Aggressive surgical therapy and radiotherapy for patients with high-risk neuroblastoma treated with rapid sequence tandem transplant

Roles of Surgery in the Treatment of Patients With High-Risk Neuroblastoma in the Children Oncology Group Study: A Systematic Review and Meta-Analysis

Purpose: Neuroblastoma is the most common extracranial solid tumor in children, and most patients are at high risk when they are initially diagnosed. The roles of surgery and induction chemotherapy in patients with high-risk neuroblastoma have been a subject of much controversy and debate. The objective of the current study was to assess the roles of surgery in high-risk neuroblastoma. Method: The review protocol was prospectively registered (PROSPEROID: CRD42021253961). The PubMed, Embase, Cochrane, and CNKI databases were searched from inception to January 2020 with no restrictions on language or publication date. Clinical studies comparing the outcomes of different surgical ranges for the treatment of high-risk neuroblastoma were analyzed. The Mantel-Haenszel method and a random effects model was utilized to calculate the hazard ratio (95% CI). Results: Fourteen studies that assessed 1,915 subjects met the full inclusion criteria. Compared with the gross tumor resection (GTR) group, complete tumor resection (CTR) did not significantly improve the 5-year EFS [p = 1.0; HR = 0.95 (95% CI, 0.87-1.05); I ² = 0%], and the 5-year OS [p = 0.76; HR = 1.08 (95% CI, 0.80-1.46); I ² = 0%] of patients. GTR or CTR resection had significantly better 5-year OS [p = 0.45; HR = 0.56 (95% CI, 0.43-0.72); I ² = 0%] and 5-year EFS [p = 0.15; HR = 0.80 (95% CI, 0.71-0.90); I ² = 31%] than subtotal tumor resection (STR) or biopsy only; however, both CTR or GTR showed a trend for more intra and post-operative complications compared with the STR or biopsy only [p = 0.37; OR = 1.54 (95% CI, 1.08-2.20); I ² = 0%]. The EFS of the patients who underwent GTR or CTR at the time of diagnosis and after induction chemotherapy were similar [p = 0.24; HR = 1.53 (95% CI, 0.84-2.77); I ² = 29%]. Conclusion: For patients with high-risk neuroblastoma, complete tumor resection and gross tumor resection of the primary tumor were related to improved survival, with very limited effects on reducing intraoperative and postoperative complications. It is necessary to design strong chemotherapy regimens to improve the survival rate of advanced patients. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, PROSPEROID [CRD42021253961].

Influence of Surgical Excision on the Survival of Patients With Stage 4 High-Risk Neuroblastoma: A Report From the HR-NBL1/SIOPEN Study

PURPOSE

To evaluate the impact of surgeon-assessed extent of primary tumor resection on local progression and survival in patients in the International Society of Pediatric Oncology Europe Neuroblastoma Group High-Risk Neuroblastoma 1 trial.

PATIENTS AND METHODS

Patients recruited between 2002 and 2015 with stage 4 disease > 1 year or stage 4/4S with MYCN amplification < 1 year who had completed induction without progression, achieved response criteria for high-dose therapy (HDT), and had no resection before induction were included. Data were collected on the extent of primary tumor excision, severe operative complications, and outcome.

RESULTS

A total of 1,531 patients were included (median observation time, 6.1 years). Surgeon-assessed extent of resection included complete macroscopic excision (CME) in 1,172 patients (77%) and incomplete macroscopic resection (IME) in 359 (23%). Surgical mortality was 7 (0.46%) of 1,531. Severe operative complications occurred in 142 patients (9.7%), and nephrectomy was performed in 124 (8.8%). Five-year event-free survival (EFS) ± SE (0.40 ± 0.01) and overall survival (OS; 0.45 ± 0.02) were significantly higher with CME compared with IME (5-year EFS, 0.33 ± 0.03; 5-year OS, 0.37 ± 0.03; P < .001 and P = .004). The cumulative incidence of local progression (CILP) was significantly lower after CME (0.17 ± 0.01) compared with IME (0.30 ± 0.02; P < .001). With immunotherapy, outcomes were still superior with CME versus IME (5-year EFS, 0.47 ± 0.02 v 0.39 ± 0.04; P = .038); CILP was 0.14 ± 0.01 after CME and 0.27 ± 0.03 after IME (P < .002). A hazard ratio of 1.3 for EFS associated with IME compared with CME was observed before and after the introduction of immunotherapy (P = .030 and P = .038).

CONCLUSION

In patients with stage 4 high-risk neuroblastoma who have responded to induction therapy, CME of the primary tumor is associated with improved survival and local control after HDT, local radiotherapy (21 Gy), and immunotherapy.

Long term outcomes after concurrent ipsilateral nephrectomy versus kidney-sparing surgery for high-risk, intraabdominal neuroblastoma

PURPOSE

The impact of the extent of surgical resection including nephrectomy for high-risk neuroblastoma patients is controversial. In this study, we compared the renal late effects and long-term survival for patients who underwent kidney-sparing surgery (KSS) versus concurrent ipsilateral nephrectomy (CIN) for high-risk, intraabdominal neuroblastoma (HRIN).

METHODS

A retrospective analysis of patients diagnosed with HRIN between Jan 1998 and Dec 2008 in a tertiary referral center was performed. Demographics, preoperative features, surgical resection extent and outcomes were analyzed.

