CLINICAL AND EPIDEMIOLOGICAL CHARACTERISTICS AND SURVIVAL OUTCOMES OF CHILDREN WITH NEUROBLASTOMA: 21 YEARS OF EXPERIENCE AT THE INSTITUTO DE ONCOLOGIA PEDIÁTRICA, IN SÃO PAULO, BRAZIL

Transcriptionally distinct malignant neuroblastoma populations show selective response to adavosertib treatment

Neuroblastoma is an aggressive childhood cancer that arises from the sympathetic nervous system. Despite advances in treatment, high-risk neuroblastoma remains difficult to manage due to its heterogeneous nature and frequent development of drug resistance. Drug repurposing guided by single-cell analysis presents a promising strategy for identifying new therapeutic options. Here, we aim to characterize high-risk neuroblastoma subpopulations and identify effective repurposed drugs for targeted treatment. We performed single-cell transcriptomic analysis of neuroblastoma samples, integrating bulk RNA-seq data deconvolution with clinical outcomes to define distinct malignant cell states. Using a systematic drug repurposing pipeline, we identified and validated potential therapeutic agents targeting specific high-risk neuroblastoma subpopulations. Single-cell analysis revealed 17 transcriptionally distinct neuroblastoma subpopulations. Survival analysis identified a highly aggressive subpopulation characterized by elevated UBE2C/PTTG1 expression and poor patient outcomes, distinct from a less aggressive subpopulation with favorable prognosis. Drug repurposing screening identified Adavosertib as particularly effective against the aggressive subpopulation, validated using SK-N-DZ cells as a representative model. Mechanistically, Adavosertib suppressed cell proliferation through AKT/mTOR pathway disruption, induced G2/M phase cell cycle arrest, and promoted apoptosis. Further analysis revealed UBE2C and PTTG1 as key molecular drivers of drug resistance, where their overexpression enhanced proliferation, Adavosertib resistance, and cell migration. This study establishes a single-cell-based drug repurposing strategy for high-risk neuroblastoma treatment. Our approach successfully identified Adavosertib as a promising repurposed therapeutic agent for targeting specific high-risk neuroblastoma subpopulations, providing a framework for developing more effective personalized treatment strategies.

Vasoactive Intestinal Peptide-Producing Neuroblastic Tumors: A Rare Cause of Refractory Diarrhea

Neuroblastic tumors are the most common malignant extracranial solid tumors of childhood. A small subgroup presents chronic incoercible diarrhea due to the tumor's production of vasoactive intestinal peptide (VIP). The hypothesis of an occult tumor is not always considered, which delays and impairs treatment. We aim to identify these patients' characteristics and help alert health professionals to the hypothesis of a neuroblastic tumor in children with chronic diarrhea refractory to the usual approach. We carried out an epidemiological study on all retrievable reports of neuroblastic tumors between 1975 and 2021 described in the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), and Latin American & Caribbean Health Sciences Literature (LILACS) databases. Patient information was divided into categories, and we performed a descriptive analysis. We analyzed 96 cases; 83 (86.5%) cases had diarrhea prior to the diagnosis of the neoplasm, 49 (51%) were ganglioneuroblastomas, 69 (71.8%) were abdominal, and 59 of the 60 patients (98%) with reported acid-base disorders had hypokalemia. When serum VIP was reported, the majority of values varied between one and 20 times the upper reference limit. Seventy-two (75%) patients underwent complete tumor resection, and the overall survival rate was 70%. Serum VIP production by neuroblastic tumors is related to cell differentiation and better prognosis. Such children often require intensive hospital support to reverse the malnutrition and acid-base disorders related to this paraneoplastic syndrome. Its early diagnosis and treatment significantly change the prognosis and quality of life. We, therefore, suggest screening for neuroblastic tumors when health professionals encounter unmanageable chronic secretory diarrhea in children with no defined etiology in the usual investigations.

