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Advances in the Diagnosis and Treatment

of Neuroblastoma
JOANNA L. WEINSTEIN,a,b HOWARD M. KATZENSTEIN,c,d,e SUSAN L. COHNa,b
a
Department of Pediatrics and bRobert H. Lurie Comprehensive Cancer Center, Northwestern University,
The Feinberg School of Medicine, Chicago, Illinois, USA; cAFLAC Cancer Center, dChildren’s Healthcare
of Atlanta, and eEmory University, Atlanta, Georgia, USA

Key Words. Neuroblastoma · Tumor biology · Retinoids · Immunotherapy · Risk-based therapy

L EARNING O BJECTIVES
After completing this course, the reader will be able to:
1. Appreciate the heterogeneity of neuroblastoma and identify clinical and biological prognostic factors.
2. Explain the determinants and the clinical significance of the neuroblastoma risk stratification system.
3. Select appropriate treatment regimens for neuroblastoma patients that are tailored according to risk stratification.

CME Access and take the CME test online and receive one hour of AMA PRA category 1 credit at CME.TheOncologist.com

A BSTRACT
Neuroblastoma, a childhood neoplasm arising from contributed to the understanding of tumor predisposi-
neural crest cells, is characterized by a diversity of clin- tion, metastasis, treatment responsiveness, and progno-
ical behavior ranging from spontaneous remission to sis. The Children’s Oncology Group recently developed
rapid tumor progression and death. To a large extent, a Neuroblastoma Risk Stratification System that is cur-
outcome can be predicted by the stage of disease and the rently in use for treatment stratification purposes,
age at diagnosis. However, the molecular events respon- based on clinical and biologic factors that are strongly
sible for the variability in response to treatment and the predictive of outcome. This review discusses the current
rate of tumor growth remain largely unknown. Over the risk-based treatment approaches for children with neu-
past decade, transformation-linked genetic changes roblastoma and recent advances in biologic therapy.
have been identified in neuroblastoma tumors that have The Oncologist 2003;8:278-292

INTRODUCTION disease [6] can be cured with surgery alone [7, 8]. In addi-
Neuroblastoma (NB), the most common extracranial tion, most infants with disseminated disease have favorable
solid tumor of childhood, is remarkable for its broad spec- outcomes following treatment with chemotherapy and
trum of clinical behavior [1, 2]. Some NB tumors undergo surgery [9, 10]. In contrast, the majority of children older
spontaneous regression or differentiate into benign gan- than 1 year of age with advanced-stage NB die from pro-
glioneuromas [3-5]. Most children with stages 1 and 2 gressive disease despite intensive multimodality therapy

Correspondence: Susan L. Cohn, M.D., Children’s Memorial Hospital, Division of Hematology/Oncology, Box #30, 2300
Children’s Plaza, Chicago, Illinois 60614, USA. Telephone: 773-880-4562; Fax: 773-880-3053; e-mail: [email protected]
Received December 3, 2002; accepted for publication February 24, 2003. ©AlphaMed Press 1083-7159/2003/$12.00/0