RESULTS

Of 58 patients who underwent surgical management of HRIN, 6 underwent CIN and 52 underwent KSS. Renal image-defined risk factors (IDRFs) were more common in patients who underwent CIN. Operating time was longer and EBL higher in CIN patients. There was no difference in recurrence or overall survival between the groups. Estimated GFR (eGFR) was comparable between the groups preoperatively, but was reduced postoperatively and at long-term follow-up in patients who underwent CIN.

CONCLUSION

Compared to KSS, CIN is not associated with an increase in local recurrence or inferior survival but does lead to reduced kidney function (eGFR of 90 ml/min/1.73 m² for CIN versus 127 ml/min/1.73 m² for KSS, p = 0.03) but without significant impact on clinical outcome.

LEVELS OF EVIDENCE

III (Retrospective comparative study).

Impact of extent of resection on survival in high-risk neuroblastoma: A systematic review and meta-analysis

BACKGROUND

Despite the development of new treatment options, the prognosis of high-risk neuroblastoma patients is still poor. Many studies designed to elaborate the association between the extent of resection (EOR) and outcome have reported conflicting results. We performed a meta-analysis to assess whether greater EOR is associated with improved overall survival (OS) and event-free survival (EFS) in patients with high-risk neuroblastoma.

METHODS

Embase, PubMed, Cochrane library, and conference proceedings were searched between March 10 and October 1, 2017. Studies of pediatric patients with newly diagnosed high-risk neuroblastoma comparing various EOR and presenting objective overall or event-free survival data were included. Primary outcomes were relative risk (RR) for mortality at 3 and 5 years. Secondary outcomes were 3-year and 5-year EFS rates.

RESULTS

19 retrospective studies including a total of 2358 cases were identified. Compared with subtotal resection (STR), patients who underwent gross total resection (GTR) had significantly decreased mortality at 3 years (RR, 0.69; 95% CI, 0.58-0.82; P < 0.001; I² = 27%) and 5 years (RR, 0.70; 95% CI, 0.60-0.82; P < 0.001; I² = 38%). A similar decrease was revealed in the 3-year risk for mortality for STR compared with biopsy (RR, 0.71; 95% CI, 0.53-0.95; P = 0.02; I² = 0%). When comparing any resection with biopsy, resection group also showed a decreased risk for mortality at 3 years (RR, 0.66; 95% CI, 0.53-0.83; P < 0.001; I² = 8%) and 5 years (RR, 0.67; 95% CI, 0.50-0.91; P = 0.009; I² = 61%). With respect to the risk ratio for EFS, there were no significant differences in any comparisons.

CONCLUSION

This literature highlights the importance of "extent of resection" in treating high-risk neuroblastoma, and when feasible, the currently available evidences in favor of the use of GTR for high-risk neuroblastoma for reducing 3- and 5-year mortality.

LEVEL OF EVIDENCE

3A.

The Evidence for External Beam Radiotherapy in High-Risk Neuroblastoma of Childhood: A Systematic Review

AIMS

External beam radiotherapy is widely used in various ways in the management of neuroblastoma. Despite extensive clinical experience, the precise role of radiotherapy in neuroblastoma remains unclear. The purpose of this systematic review was to survey the published literature to identify, without bias, the evidence for the clinical effectiveness of external beam radiotherapy as part of the initial multimodality treatment of high-risk neuroblastoma. We considered four areas: treatment of the tumour bed and residual primary tumour, identification of any dose-response relationship, treatment of metastatic sites, identification of any technical advances that may be beneficial. We also aimed to define uncertainties, which may be clarified in future clinical trials.

MATERIALS AND METHODS

Bibliographic databases were searched for neuroblastoma and radiotherapy. Reviewers assessed 1283 papers for inclusion by title and abstract, with consensus achieved through discussion. Data extraction on 57 included papers was carried out by one reviewer and checked by another. Studies were assessed for their level of evidence and risk of bias, and a descriptive analysis of data was carried out.

RESULTS

Fifteen papers provided some evidence that radiotherapy to the tumour bed and residual tumour may possibly be of value. However, there is a significant risk of bias and no evidence that all subgroups will benefit. There is some suggestion from six papers that dose may be important, but no hard evidence. It remains unclear whether irradiation of metastatic sites is helpful. Technical advances may be of value in radiotherapy of high-risk neuroblastoma.

CONCLUSIONS

There are data that show that radiotherapy is of some efficacy in the management of high-risk neuroblastoma, but there is no level one evidence that shows that it is being used in the best possible way. Prospective randomised trials are necessary to provide more evidence to guide development of optimal radiotherapy treatment schedules.

Radical Surgery Improves Survival in Patients with Stage 4 Neuroblastoma

BACKGROUND

Neuroblastoma (NBL) is the most common extracranial solid tumor in children. Despite a good overall prognosis in NBL patients, the outcome of children with stage 4 disease, even with multimodal intensive therapy, remains poor. The role of extended surgical resection of the primary tumor is in numerous studies controversial. The aim of this study was to retrospectively analyze the impact of radical surgical resection on the overall- and event-free survival of stage 4 NBL patients.