The causal relationship between gut microbiota and neuroblastoma: a bidirectional Mendelian randomization analysis and meta-analysis

Neuroblastoma (NB) is a type of neuroectodermal tumor that originates from primitive sympathetic ganglion cells. Although many risk factors contributing to the occurrence of NB have been reported in recent years, the role of the gut microbiota in its development remains unclear. A bidirectional Mendelian randomization (MR) analysis was conducted to elucidate the causal relationship between the gut microbiota and NB. In the MR analysis, we employed the inverse-variance weighted (IVW) method as the primary criterion for assessing causality, while also utilizing three additional approaches, including MR-Egger, weighted median model, and weighted mode, for comprehensive evaluation. For gut microbiota that were causally associated with NB, a reverse MR was also used to assess the stability of this causal relationship. Finally, we also used external cohorts for validation and performed a meta-analysis of the results. The IVW results indicated a causal relationship between six gut microbiota and NB. Among the six gut microbiota, genus Lachnospiraceae [IVW odds ratio (OR): 2.66, 95% confidence interval (CI): 1.09-6.51, P value: 0.03] exhibited a detrimental effect against NB. On the other hand, the class Actinobacteria (IVW OR: 0.24, 95% CI: 0.07-0.77, P value: 0.02), the family Bifidobacteriaceae (IVW OR: 0.40, 95% CI: 0.17-0.96, P value: 0.04), the genus Desulfovibrio (IVW OR: 0.50, 95% CI: 0.25-0.97, P value: 0.04), the genus Bifidobacterium (IVW OR: 0.39, 95% CI: 0.16-0.92, P value: 0.03), and the genus Howardella (IVW OR: 0.55, 95% CI: 0.31-0.97, P value: 0.04) displayed a protective effect on NB. A reverse MR analysis did not reveal a causality between NB and the six gut microbiota. Meta-analysis showed that genus Bifidobacterium (meta OR: 0.41, 95% CI: 0.22-0.75, P < 0.01) and genus Lachnospiraceae (meta OR: 2.20, 95% CI: 1.01-4.79, P < 0.05) were still significant.

IMPORTANCE

Bidirectional Mendelian randomization was used to explore the causality between gut microbiota and neuroblastoma (NB). The results showed that there is a causal relationship between the six gut microbiota and NB, of which two gut microbiota were further confirmed in the meta-analysis. This may provide a new perspective on the prevention and treatment of NB.

Epidemiological and clinical characteristics of children with peripheral neuroblastic tumors: a study on a Moroccan population

PURPOSE

Peripheral neuroblastic tumors are the most common extracranial cancers found in children, and they are characterized by a diverse spectrum of clinical manifestations and heterogeneous behaviors. This study aimed to investigate the epidemiological and clinical characteristics of children with peripheral neuroblastic tumors admitted to the Department of Pediatric Hematology and Oncology of the Hospital August 20 in Casablanca.

METHODS

The medical files of 48 children with peripheral neuroblastic tumors addressed to our department between February 2018 and February 2023 were reviewed. The clinical and demographic characteristics of patients were analyzed by the Statistical Package for the Social Sciences (SPSS), survival curves were obtained by Kaplan-Meier technique, and we assigned the tumor stage to patients based on the International Neuroblastoma Risk Group Staging System (INRGSS).

RESULTS

The median age of diagnosis was 30 months (1-174), with a ratio F/M of 1.28. 93.75% of patients had neuroblastoma, and the rest had ganglioneuroma. About 64.6% of patients had at their initial presentations stage M of peripheral neuroblastic tumors. The adrenal region made up 71% of the primary tumor site. The bone was one of the most prevalent metastatic sites (54.2%). The five-year overall survival rate was 35.4%.

CONCLUSION

Overall, this study revealed a high stage of peripheral neuroblastic tumors in the majority of the diagnosed patients in our Department of Pediatric Hematology and Oncology. Moreover, the heterogeneity of peripheral neuroblastic tumors makes clinical recognition difficult and, in general, too late.