The Oncologist 2003;8:278-292 www.TheOncologist.com

Weinstein, Katzenstein, Cohn 279

[11]. This clinical diversity correlates closely with numer- of disease. Patients with localized disease are often asympto-
ous clinical and biological factors, including tumor stage, matic, while children with metastatic disease typically appear
patient age, tumor histology, and genetic abnormalities [12- ill at presentation with systemic symptoms, including fever
15]. However, the molecular basis underlying the variability and bone pain secondary to tumor dissemination. Metastatic
in tumor growth, clinical behavior, and responsiveness to disease to the orbit may manifest as orbital ecchymoses and
therapy remains largely unknown. is commonly mistaken for child abuse. Patients with
Because outcome is significantly better for patients paraspinal tumors may present with signs of spinal cord com-
with localized disease and younger age, many investigators pression, while Horner’s syndrome is sometimes observed in
speculated that screening infants for NB would lead to individuals with cervical or apical thoracic masses (Fig. 1).
reduced mortality. Pioneering studies performed in Japan in Several paraneoplastic syndromes may also be seen at pre-
the 1980s demonstrated that NB could be detected by sentation, including opsoclonus, myoclonus, and ataxia.
screening for urinary catecholamines at 6 months of age Rarely, tumor secretion of vasoactive intestinal peptide can
and suggested that preclinical detection led to improved result in profuse diarrhea.
survival [16-18]. However, population-based approaches
for screening were not used in these studies and no concur- DIAGNOSTIC STUDIES AND TESTS
rent control groups were evaluated. Subsequent trials The International Neuroblastoma Staging System (INSS),
demonstrated that the incidence of diagnosis of NB was which was initially developed in 1986 and subsequently
increased in Japan and that virtually all tumors detected by revised in 1993 [12], has been implemented worldwide (Table
screening had favorable biologic features [19, 20]. These 1). According to INSS criteria, the diagnosis of NB can be
observations suggest that many of the tumors detected by made by either characteristic histolopathologic evaluation of
screening were likely to undergo spontaneous regression tumor tissue or by the presence of tumor cells in a bone
and would never have been diagnosed clinically. To marrow aspirate/biopsy and elevated levels of urinary cate-
directly answer the question of whether routine screening cholamines. Specific requirements for staging include bilat-
for NB would result in lower mortality, two prospective eral bone marrow aspirations and biopsies, computed
population-based, controlled trials were recently conducted tomography of the body (excluding the head if clinically
in Germany and North America [21, 22]. The studies not indicated), bone scan, and metaiodobenzylguanadine
demonstrated that screening infants for NB at 3 weeks, (mIBG) scintography (Fig. 2) [12].
6 months, or 1 year did not reduce mortality due to this dis-
ease. Furthermore, similar to the previous reports from PROGNOSTIC FACTORS
Japan, almost all tumors detected by screening had favor-
able biologic features. Thus, there appears to be no role for Stage and Age
screening infants for NB. Table 2 lists a number of clinical and biological prog-
There are approximately 600 new cases of NB in the nostic factors for patients with NB. As with most malignan-
U.S. each year, with a prevalence of approximately one case cies, stage of disease is the most important prognostic factor
per 7,000 births [23]. This tumor is derived from neural crest in NB [13], and several retrospective analyses have con-
cells, and it most commonly arises in the adrenal medulla or firmed the clinical relevance of the INSS staging system [28,
paraspinal sympathetic ganglia. The etiology of NB remains 29]. Age at diagnosis remains the only other independent
obscure. To date, no environmental influences or parental
exposures that significantly impact on disease occurrences
have been identified [24]. NB usually occurs sporadically;
however, in 1%-2% of cases there is a family history [25,
26]. Interestingly, considerable biological and clinical het-
erogeneity is also observed in the familial cases [27]. While
the occurrence of familial NB suggests the presence of a
unifying underlying genetic abnormality, studies to date
have failed to identify a specific tumor suppressor gene
responsible for NB tumorigenesis [15, 27].

CLINICAL PRESENTATION
Presenting signs and symptoms of children with NB Figure 1. Computed tomography scan of an apical paraspinal NB
reflect both the location of the primary tumor and the extent in a child who presented with Horner’s Syndrome.
280 Diagnosis and Treatment of Neuroblastoma

Table 1. International neuroblastoma staging system

Stage Definition
1 Localized tumor with complete gross excision, with or without microscopic residual disease; representative ipsilateral lymph nodes
negative for tumor microscopically (nodes attached to and removed with the primary tumor may be positive).
2A Localized tumor with incomplete gross excision; representative ipsilateral nonadherent lymph nodes negative for tumor microscopically.
2B Localized tumor with or without complete gross excision, with ipsilateral nonadherent lymph nodes positive for tumor. Enlarged
contralateral lymph nodes must be negative microscopically.
3 Unresectable unilateral tumor infiltrating across the midline,* with or without regional lymph node involvement; or localized
unilateral tumor with contralateral regional lymph node involvement; or midline tumor with bilateral extension by infiltration
(unresectable) or by lymph node involvement.
4 Any primary tumor with dissemination to distant lymph nodes, bone, bone marrow, liver, skin, and/or other organs (except as defined
by stage 4S).
4S Localized primary tumor (as defined for stage 1, 2A, or 2B) with dissemination limited to skin, liver, and/or bone marrow+. Limited
to infants <1 year of age.