METHODS

We retrospectively analyzed patient charts of 40 patients with stage 4 NBL treated in our institution between January 1990 and May 2012. All clinical and pathological findings of stage 4 NBL patients were included. Extent of surgery was assessed from the operation records and was classified as non-radical (tumor biopsy, partial 50-90% resection) or radical (near-complete >90% resection, complete resection). Overall- (OS) and event-free (EFS) survival was assessed using the Kaplan-Meier analysis and log-rank test. A multivariate Cox regression analysis was used to demonstrate independency.

RESULTS

In total, 29/40 patients were operated radically (>90% resection), whereas 11 patients received subtotal resection or biopsy only. OS and EFS were significantly increased in patients with radical operation compared with non-radical resection (p = 0.0003 for OS, p = 0.004 for EFS; log-rank test). A multivariate Cox regression analysis revealed radical operation as a significant and independent parameter for OS and EFS.

CONCLUSIONS

Our data indicate that radical (over 90% resection) surgery improves OS and EFS in stage 4 NBL patients.

Neuroblastoma

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

Results of a phase II trial for high-risk neuroblastoma treatment protocol JN-H-07: a report from the Japan Childhood Cancer Group Neuroblastoma Committee (JNBSG)

BACKGROUND

The Japanese Children's Cancer Group (JCCG) Neuroblastoma Committee (JNBSG) conducted a phase II clinical trial for high-risk neuroblastoma treatment. We report the result of the protocol treatment and associated genomic aberration studies.

METHODS

JN-H-07 was a single-arm, late phase II trial for high-risk neuroblastoma treatment with open enrollment from June 2007 to February 2009. Eligible patients underwent five courses of induction chemotherapy followed by high-dose chemotherapy with hematopoietic stem cell rescue. Surgery for the primary tumor was scheduled after three or four courses of induction chemotherapy. Radiotherapy was administered to the primary tumor site and to any bone metastases present at the end of induction chemotherapy.

RESULTS

The estimated 3-year progression-free and overall survival rates of the 50 patients enrolled were 36.5 ± 7.0 and 69.5 ± 6.6%, respectively. High-dose chemotherapy caused severe toxicity including three treatment-related deaths. In response to this, the high-dose chemotherapy regimen was modified during the trial by infusing melphalan before administering carboplatin and etoposide. The modified high-dose chemotherapy regimen was less toxic. Univariate analysis revealed that patients younger than 547 days and patients whose tumor showed a whole chromosomal gains / losses pattern had a significantly poor prognosis. Notably, the progression-free survival of cases with MYCN amplification were not inferior to those without MYCN amplification.

CONCLUSIONS

The outcome of patients treated with the JN-H-07 protocol showed improvement over the results reported by previous studies conducted in Japan. Molecular and genetic profiling may enable a more precise stratification of the high-risk cohort.

Retrospective analysis of relapsed abdominal high-risk neuroblastoma

BACKGROUND/PURPOSE

The impact of abdominal topography and surgical technique on resectability and local relapse pattern of relapsed abdominal high-risk neuroblastoma (R-HR-NB) is not clearly defined.

METHODS

A sample of thirty-nine patients with R-HR-NB enrolled in the German neuroblastoma trials between 2001 and 2010 was analyzed retrospectively using surgical and imaging reports. We evaluated resectability and local relapse pattern within 6 standardized abdominal regions, impact of extent of the first resective surgery on overall survival (OS), and of number of operations and a higher cumulative surgical assessment score (C-SAS) on OS after the first event.

RESULTS

In the left upper abdomen, rates for tumor persistence and relapse were 45.9% and 13.5% and in the left lower abdomen 27.7% and 8.3%, respectively. OS in months did not differ between complete and incomplete first resections (median (interquartile range): 35 (45.6) vs. 40 (65.4), P=.649). Better OS after the first event was associated with repeated as compared to single surgery (47.7 (64.7) vs. 4.3 (12.5), P=.000), and with higher as compared to lower C-SAS (47.7 (64.3) vs. 7.6 (14.7), P=.002).

CONCLUSIONS

OS after relapse/progression was not dependent on the extent of first resection. The number of operations was associated with better outcome after event.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

LEVEL III Retrospective comparative study.

Favorable Local Control From Consolidative Radiation Therapy in High-Risk Neuroblastoma Despite Gross Residual Disease, Positive Margins, or Nodal Involvement

PURPOSE

To report the influence of radiation therapy (RT) dose and surgical pathology variables on disease control and overall survival (OS) in patients treated for high-risk neuroblastoma at a single institution.

METHODS AND MATERIALS

We conducted a retrospective study of 67 high-risk neuroblastoma patients who received RT as part of definitive management from January 2003 until May 2014.

RESULTS

At a median follow-up of 4.5 years, 26 patients (38.8%) failed distantly; 4 of these patients also failed locally. One patient progressed locally without distant failure. Local control was 92.5%, and total disease control was 59.5%. No benefit was demonstrated for RT doses over 21.6 Gy with respect to local relapse-free survival (P=.55), disease-free survival (P=.22), or OS (P=.72). With respect to local relapse-free survival, disease-free survival, and OS, no disadvantage was seen for positive lymph nodes on surgical pathology, positive surgical margins, or gross residual disease. Of the patients with gross residual disease, 75% (6 of 8) went on to have no evidence of disease at time of last follow-up, and the 2 patients who failed did so distantly.