Aspectos Clínicos e Fatores Prognósticos do Neuroblastoma: Relato de Caso

Introdução: O neuroblastoma é um tumor extracraniano originado de falhas das células da crista neural. É a neoplasia maligna mais comum dos lactentes e apresenta perfil clínico bastante heterogêneo. O objetivo deste artigo é relatar o caso de um neuroblastoma em estádio avançado e sobrevida satisfatória, a despeito dos fatores prognósticos desfavoráveis. Relato do caso: Paciente feminina, 1 ano e 4 meses, iniciou quadro de irritabilidade, distensão abdominal e febre intermitente com três meses de evolução. Ao exame físico, apresentou alopecia sugestiva de tricotilomania, linfonodomegalia cervical, inguinal e axilar e distensão abdominal. A tomografia computadorizada de abdome evidenciou massa expansiva, medindo 6,8 x 5,8 x 4,0 cm, localizada no espaço pararrenal anterior esquerdo. À cintilografia óssea e ressonância nuclear magnética, foram visualizadas imagens sugestivas de implantes secundários a distância. Após exérese tumoral total, foi confirmado neuroblastoma pouco diferenciado, com gene MYCN não amplificado e histologia desfavorável. Biópsia da crista ilíaca bilateral revelou áreas compatíveis com infiltração medular. Por se tratar de neuroblastoma estádio IV, estabeleceu-se terapêutica multimodal, com quimioterapia adjuvante após cirurgia, seguida de transplante autólogo de medula óssea, radioterapia no sítio primário da lesão e nos locais de metástases ósseas e uso de ácido 13-cis-retinoico. Conclusão: Apesar de apresentar diversos indicadores de mau prognóstico (idade, metástases ósseas, estadiamento IV, infiltração medular), a paciente permanece em remissão completa da doença há 39 meses.

Neuroblastoma Among Omani Children: Clinical characteristics and survival outcome from a dedicated centre

Objectives

A limited number of publications from the Middle East have focused on neuroblastoma, a common childhood malignancy. This study describes the clinical characteristics and survival outcome of Omani children with neuroblastoma treated at the National Oncology Centre, Oman, between 2010 and 2017.

Methods

From January 2010 to December 2017, data on Omani children aged less than 13 years with neuroblastoma were retrospectively collected. Survival data were statistically correlated with known prognostic factors, including age, stage of disease, MYCN profile and presence of metastasis.

Results

A total of 56 Omani children were included. in this study. The male to female ratio was 1:1. The mean age at presentation was one year and 10 months. The two most common presenting complaints were body masses (48.2%) and constitutional symptoms (33.9%). Approximately, 54.5% were high risk, 35.7% were intermediate risk and 9.8% were low risk. High-risk neuroblastoma was mainly found in children older than one year (76.6%), with low risk mainly observed in children less than one year of age (80%). The overall survival of all groups combined was 74% (P <0.05); the event-free survival (EFS) was 67% (P <0.05). The overall survival rates over five years for the high-risk, intermediate-risk and low risk groups were 60%, 88% and 100%, respectively, and the EFS was 51%, 79% and 100%, respectively.

Conclusion

Omani children with neuroblastoma mainly presented with masses or constitutional symptoms and had an advanced disease at presentation which was associated with inferior survival. The survival outcomes were reasonably similar to published international data.

Clinico-histopathological Profile of Primary Paediatric Intra-abdominal Tumours: a Multi-hospital-Based Study

Paediatric cancers are gradually on the rise in India. Its proportion among children aged < 15 years constitutes close to 5% of the total cancer affected population. A high proportion of this constitutes intra-abdominal tumours. This study was done to study the demographic profile, clinical features and management of intra-abdominal tumours among children. Data of all histopathologically confirmed patients aged < 15 years with various primary intra-abdominal tumours diagnosed from 2009 to 2019 were included in this study. The median age of the patients (n = 50) was 3 years (IQR 1.4, 6). The median age at diagnosis of cancer (n = 23) was 2.5 years (IQR 1, 4). Tumours were more common among males (70%). The most common tumour in this study was Wilm's tumour (17 (34%)). Forty-eight (96%) patients had malignant tumours. Fever was present among the majority (27 (54%)) of the patients. The most common anti-cancer drug used for management was Vincristine, used among 23 patients. Remission was more among infants with Wilm's tumour (P = 0.0221) and among patients with Hodgkin's lymphoma (HL) (P = 0.0444). Default with treatment was more among patients with stage 4 malignancy (P = 0.0186). Recovery following treatment was more among patients with germ cell tumour (P = 0.0082). Reasons for default with treatment in the late stages of malignancies need to be identified in future research studies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-021-01365-x.