* The midline is defined as the vertebral column. Tumors originating on one side and crossing the midline must infiltrate to or beyond the
opposite side of the vertebral column.
+
Marrow involvement in stage 4S should be minimal, i.e., <10% of total nucleated red blood cells identified as malignant on bone marrow biopsy
or on marrow aspirate. More extensive marrow involvement would be considered to be stage 4. The mIBG scan (if performed) should be
negative in the marrow.
Reprinted with permission [12].

clinical prognostic factor. For all stages of disease beyond disease have a better outcome than children over 2 years
localized tumors, infants less than 1 year of age have signif- of age [32].
icantly better disease-free survival rates than older children
with equivalent stages of disease [30, 31]. Additional stud- Histology
ies suggest that 1- to 2-year-old children with disseminated In 1984, Shimada and colleagues devised a classifica-
tion schema that relates the histopathologic features of the
tumor to clinical behavior [33]. Tumors are classified as
favorable or unfavorable depending upon the degree of neu-
roblast differentiation, Schwannian stroma content, mitosis-
karyorrhexis index, and age at diagnosis. The International
Neuroblastoma Pathology Classification system, a modifi-
cation of the Shimada system, was established in 1999, and
the prognostic significance of this system has been con-
firmed [14]. Although it remains unknown why unfavorable
histology tumors are more clinically aggressive, amplifica-
tion of the MYCN oncogene is strongly associated with
unfavorable histology [34, 35].

MYCN Oncogene
MYCN amplification occurs in approximately 20% of
primary NB tumors and is strongly associated with the pres-
ence of metastatic disease and poor prognosis [36, 37]. These
observations suggest that MYCN critically contributes to the
clinically aggressive behavior of high-risk NB tumors, and
laboratory studies support this hypothesis [38, 39]. The level
of expression of MYCN has been shown to directly correlate
with the growth potential of NB cells in vitro as well as in

Figure 2. 131I-mIBG scan of a patient with stage 4 NB showing an

adrenal primary tumor and bone lesions in the femur and spine.
Weinstein, Katzenstein, Cohn 281

Table 2. Prognostic factors in neuroblastoma

Prognostic factor Favorable Unfavorable Reference
Clinical factors
Stage 1, 2, 4S 3, 4
Age <365 days >365 days [30, 31]
Tumor markers
Ferritin Low High [165, 166]
LDH Low High [167]
NSE Low High [168]
Histology Favorable Unfavorable [33]
Biologic Factors
MYCN oncogene Normal Copy Amplified [36, 37]
DNA index >1.0 (hyperdiploid) 1.0 (diploid) [48, 32]
Chromosome 1p Normal Deletion [54, 57]
Chromosome 17q Normal Gain [52]
TrkA expression High Low [65, 15, 66]
TrkC expression High Low [67, 68]
TrkB expression High/FL [69]
CD44 expression High Low [169-171]
MRP expression Low High [172]
Vascularity Low High [148, 149, 173, 174]

Abbreviations: LDH = lactate dehydrogenase; NSE = neuron-specific enolase; FL = full-length transcript; MRP = multidrug-related protein.

vivo [38-41]. A role for MYCN in NB pathogenesis is further Chromosome Abnormalities

supported by studies demonstrating NB tumor development Both gains and losses of genetic material are com-
in transgenic mice with targeted expression of MYCN [42]. monly detected in NB cell lines and primary tumors. The
Although MYCN amplification clearly identifies a sub- most common genetic abnormality in primary NB is gain
set of NBs with highly malignant behavior, the clinical sig- of 17q genetic material. This abnormality is strongly asso-
nificance of greater MYCN expression in children with NB ciated with high-risk features and adverse outcome [15,
remains controversial [43-46]. The reason for the discordant 52]. Consistent areas of chromosomal loss of heterozygos-
results may, in part, be due to disparities in patient popula- ity (LOH) include chromosome band 1p36, 11q23, and
tions, as the proportions of infants <1 year of age, patients 14q23-qter [15]. A strong correlation exists between the
with advanced-stage disease, and children with MYCN- allelic loss of 1p and high-risk NB features, including older
amplified tumors differ in the various series. Recently, high age, metastatic disease, MYCN amplification, and unfa-
levels of MYCN expression were found not to be predictive vorable outcome [53-55]. Two large independent studies
of a worse outcome in a retrospective analysis of patients have shown that, while deletion of 1p was associated with
with advanced-stage disease and normal MYCN copy num- unfavorable outcome in a univariate analysis, this factor
ber [47]. Thus, the precise role, if any, that MYCN plays in was not prognostic after adjusting for MYCN copy number
nonamplified tumors remains unknown. [55, 56]. In contrast, Caron and colleagues reported that
loss of 1p was predictive of unfavorable outcome, inde-
Tumor Cell Ploidy pendent of MYCN amplification [54]. Recently, a large
A number of studies have shown that cellular DNA Children’s Cancer Group (CCG) study showed that 1p
content is predictive of outcome in patients with NB, par- deletion independently predicted for lower event-free sur-
ticularly in infants less than 1 year of age [32, 48-50]. vival but not overall survival [57].
Hyperdiploidy, mostly in near-triploid constitution, is In contrast to 1p LOH, 11q LOH and 14q LOH are
mainly observed in low-stage tumors of infants and is asso- inversely correlated with MYCN amplification [58-60]. A
ciated with excellent long-term survival. On the other univariate analysis revealed no survival disadvantage for
hand, diploidy in this age group is often associated with patients whose tumors had 11q genetic loss. However, within
early treatment failure [35, 48, 51]. While a correlation the cohort of patients with normal MYCN copy number
exists between diploidy and MYCN amplification, each tumors, 11q LOH was associated with a significantly lower
factor has been validated as an independent prognostic overall survival probability. The clinical relevance of 14q
variable [32, 35, 50]. LOH is not clear.
282 Diagnosis and Treatment of Neuroblastoma