CONCLUSIONS

Patients with high-risk neuroblastoma in this series maintained excellent local control, with no benefit demonstrated for radiation doses over 21.6 Gy, and no disadvantage demonstrated for gross residual disease after surgery, positive surgical margins, or pathologic lymph node positivity. Though the limitations of a retrospective review for an uncommon disease must be kept in mind, with small numbers in some of the subgroups, it seems that dose escalation should be considered only in exceptional circumstances.

Impact of Extent of Resection on Local Control and Survival in Patients From the COG A3973 Study With High-Risk Neuroblastoma

Purpose This analysis of patients in the Children's Oncology Group A3973 study evaluated the impact of extent of primary tumor resection on local progression and survival and assessed concordance between clinical and central imaging review-based assessments of resection extent. Patients and Methods The analytic cohort (n = 220) included patients who had both central surgery review and resection of the primary tumor site. For this analysis, resection categories of < 90% and ≥ 90% were used, with data on resection extent derived from operating surgeons' assessments (all patients), as well as blinded central imaging review of computed tomography scans for a subset of 84 patients; assessment results were compared for concordance. Treatment outcomes included event-free survival (EFS), overall survival (OS), and cumulative incidence of local progression (CILP). Results Surgeon-assessed extent of resection was ≥ 90% in 154 (70%) patients and < 90% in 66 (30%). Five-year EFS, OS, and CILP (± SE) were 43.5% ± 3.7%, 54.9% ± 3.7%, and 11.9% ± 2.2%, respectively. EFS was higher with ≥ 90% resection (45.9% ± 4.3%) than with < 90% resection (37.9% ± 7.2%; P = .04). Lower CILP ( P = .01) was associated with ≥ 90% resection (8.5% ± 2.3%) compared with < 90% resection (19.8% ± 5.0%). On multivariable analysis, ≥ 90% resection was associated with longer EFS after adjustment for MYCN amplification or diploidy but had no significant effect on OS. Concordance between surgeons' assessments of resection extent and central image-guided review was low, with agreement of 63% (< 90% v ≥ 90%; simple κ = -0.0301). Conclusion Despite discordance between clinical assessment of resection extent and assessment via central imaging review, a surgeon-assessed resection extent ≥ 90% was associated with significantly better EFS and lower CILP. Improving OS, however, remains a challenge in this disease. These findings support continued attempts at ≥ 90% resection of the primary tumor in high-risk neuroblastoma.

N-Myc expression enhances the oncolytic effects of vesicular stomatitis virus in human neuroblastoma cells

N-myc oncogene amplification is associated but not present in all cases of high-risk neuroblastoma (NB). Since oncogene expression could often modulate sensitivity to oncolytic viruses, we wanted to examine if N-myc expression status would determine virotherapy efficacy to high-risk NB. We showed that induction of exogenous N-myc in a non-N-myc-amplified cell line background (TET-21N) increased susceptibility to oncolytic vesicular stomatitis virus (mutant VSVΔM51) and alleviated the type I IFN-induced antiviral state. Cells with basal N-myc, on the other hand, were less susceptible to virus-induced oncolysis and established a robust IFN-mediated antiviral state. The same effects were also observed in NB cell lines with and without N-myc amplification. Microarray analysis showed that N-myc overexpression in TET-21N cells downregulated IFN-stimulated genes (ISGs) with known antiviral functions. Furthermore, virus infection caused significant changes in global gene expression in TET-21N cells overexpressing N-myc. Such changes involved ISGs with various functions. Therefore, the present study showed that augmented susceptibility to VSVΔM51 by N-myc at least involves downregulation of ISGs with antiviral functions and alleviation of the IFN-stimulated antiviral state. Our studies suggest the potential utility of N-myc amplification/overexpression as a predictive biomarker of virotherapy response for high-risk NB using IFN-sensitive oncolytic viruses.

Is complete resection of high-risk stage IV neuroblastoma associated with better survival?

BACKGROUND

The role of surgery in the management of stage IV neuroblastoma is controversial. In this study, we attempted to study if complete tumor resection had any impact on event-free survival (EFS) and overall survival (OS).

METHODS

A retrospective analysis of patients with stage IV neuroblastoma between November 2000 and July 2014 in a tertiary referral center was performed. Demographics data, extent of surgical resection, and outcomes were analyzed.

RESULTS

A total of 34 patients with stage IV neuroblastoma according to International Neuroblastoma Staging System (INSS) were identified. The median age at diagnosis and operation was 3.5 (±1.9) years and 3.8 (±2.0) years, respectively. Complete gross tumor resection (CTR) was achieved in twenty-four patients (70.1%), in which one of the patients had nephrectomy and another had distal pancreatectomy. Gross total resection (GTR) with removal of >95% of tumor was performed in six patients (17.6%) and subtotal tumor resection (STR) with removal of >50%, but <95% of tumor was performed in four patients (11.8%). There was no statistical significance in terms of 5-year EFS and OS among the 3 groups. There was no surgery-related mortality or morbidity.

CONCLUSIONS

From our center's experience, as there was no substantial survival benefit in stage IV neuroblastoma patients undergoing complete tumor resection, organ preservation and minimalization of morbidity should also be taken into consideration.

Value of surgical resection in children with high-risk neuroblastoma

BACKGROUND

The value of gross total resection (GTR) for children with high-risk neuroblastoma (NB) is controversial. We hypothesized that patients undergoing GTR would demonstrate improved overall survival (OS) compared those having <GTR.

