ prognosis.

Results: High expression of PSPH was significantly associated with unfavorable overall survival (OS) and event-free survival (EFS) in both the TARGET dataset and our hospital-based cases, and was an independent predictor of OS (hazard ratio, 2.00; 95% confidence intervals, 1.21–3.30, p = 0.0067). In vitro experiments showed that high expression of PSPH significantly promoted cell growth and metastasis. Further, the ESTIMATE result suggested that high expression level of PSPH was negatively associated with low stromal and ESTIMATE score. Specifically, high PSPH expression was found to be negatively associated with CD8⁺ T cell, macrophages and neutrophils, which negatively affected survival of neuroblastoma patients (p < 0.0001, p = 0.0005, and p = 0.0004, respectively).

Conclusion: These findings suggested that PSPH expression could be a promising indicator for prognosis and immunotherapy in neuroblastoma patients by potentially influencing infiltration levels of immune cells.

Bilateral adrenal primary tumor in Stage 4S neuroblastoma: The Italian experience and review of the literature

Bilateral adrenal neuroblastoma (NB) is rare and is mainly stage 4S. Its incidence, presenting features, management, and outcome have not been fully defined yet. We searched the Italian NB Registry (RINB) for stage 4S NB infants with bilateral adrenal primary tumor to compare them with stage 4S NB with unilateral tumor. Between 1979 and 2016, the RINB enrolled 3731 NB patients aged 0-18 years including 317 infants (8.5%) diagnosed with stage 4S NB. Eleven/317 (3.5%) had a bilateral adrenal primary tumor (Group 1) and 190/317 (59.9%) had a unilateral tumor (Group 2). Group 1 infants were significantly younger (51 vs. 89 days) but were comparable with Group 2 for any other presenting features. In the absence of specific protocols, upfront treatment was based on symptoms, size of adrenal tumors, and biology, and consisted of observation in 5 cases, radiotherapy in one, chemotherapy in 2, and surgery in 3. Five/11 developed progression and 2 of them, both with MYCN amplification, died. The 5-year EFS rates of Group 1 and 2 were 54.5% vs. 73.3% (P=.14) and 5-year OSs were 81.8% and 89.4%, respectively (P=.44). Our data support the hypothesis that 4S NB infants with bilateral adrenal tumors can have favorable outcome with personalized therapeutic approach. The three patients with MYCN amplified tumor benefited from upfront aggressive chemotherapy, in accordance with current protocols. Because of the rarity of this intriguing form of neuroblastoma, collaborative prospective studies are warranted, especially in view of gaining a better insight on its biological and genetic features.

Linking neural crest development to neuroblastoma pathology

Although rare, childhood (paediatric) cancers are a major cause of death in young children. Unlike many adult cancers, paediatric cancers, such as neuroblastoma (NB), are developmental diseases that rarely show genetic predispositions. NB is the most common extracranial solid tumour in children, accounting for ∼15% of paediatric cancer deaths. This heterogeneous cancer arises from undifferentiated neural crest-derived progenitor cells. As neural crest cells are multipotent and migratory, they are often considered the embryonic paradigm of cancer stem cells. However, very little is known about the events that trigger tumour initiation and progression. Here, we discuss recent insights into sympathoadrenal lineage specification, as well as genetic factors associated with NB. With this in mind, we consider the molecular underpinnings of NB in the context of developmental trajectories of the neural crest lineage. This allows us to compare distinct subtypes of the disease and gene-function interactions during sensitive phases of neural crest development.

Tumor Resident, B-Cell Receptor Chemical Characteristics Associated with Better Overall Survival for Neuroblastoma

Pediatric neuroblastoma (NBL) is one of the most common pediatric cancers, and it can often be aggressive. Genetic and demographic factors can correlate with the severity of NBL, but the variations in the B-cell receptors (BCRs) or immunoglobulin proteins present in the NBL tumors, and their relationships to survival, are not well understood. BCRs contain variations in their complementary determining region-3 (CDR3s) amino acid sequences, due to variable recombinations of the V- and J-gene segments. Accordingly, these variations in CDR3s may represent different antigen interactions and thereby different survival probabilities. Thus, we mined the TARGET project, NBL tumor RNAseq files for BCR recombination reads. Evaluations of the physicochemical properties of IGK, IGL, and IGH CDR3s from these tumors pointed to properties of IGK and IGL in particular as associated with survival distinctions, based on several independent bioinformatics approaches, including a novel homology grouping approach facilitated by a recently developed web tool, adaptivematch.com. In conclusion, tumor resident BCR chemical features are likely useful for better risk stratification and for guiding therapy, and the availability of a user-friendly web tool will likely facilitate using BCR chemical features to meet those goals.