Flow cytometry as a diagnostic tool in neuroblastoma

In recent years, there has been an expansion in the use of flow cytometry (FC) immunophenotyping in the diagnosis and monitoring of childhood solid neoplasms. Neuroblastoma (NB), in turn, is the most common extracranial solid tumor in childhood. In the present study, we sought to compare FC and anatomopathological examination (PA) / immunohistochemistry (IHC) of children diagnosed or suspected with NB. The median age was 59 months (minimum 0; maximum 325 months), of these 12 were male (57.1%, 12/21). Forty-eight samples (27 bone marrow (BM), 10 peripheral blood (PB), 8 primary tumors (PT) and 2 liver nodules (HN) and 1 rib fragment (RF)) from 21 patients were evaluated. Twenty-nine samples were from patients with clinical suspicion while 19 samples were from patients with previously confirmed diagnosis. Thirteen samples (7 BM, 5 PT and 1 HN) presented NB when analyzed in FC while 8 (3 BM and 5 PT) samples were positive for NB in the PA/IHC. They were concordant in 88.9% of the cases. No NB cells were identified in any PB. Considering the PA as the gold standard, the FC obtained a sensitivity of 100%, a specificity of 86%, a positive predictive value of 67% and a negative predictive value of 100%. This study demonstrates that FC can be used as a methodology for diagnosis and assessment of NB involvement. In addition, FC has the advantage of allowing a quick diagnosis and accurate classification of the disease, and can also assist in monitoring the treatment.

The development and initial evaluation of referral flowchart for suspected neuroblastoma for pediatricians in nononcology clinics in China

BACKGROUND

The delayed diagnosis of neuroblastoma (NB) is common in China, which results in the prognosis of NB in China lagging behind that in developed countries.

METHODS

A referral flowchart for suspected NB was implemented in nononcology clinics at Beijing Children's Hospital (BCH). Patients with symptoms of suspected NB were referred from nononcology clinics in BCH to oncology clinics and confirmed NB cases were regarded as referral group. The control group comprised patients initially diagnosed with NB who came directly to oncology clinics in BCH from other regions nationwide. The age at NB diagnosis was compared as primary outcome, and the 5-year overall survival (OS) and event-free survival (EFS) were compared via the Kaplan-Meier method and log-rank tests.

RESULTS

In total, 3337 children with suspected NB were screened consecutively from 687 070 pediatric patients. Through examination of urine vanillylmandelic acid and homovanillic acid, or B-ultrasound, 102 of 3337 patients were referred to oncologists for comprehensive evaluations. Eventually, 29 referred patients were diagnosed as NB and the hospital-based diagnosis rate of NB was 4.2 per 100 000 visits. The median age at diagnosis in the referral group was 21.0 months, which was 9 months earlier than that of the control group (30.0 months, P = .026). The 5-year OS rate was 72.4% in the referral group, which was higher than that of the control group (66.7%) but without statistical significance (P = .664).

CONCLUSION

Delayed NB detection could be avoided by training pediatricians in nononcology clinics to detect suspected NB and refer these patients to oncologists.

Metastatic Spread of Neuroblastoma to the Left Atrium Mimicking Atrial Myxoma: A Rare Occurrence in an Adolescent

Neuroblastoma is the most common childhood malignancy arising from the sympathetic neuroblast cells. The most common sites of origin are the adrenal glands and paravertebral regions. However, the involvement of the heart is a rare occurrence in adolescents. Here, we report a case of a 12-year-old male child who was misdiagnosed as a case of cardiac myxoma on initial presentation. Following surgical resection and histological examination, neuroblastoma was revealed. This case report highlights the differential diagnosis for the cardiac mass in an adolescent with an unknown primary origin and also the importance of tissue histopathology for the diagnosis and management of neuroblastoma.