METHODS

Using a single institutional database, we reviewed the medical records of all children with high-risk NB undergoing hematopoietic stem cell transplantation (HSCT) as part of multimodality therapy from 1990 to 2012. Children had received surgical care at multiple institutions (n = 14) prior to HSCT and were divided into two groups based on extent of surgical resection: GTR (no visible or palpable disease at end of operation) and <GTR (no surgery, biopsy only, or subtotal resection). Kaplan-Meier curves and Cox hazards models evaluated differences in overall survival (OS).

RESULTS

One hundred four children underwent HSCT, and 87 (83.6%) had adequate data for analysis. Thirty eight percent had GTR while 62% had <GTR prior to HSCT. There was no significant difference in OS in patients undergoing GTR compared to <GTR (Log rank test: P = 0.49). Post-hoc analysis demonstrated a survival advantage for patients undergoing >90% resection compared to <90% resection (P = 0.008). Multivariable Cox models confirmed these findings with improved survival in children undergoing >90% vs. <90% resection but no difference in GTR vs. <GTR.

CONCLUSION

Gross total resection prior to HSCT in high-risk NB patients is not associated with improved OS compared to <GTR; however, these results suggest that >90% resection is associated with improved OS compared to less than 90% resection.

Does aggressive surgical resection improve survival in advanced stage 3 and 4 neuroblastoma? A systematic review and meta-analysis

The role of surgery in the management of advanced staged neuroblastoma (NBL) is controversial. A systematic review and meta-analysis is reported to address robust evidence for curative "gross total tumor resection" (GTR) in Stage 3 and Stage 4 neuroblastoma. Studies were identified using Medline, Embase, and Cochrane databases using pre-specified search terms. Primary outcomes were 5-year overall (OS) and disease-free survival (DFS) after GTR and subtotal resection (STR) in Stage 3 or 4 NBL. Data were analyzed using Review Manager. The Mantel-Haenszel method and a random effects model was utilized to calculate odds ratios (95% CI). Fifteen studies (five Stage 3 and 13 Stage 4) met full inclusion criteria. The pooled odds ratio for 5 year OS in Stage 3 following GTR compared to STR was 2.4 (95% CI 1.19-4.85). In Stage 4 disease, the pooled odds ratio for 5 year overall survival (OS) following GTR compared to STR was 1.65 (95% CI 0.96-1.91); a pooled odds ratio for 5 year DFS following GTR compared to STR was 1.55 (95% CI 1.12-2.14). A clear survival benefit is shown for GTR over STR in Stage 3 NBL only. Though some advantage can be demonstrated for GTR as defined by DFS in Stage 4 NBL GTR did not significantly improve OS in Stage 4 disease.

State of the art in oncology: high risk neuroblastoma, alveolar rhabdomyosarcoma, desmoplastic small round cell tumor, and POST-TEXT 3 and 4 hepatoblastoma

Despite advances in the treatment of pediatric cancers during the past few decades, high-risk neuroblastoma, alveolar rhabdomyosarcoma, desmoplastic small round cell tumor, and hepatoblastomas with 3 or 4 sector involvement after chemotherapy continue to present significant challenges. This review summarizes recent research on the management of these diseases, with a special focus on the use of surgical debulking, genetic analysis, immunotherapy, and chemotherapy in improving outcomes of patients with these solid tumors.

"Trap-door" and "clamshell" surgical approaches for the management of pediatric tumors of the cervicothoracic junction and mediastinum

BACKGROUND/PURPOSE

For pediatric tumors of the cervicothoracic junction, an isolated cervical or thoracic surgical approach provides insufficient exposure for achieving complete resection. We retrospectively examined "trap-door" and "clamshell" pediatric thoracotomies as a surgical approach to these tumors.

METHODS

We searched our database for pediatric patients with cervicothoracic tumors who underwent clamshell or trap-door thoracotomy between 1991 and 2013, reviewing tumor characteristics, surgical technique, completeness of resection, morbidity, and outcome.

RESULTS

Trap-door (n=13) and clamshell (n=4) thoracotomies were performed for neuroblastoma (n=9), non-rhabdomyosarcoma soft tissue sarcoma (n=4), germ cell tumor (n=2), rhabdomyosarcoma (n=1), and neuroendocrine small cell carcinoma (n=1). Fourteen of these cervicothoracic tumors were primary, and three were metastatic. Gross total resection was achieved in 15 patients (94%). Operative complications included vocal cord paralysis (n=2), mild upper-extremity neuropraxia (n=2), and hemidiaphragm paralysis (n=1), All but one involved encased nerves. Overall survival was 61% for the series and 80% for patients with primary tumors. Eleven (73%) of 15 patients who underwent gross total resection had no evidence of recurrence. Three patients with metastatic disease died of distant progression within 1.3years.

CONCLUSIONS

Gross total resection of primary cervicothoracic tumors can be accomplished with specialized exposure in pediatric patients with minimal morbidity.

Role of surgery in the treatment of patients with stage 4 neuroblastoma age 18 months or older at diagnosis

PURPOSE

Although intensive multimodal treatment has improved the prognosis of patients with metastatic neuroblastoma, the impact of primary tumor resection on outcome is a matter of medical debate.

PATIENTS AND METHODS

Patients from the German prospective clinical trial NB97 with stage 4 neuroblastoma and age 18 months or older at diagnosis were included. Operation notes and imaging reports were reviewed by two independent experienced physicians. Finally, the extent of tumor resections was correlated with local control rate and outcome.