Neurotrophins and Neurotrophin Receptors have shown that treatment with surgery alone resulted in sur-
The Trk family of tyrosine kinases are critical mediators vival (S) rates of >95% for patients with stage 1 disease (Fig.
of neurotrophin signaling and play an essential role in normal 3) [7, 8]. The management of the infrequent patient with stage
neuronal development [61]. Differential expression of these 1 or 2 disease with MYCN amplification remains controver-
neurotrophin receptors is highly associated with the variable sial [8, 74, 75]. Although patients with MYCN-amplified
biologic and clinical characteristics of NB [62]. trkA expres- stage 1 tumors have significantly worse event-free survival
sion is inversely related to disease stage and MYCN amplifi- (EFS) and S rates, a subset may achieve long-term remission
cation status [63], and accordingly, high trkA expression is following surgery alone [7, 74]. These rare cases require con-
associated with favorable prognosis [64-66]. Similar to trkA, tinued prospective evaluation to clarify optimal management.
trkC is also highly expressed in biologically favorable NBs A high rate of spontaneous regression is seen in infants
[62, 67, 68]. Conversely, trkB is expressed primarily in with stage 4S NB, and high survival rates have been
advanced-stage tumors that are MYCN amplified [69], reported in 4S infants whose tumors lack MYCN amplifi-
whereas it is expressed at low levels or in a truncated form in cation [76, 77]. Interestingly, Tonini and colleagues
biologically favorable tumors [62, 67, 68]. reported that, in the Italian experience, favorable outcome
was also seen in infants with MYCN-amplified stage 4S
RISK GROUP STRATIFICATION SYSTEM NB [78]. Newborns with small adrenal masses constitute a
The Children’s Oncology Group (COG) Neuro- particularly favorable cohort of patients [79-81]. Recently,
blastoma Risk Stratification System is based on the Yamamoto and colleagues defined criteria for observing
International Risk Grouping System [70], and it is used for NB tumors detected by screening, and to date, all tumors
treatment stratification purposes. Patients are assigned into have decreased in size or resolved spontaneously [82].
low-, intermediate-, and high-risk categories (and accord- Others have reported spontaneous regression of adrenal
ingly, phase III treatment protocols) based upon an analysis NBs detected antenatally by ultrasound [83]. These obser-
of age at diagnosis, INSS stage, histopathology, MYCN vations suggest that newborns with small or cystic localized
amplification status, and DNA index (Table 3). NBs can be safely observed with a low risk of progression
to advanced-stage disease. To prospectively test this
RISK-BASED TREATMENT hypothesis, the COG recently developed a clinical trial in
which infants with small adrenal primary NBs will be
Low-Risk Disease observed rather than undergo major surgery.
Low-risk NB patients require minimal therapy [71-73]. Excellent outcome is also seen in patients with stages 2A
Previous Pediatric Oncology Group (POG) and CCG studies and 2B disease. Four-year EFS and S rates of 81% ± 4% and

Table 3. Children’s Oncology Group: neuroblastoma risk-group schema

INSS Stage Age MYCN status Shimada histology DNA index Risk group
1 0-21 years Any Any Any Low
2A/B <365 days Any Any Any Low
365 days-21 years Normal Any - Low
365 days-21 years Amplified Favorable - Low
365 days-21 years Amplified Unfavorable - High
3 <365 days Normal Any Any Intermediate
<365 days Amplified Any Any High
365 days-21 years Normal Favorable - Intermediate
365 days-21 years Normal Unfavorable - High
365 days-21 years Amplified Any - High
4 <365 days Normal Any Any Intermediate
<365 days Amplified Any Any High
365 days-21 years Any Any - High
4S <365 days Normal Favorable >1 Low
<365 days Normal Any =1 Intermediate
<365 days Normal Unfavorable Any Intermediate
<365 days Amplified Any Any High

Reprinted with permission from the COG.