BET and CDK Inhibition Reveal Differences in the Proliferation Control of Sympathetic Ganglion Neuroblasts and Adrenal Chromaffin Cells

Neuroblastoma arising from the adrenal differ from ganglionic neuroblastoma both genetically and clinically, with adrenal tumors being associated with a more severe prognosis. The different tumor properties may be linked to specific tumor founder cells in adrenal and sympathetic ganglia. To address this question, we first set up cultures of mouse sympathetic neuroblasts and adrenal chromaffin cells. These cultures were then treated with various proliferation inhibitors to identify lineage-specific responses. We show that neuroblast and chromaffin cell proliferation was affected by WNT, ALK, IGF1, and PRC2/EZH2 signaling inhibitors to a similar extent. However, differential effects were observed in response to bromodomain and extraterminal (BET) protein inhibitors (JQ1, GSK1324726A) and to the CDK-7 inhibitor THZ1, with BET inhibitors preferentially affecting chromaffin cells, and THZ1 preferentially affecting neuroblasts. The differential dependence of chromaffin cells and neuroblasts on BET and CDK signaling may indicate different mechanisms during tumor initiation in sympathetic ganglia and adrenal.

Metastatic neuroblastoma presenting without a primary tumor: A case report

Neuroblastoma is the most common extracranial, intrabdominal, suprarenal solid tumor of childhood. It usually presents with painless abdominal mass with or without abdominal pain. We report an unusual subtle cervical lymph nodes enlargement associated with fever and joint pain. Neuroblastoma usually starts in the adrenal glands. What is unique in our case is that the presentation is without a primary tumor. We present a case of 4-year-old female Egyptian complaining of recurrent pattern of fever and generalized joint pain, with lower neck swelling for 1-month duration. Laboratory investigations revealed a normochromic normocytic anemia and increased inflammatory markers. Immunohistochemistry staining and immunophenotyping of the cervical lymph nodes and bone marrows confirmed the diagnosis of Neuroblastoma. This case report highlights the importance of recognizing the possibility of a metastatic neuroblastoma without primary tumor in children who presented solely of lymphadenopathy.

Cell Adhesion Molecules in Neuroblastoma: Complex Roles, Therapeutic Potential

Neuroblastoma, a biologically heterogeneous tumor derived from neural crest cells, accounts for approximately 15% of childhood deaths from cancer. Recently, scientific literature has explored the role of cell adhesion molecules (CAMs) in cancer metastasis through cell detachment, migration, and invasion. Through a review of the current literature, it is evident that expression of different CAMs on neuroblastoma tumors is associated with favorable or unfavorable clinical prognosis. In patients diagnosed with neuroblastoma, treatment strategies include chemotherapy, surgery, radiotherapy, stem cell transplant, and more recently, immunotherapy and other targeted therapies. Long term survival remains poor despite multimodality treatment, especially for children with high-risk neuroblastoma, making it more necessary to explore innovative targeted therapies. CAMs have immense potential as therapeutic targets, but there is a need for growth and scientific exploration before CAM therapies become clinically useful.

Prognostic impact of tumor size on patients with neuroblastoma in a SEER-based study

Objective

The prognostic value of tumor size in neuroblastoma (NB) patients has not been fully evaluated. Our purpose is to elucidate the prognostic significance of tumor size in surgery performed on neuroblastoma patients.

Methods

Neuroblastoma patients diagnosed from 2004 to 2015 were selected from the Surveillance, Epidemiology, and End Results Program (SEER) for the study. Univariate and multivariate Cox proportional hazard regression models were used to identify risk factors and the independent prognostic influences of tumor size on NB patients. Overall survival (OS) was analyzed through univariate Cox regression analysis. To determine the optimal cutoff value of tumor size, we first divided the cohort into three groups (≤5 cm, 5–10 cm, >10 cm). Subsequently, the patients were divided into two groups repeatedly, with tumor size at 1 cm intervals. The cutoff value that maximized prognostic outcome difference was selected. Furthermore, we performed the Kaplan–Meier methods to visually present differences in prognosis between the optimal tumor size cutoff value in different subgroups.

Results

A total of 591 NB patients who met the inclusion criteria were selected from the SEER database in this study. Cox analysis showed that age >1 year (HR = 2.42, p < 0.0001), originate from adrenal site (HR = 1.7, p = 0.014), distant stage (HR = 6.4, p < 0.0001), undifferentiated grade (HR = 1.94, p = 0.002), and large tumor size (HR = 1.5, p < 0.0001) independently predicted poor prognosis. For tumor size, there were significant differences in tumor size distribution in different ages, tumor grade, disease stage, and primary site subgroup but not in sex, race, and histology subgroup. Furthermore, both univariate (HR = 4.96, 95% CI 2.31–10.63, p < 0.0001) and multivariable analysis (HR = 2.8, 95% CI 1.29–6.08, p < 0.0001) indicated the optimal cutoff value of tumor size was 4 cm for overall survival of NB patients. Using a 4 cm of tumor size cutoff in subgroups, we found that it can identify poor prognosis patients whatever their age or primary site. Interestingly, tumor size of 4 cm cutoff can only identify unfavorable NB patients with diagnosis at distant‐stage disease, or differentiated grade tumor, but not with regional and local or undifferentiated tumor.

Conclusions

Tumor size is first to be recognized as a key prognostic factor of neuroblastoma patients and a cutoff value >4 cm might predict poor prognosis, which should be included in the evaluation of prognostic factors for NB.