RESULTS

A total of 278 patients were included in this study. Image-defined risk factors present at diagnosis were found to be predictive for the extent of tumor resection at first (P < .001) and best (P < .001) operation. No patient died from surgery. Before chemotherapy, complete resection, incomplete resection, and biopsy or no surgery were performed in 6.1%, 5.0%, and 88.5% of patients, respectively. The extent of first operation had no impact on event-free survival (EFS; P = .207), local progression-free survival (LPFS; P = .195), and overall survival (OS; P = .351). After induction chemotherapy, 54.7% of patients underwent complete resection of the primary tumor, 30.6% underwent incomplete resection, and 13.3% had only biopsy or no surgery of the primary tumor. The extent of best operation also had no impact on EFS (P = .877), LPFS (P = .299), and OS (P = .778). Moreover, multivariate analyses showed that surgery did not affect EFS, LPFS, and OS.

CONCLUSION

In intensively treated patients with stage 4 neuroblastoma age 18 months or older at diagnosis, surgery of the primary tumor site has no impact on local control rate and outcome.

Is complete surgical resection of stage 4 neuroblastoma a prerequisite for optimal survival or may >95 % tumour resection suffice?

Numerous studies have shown that for optimal survival in localized International Neuroblastoma Staging System stage 1-3 neuroblastoma, complete tumour resection (CR, macroscopic total tumour removal) is usually mandatory. In contrast, it is conceivable that in stage 4 disseminated disease, less extensive surgery [gross total resection (GTR), >95 % tumour removal] may suffice. This review shows substantial survival benefit in studies reporting on stage 4 patients undergoing CR, but also in studies reporting on patients undergoing GTR. Comparison between these studies is severely hampered by treatment heterogeneity. We found only four studies that explicitly compared survival between patients undergoing either CR or GTR. Two of these studies showed favourable results for patients treated with CR, while the other two did not show differences in survival.

Neuroblastoma: a 20-year experience in a UK regional centre

PURPOSE

The role of surgery in the management of neuroblastoma yields conflicting reports. We report a 20-year experience from a UK centre in the context of evolving cancer therapies for neuroblastoma.

METHODS

Hospital records of 91 neuroblastoma patients from 1985 to 2005 were studied. Patient demographics, data from operating notes and tumour biology (MYCN status) where available were analysed.

RESULTS

Surgery consisted of primary resection or delayed operation following tumour biopsy/chemotherapy. Overall survival was 100% for stage 1(n = 3), 90% for stage 2 (n = 10), 46% for stage 3 (n = 13), 13% for stage 4 (n = 55) and 56% for stage 4S disease (n = 9). During the eras 1985-1994 versus 1995-2005, survival for stage 3 lesions was 25% and 80% (P = 0.04) with marginal increase in survival observed in stage 4 disease (12% vs. 22%, P = 0.083). Delayed tumour resection was not performed in 20 (36%) stage 4 patients due to progressive disease. Complete tumour resection was achieved in 62% of stage 3-4 patients during 1995-2005 compared to 38% in 1985-1994. The extent of surgical resection (complete vs. partial) showed no significant differences in overall survival or relapse rates. Postoperative morbidity occurred in 15.7% of cases emphasising technical challenges in resection of neuroblastoma. No child with MYCN amplification survived versus 59% survival in non-amplified cases (P = 0.012).

CONCLUSIONS

While complete tumour resection may be desirable in advanced neuroblastoma (stage 3-4) these findings suggest that the radicality of operation is not significantly associated with better overall survival/relapse. Improving outcomes in the 1995-2005 era for patients with stage 3-4 tumours complements the introduction of new high dose-intensive chemotherapy regimens and other adjuvant therapies for this enigmatic disease.

Application of high-dose rate (60)Co remote after-loading system for local recurrent neuroblastoma

The local control of neuroblastoma is a very important treatment consideration. We describe a patient who received high-dose rate 60Co remote after loading system treatment for local control of recurrent neuroblastoma and discuss the efficacy of high-dose rate 60Co remote after loading system treatment.

Lung nodules in pediatric oncology patients: a prediction rule for when to biopsy

PURPOSE

The purpose of the study was to develop a prediction rule regarding the factors that most accurately predict the diagnosis of a malignancy in a lung nodule in the pediatric oncology patient.

METHODS

A retrospective review of pediatric oncology patients that underwent lung nodule resection between 1998 and 2007 was performed. Multivariable logistic regression was used to create a prediction rule.

RESULTS

Fifty pediatric oncology patients underwent 21 thoracotomies and 48 thoracoscopies to resect discrete lung nodules seen on computed tomographic scans during workup for metastasis or routine surveillance. The mean nodule size was 10.43 ± 7.08 mm. The most significant predictors of malignancy in a nodule were peripheral location (odds ratio [OR], 9.1); size between 5 and 10 mm (OR, 2.78); location within the right lower lobe (OR, 2.43); and patients with osteosarcoma (OR, 10.8), Ewing sarcoma (OR, 3.05), or hepatocellular carcinoma (OR, 2.38).