Diagnostic Errors in Wilms' Tumors: Learning From Our Mistakes

Aim: This study aimed to analyze clinical characteristics and image findings in patients initially diagnosed with renal masses and treated on the Société Internationale d'Oncologie Pédiatrique (SIOP) 2001 protocol for Wilms tumor (WT) that eventually were diagnosed with different pathologies. Methods: We reviewed the preoperative symptoms, laboratory tests, and images of patients who were initially treated for WT and proved to have other diagnoses. Data from these patients were compared to those of the last 10 patients with WT and the last 10 patients with neuroblastoma (NBL) treated at a single institution. Results: From June 2001 to December 2020, we treated 299 patients with NBL and 194 with WT. Five patients treated with preoperative chemotherapy for WT were postoperatively diagnosed with NBL (one patient had bilateral renal masses and one with multifocal xanthogranulomatous pyelonephritis). Three underwent nephrectomy, two biopsies only, and one adrenalectomy due to intraoperative characteristics. Regarding clinical presentation, abdominal mass or swelling was very suggestive of WT (p = 0.011); pain, although very prevalent in the study group (67%), was not statistically significant, as well as intratumoral calcifications on computed tomography (CT) (67%). Urinary catecholamines were elevated in all patients mistreated for WT with the exception of the patient with pyelonephritis in which it was not collected. Conclusion: Some pathologies can be misdiagnosed as WT, especially when they present unspecified symptoms and dubious images. Diagnostic accuracy was 98.1%, which highlights the quality of the multidisciplinary team. Abdominal mass or swelling is highly suggestive of WT, especially in the absence of intratumoral calcifications on CT. If possible, urinary catecholamines should be collected at presentation as they help in the differential diagnosis of NBL.

Childhood cancer in Latin America: from detection to palliative care and survivorship

BACKGROUND

Treatment options for childhood cancer have improved substantially, although in many low- and middle-income countries survival is lagging behind. Integral childhood cancer care involves the whole spectrum from detection and diagnosis to palliative and survivorship care.

METHODS

Based on a literature review and expert opinions, we summarized current practice and recommendations on the following aspects of childhood cancer in Latin America: diagnostic processes and time to diagnosis, stage at diagnosis, treatments and complications, survivorship programs and palliative care and end-of-life services.

RESULTS

Latin America is a huge and heterogeneous continent. Identified barriers show similar problems between countries, both logistically (time and distance to centers, treatment interruptions) and financially (cost of care, cost of absence from work). Governmental actions in several countries improved the survival of children with cancer, but difficulties persist in timely diagnosis and providing adequate treatment to all childhood cancer patients in institutions with complete infrastructure. Treatment abandonment is still common, although the situation is improving. Cancer care in the region has mostly focused on acute treatment of the disease and has not adequately considered palliative and end-of-life care and monitoring of survivors.

CONCLUSIONS

Decentralizing diagnostic activities and centralizing specialized treatment will remain necessary; measures to facilitate logistics and costs of transportation of the child and caretakers should be implemented. Twinning actions with specialized centers in high income countries for help in diagnosis, treatment and education of professionals and family members have been shown to work. Palliative and end-of-life care as well as childhood cancer survivorship plans are needed.

Management of neuroblastoma in limited-resource settings

BACKGROUND

Neuroblastoma (NB) is a heterogeneous disease with variable outcomes among countries. Little is known about NB in low- and middle-income countries (LMICs).

AIM

The aim of this review was to evaluate regional management protocols and challenges in treating NB in paediatric oncology units in LMICs compared to high-income countries (HICs).

METHODS

PubMed, Global Health, Embase, SciELO, African Index Medicus and Google Scholar were searched for publications with keywords pertaining to NB, LMICs and outcomes. Only English language manuscripts and abstracts were included. A descriptive review was done, and tables illustrating the findings were constructed.

RESULTS

Limited information beyond single-institution experiences regarding NB outcomes in LMICs was available. The disease characteristics varied among countries for the following variables: sex, age at presentation, MYCN amplification, stage and outcome. LMICs were found to be burdened with a higher percentage of stage 4 and high-risk NB compared to HICs. Implementation of evidence-based treatment protocols was still a barrier to care. Many socioeconomic variables also influenced the diagnosis, management and follow-up of patients with NB.

CONCLUSION

Patients presented at a later age with more advanced disease in LMICs. Management was limited by the lack of resources and genetic studies for improved NB classification. Further research is needed to develop modified diagnostic and treatment protocols for LMICs in the face of limited resources.