CONCLUSIONS

Lesions that are between 5 and 10 mm in size and peripherally located in patients with osteosarcoma, Ewing sarcoma, or hepatocellular carcinoma are most likely to be malignant. Use of a prediction rule can help guide clinical practice by determining which patients should undergo surgical resection of lung nodules and which patients may be closely observed with continued radiologic studies.

The role of surgery in the treatment of neuroblastoma

The role of surgery varies greatly according to the clinical condition of the patients with neuroblastoma. A surgical resection is the mainstay of treatment for a localized tumor. However, in the era of intense chemotherapy associated with hematopoietic stem cell plant rescue, surgical resections are recommended without sacrificing the kidney or major vessels. Tumor biology further defines the necessity of supportive chemotherapy or radiation after surgical resection. The presence of diverse terminology concerning the range of resection may impose some confusion in the understanding of the previous papers. Therefore, the definition of a surgical resection was initially stated. In high-risk patients, the advantages of surgery for a patient's survival seem to be limited. This article reviews the efficacy of surgical resections in different clinical situations for a better understanding of the meaning of surgery in the treatment of neuroblastoma. The results of surgical resections are summarized according to the International Neuroblastoma Staging System. Finally, the long-term results regarding the strategy-related survival of the patients in the Niigata tumor board are briefly introduced.

Recent advances in neuroblastoma

PURPOSE OF REVIEW

Although there have been recent advances with multimodal therapy, treatment of neuroblastoma remains a clinical challenge. Despite the identification of several genetic features, there has not been a significant increase in 5-year survival in the last decade. This review will highlight the current operative strategies along with new research developments aimed at improving survival.

RECENT FINDINGS

The goal of surgical intervention in the early stages of neuroblastoma is complete curative resection. In advanced-stage disease, tissue biopsy for staging is the initial goal. In recent years, minimally invasive surgery (MIS) is considered in carefully selected patients. Recent advances in neuroblastoma research have focused on tyrosine kinase inhibition, differentiation, pathway inhibition, and immunotherapy. Several of these targets have shown promising results in vivo and are currently under investigation for potential clinical trials.

SUMMARY

New information on the importance of cell signaling and the targeting of specific genes of interest are providing key insights into neuroblastoma. Only through the discovery of novel treatment strategies made available through the advancement of research will neuroblastoma be survivable for patients with advanced-stage disease.

Local control of the primary tumour in metastatic neuroblastoma

The previous studies have stressed on the importance of loco-regional control in the management of high-risk neuroblastoma. We searched the Surveillance, Epidemiology and End-Results (SEER) database for patients older than 2years with metastatic neuroblastoma who were diagnosed from 1998 to 2005. We identified 291 patients (mean age, 4.35years). The 5-year survival estimate was 53.2%+/-6.4% for patients who had complete resection of their primary tumours (n=116) and 35.7%+/-4.7% for patients who did not have complete resection (p=0.003). External-beam radiotherapy did not affect survival (p=0.79); this finding has to be taken with caution due to the study limitations.

Potent antitumor effects of ZD6474 on neuroblastoma via dual targeting of tumor cells and tumor endothelium

Among children with relapsed or refractory neuroblastoma, the prognosis is poor and novel therapeutic strategies are needed to improve long-term survival. As with other solid tumors, high vascular density within neuroblastoma is associated with advanced disease, and therapeutic regimens directed against the tumor vasculature may provide clinical benefit. The receptor tyrosine kinase RET is widely expressed in neuroblastoma and is known to activate key signal transduction pathways involved in tumor cell survival and progression including Ras/mitogen-activated protein kinase and phosphatidylinositol 3-kinase/Akt. We investigated the effect of dual targeting of tumor cells and tumor endothelium with ZD6474, a small-molecule tyrosine kinase inhibitor of vascular endothelial growth factor (VEGF) receptor 2, epidermal growth factor receptor, and RET. ZD6474 inhibited the phosphorylation of RET in neuroblastoma cells and had a direct effect on tumor cell viability in seven neuroblastoma cell lines. In a human neuroblastoma xenograft model, ZD6474 inhibited tumor growth by 85% compared with treatment with vehicle alone. In contrast, no significant inhibition of tumor growth was observed after treatment with bevacizumab, an antihuman VEGF monoclonal antibody, or the epidermal growth factor receptor inhibitor erlotinib, either alone or in combination. Immunohistochemical analysis showed that ZD6474 treatment led to an increase in endothelial cell apoptosis along with inhibition of VEGF receptor-2 activation on tumor endothelium. In conclusion, dual targeting of tumor cells, potentially through RET inhibition, and tumor vasculature with ZD6474 leads to potent antitumor effects. This approach merits further investigation for patients with neuroblastoma.

Intraoperative radiation therapy for advanced neuroblastoma: the problem of securing the IORT field

The purpose of this study is to evaluate the efficacy of intraoperative radiation therapy (IORT) and the problem of securing the IORT field in advanced pediatric neuroblastoma. Between 1996 and 2005, 12 children received IORT for advanced pediatric neuroblastoma patients. Electron beam energies ranged from 10 to 12 MeV and median dose was 10 Gy (8-12 Gy). All of them had surgery with IORT against the primary tumor site and the abdominal aorta surroundings. A gross total resection (GTR) was achieved in 10 patients and subtotal resection (STR) was two patients. All of 12 patients were classified as high risk. Nine patients were alive 17-120 (mean 48 months) after diagnosis. Local tumor control was achieved in 100% of patients, of whom one experienced local recurrence outside the IORT field. At the operation, it was difficult to secure the IORT field because of the angle of the radiation cylinder in three patients. One of the three of these patients experienced local recurrence outside of the IORT field in the upper side of superior mesenteric artery and two of three patients had an external beam radiation after surgery, and there was no local recurrence. One patient had a postoperative ileus, and one patient had transient diarrhea and hydronephrosis. For advanced neuroblastoma patients, IORT produced excellent local control after surgery. However, there is a problem of securing the IORT field. For local control, it is necessary to add an external beam radiation after IORT when it is difficult to secure the IORT field.

Neuroblastoma

Neuroblastomas continue to remain a clinical challenge, despite advances in multimodal therapy. Currently, studies are aimed at novel targets for neuroblastoma directed toward poor prognostic indicators such as the MYCN oncogene and marked angiogenesis. There have also been recent discoveries in neuroblastoma pathogenesis involving epigenetic regulation and retinoic acid therapy. Understanding the intricate complexities of this tumor may lead to innovative agents for more effective combinational therapy.

Recent advances on the molecular mechanisms involved in the drug resistance of cancer cells and novel targeting therapies

This review summarizes the recent knowledge obtained on the molecular mechanisms involved in the intrinsic and acquired resistance of cancer cells to current cancer therapies. We describe the cascades that are often altered in cancer cells during cancer progression that may contribute in a crucial manner to drug resistance and disease relapse. The emphasis is on the implication of ATP-binding cassette (ABC) multidrug efflux transporters in drug disposition and antiapoptotic factors, including epidermal growth factor receptor cascades and deregulated enzymes in ceramide metabolic pathways. The altered expression and activity of these signaling elements may have a critical role in the resistance of cancer cells to cytotoxic effects induced by diverse chemotherapeutic drugs and cancer recurrence. Of therapeutic interest, new strategies for reversing the multidrug resistance and developing more effective clinical treatments against the highly aggressive, metastatic, and recurrent cancers, based on the molecular targeting of the cancer progenitor cells and their further differentiated progeny, are also described.

Markedly improving survival of neuroblastoma: a 30-year analysis of 1,646 patients

We sought to define current incidence trends and outcomes for pediatric patients with neuroblastoma. The SEER registry was queried from 1973 to 2002. Overall, 1,646 patients with neuroblastoma were identified. The annual incidence has remained unchanged at 0.9 per 100,000. The median age of the population was 1 year, with 42% of patients presenting at <1 year of age. The majority of tumors arose in the retroperitoneum (75.6%) with the remainder located in the mediastinum (15.3%), cervical region (6.6%) and pelvis (2.2%). Markedly improved survival has been noted in each decade (P < 0.002). Sixteen percent of lesions were over 10 cm in greatest dimension, while 84% were high-grade. Disease-specific survival at 1, 2, 5 and 20 years for the entire cohort was 81, 70, 61 and 59%, respectively. Superior survival was observed for infants <1 year of age (P < 0.001). Neuroblastomas in the mediastinum and pelvis had a better prognosis (P < 0.05) while high-grade and lesions over 10 cm carried a worse prognosis (P < 0.022). Surgery but not radiotherapy was associated with improvement in survival (P < 0.001). Multivariate analysis identified age, tumor location, stage, decade of diagnosis and surgical treatment as independent prognostic factors. Neuroblastoma remains a common malignancy with markedly improving patient outcomes. Early diagnosis and surgical therapy continue to provide the best chance for cure. More effective therapies for patients presenting over 1 year of age or those with advanced disease are still needed.

High-risk neuroblastoma treated with tandem autologous peripheral-blood stem cell-supported transplantation: long-term survival update

PURPOSE

To provide an update on long-term survival of patients with high-risk neuroblastoma treated with tandem cycles of myeloablative therapy and peripheral-blood stem-cell rescue (PBSCR).

PATIENTS AND METHODS

Ninety-seven patients with high-risk neuroblastoma were treated between 1994 and 2002. Patients underwent induction therapy with five cycles of standard agents, resection of the primary tumor and local radiation, and two consecutive courses of myeloablative therapy (including total-body irradiation) with PBSCR.

RESULTS

Fifty-one patients have experienced relapse or died. Median follow-up time among the 46 patients who remain alive without progression is 5.6 years (range, 15.1 months to 9.9 years). Progression-free survival (PFS) rate at 5 years from diagnosis was 47% (95% CI, 36% to 56%), and PFS rate at 7 years was 45% (95% CI, 34% to 55%). Overall survival rate was 60% (95% CI, 48% to 69%) and 53% (95% CI, 40% to 64%) at 5 and 7 years, respectively. The 5- and 7- year PFS rates from time of first transplantation for 82 patients who completed both transplants were 54% (95% CI, 42% to 64%) and 52% (95% CI, 40% to 63%), respectively. Five patients died from treatment-related toxicity after tandem transplantation. Relapse occurred in 37 (42%) of 89 patients, mainly within 3 years of transplantation and primarily in diffuse osseous sites. No primary CNS relapse or secondary leukemia was seen. One patient developed synovial cell sarcoma 8 years after therapy.

CONCLUSION

High-dose therapy with tandem autologous stem-cell rescue is effective for treating high-risk neuroblastoma, with encouraging long-term survival. CNS relapse and secondary malignancies are rare after this therapy.