Weinstein, Katzenstein, Cohn 283

Figure 3. Kaplan-Meier S and EFS

curves and life tables for patients with 100 241
144 62 S (n = 328)
INSS stage 1 NB. Reprinted with
permission [7]. 221 132 57 EFS (n = 328)
80
98% ± 1.5%, respectively, were

Rate (%)
reported in previous CCG studies 60
following treatment with surgery
alone [8]. In POG studies, local- 40
ized disease that was not com-
pletely resected (analogous to 20
INSS stage 2A) was treated post-
operatively with chemotherapy. 0
The estimated 3-year S rate for 0 1 2 3 4 5 6 7 8 9
patients with hyperdiploid tumors Years followed
that lacked MYCN amplification
was 96% [9]. Similarly, excellent Interval EFS rate n n S rate n n
(SE) Failures at risk (SE) Failures at risk
outcomes for patients with local-
ized NBs (defined as INSS stages 0-1 year 93.1 (1.5) 22 328 99.1 (0.6) 3 328
1-2 years 91.0 (1.8) 6 281 98.3 (0.8) 2 300
1, 2, and 3) were seen in the French 2-3 years 90.5 (2.2) 1 221 97.0 (1.3) 3 241
3-4 years 90.5 (2.4) 0 165 96.4 (1.5) 1 179
NBL 90 Study [75]. These findings 4-5 years 90.5 (2.9) 0 132 95.7 (2.0) 1 144
support the reduction-in-therapy 5-6 years 90.5 (3.7) 0 90 95.7 (2.5) 0 99
6-7 years 90.5 (6.1) 0 57 95.7 (4.1) 0 62
approach that is being tested in the 7-8 years 90.5 (19.7) 0 21 95.7 (14.0) 0 23
8-9 years 0 2 0 2
current COG low-risk study. The
overall objective of the COG low-
risk study is to preserve the excellent survival rate for Excellent S rates have been reported in patients older
patients with low-risk NB by using surgery as the primary than 1 year with favorable biology regional tumors fol-
treatment approach, thereby minimizing the risks of acute lowing treatment with surgery and chemotherapy [84, 85].
and long-term chemotherapy-related morbidity for the However, the use of adjuvant therapy for patients with
majority of these patients. regional disease has been challenged in a single-institu-
tion study in which 88% of patients with INSS stages 2B
Intermediate-Risk Disease and 3 tumors that lacked MYCN amplification survived
In previous POG studies, treatment for infants with without disease progression following surgery alone [86].
regional and metastatic disease was stratified by MYCN These observations suggest that, for the majority of
amplification and tumor cell ploidy. Infants with hyper- patients with biologically favorable regional tumors,
diploid tumors were treated with cyclophosphamide and dox- chemotherapy may be safely reduced or eliminated. In an
orubicin, whereas infants with diploid tumors received effort to avoid associated acute and long-term complica-
cisplatin and teniposide after an initial course of cyclophos- tions while maintaining high cure rates, adjuvant
phamide plus doxorubicin [9]. The most recent analysis of chemotherapy and radiotherapy have been reduced in the
patients enrolled in that study demonstrates estimated 11- current COG Intermediate-Risk Study. Intermediate-risk
year S rates of 94% ± 5% and 52% ± 16% for patients with patients with favorable biology tumors are treated with a
hyperdiploid and diploid tumors, respectively (personal com- short course of chemotherapy (four cycles), while inter-
munication; Wendy London, Ph.D., COG Data Statistical mediate-risk patients with unfavorable biology receive a
Center, University of Florida, Gainsville, FL). An S rate of longer course of chemotherapy (eight cycles).
71% ± 7% was reported in a prospective CCG trial in which
infants with regional and metastatic disease were treated with High-Risk Disease
a four-drug chemotherapy regimen, surgery, and local radia- Survival for high-risk children has improved modestly
tion to residual disease [10]. Infants with tumors that lacked during the past 20 years, although cure rates remain low
MYCN amplification had a 93% ± 4% 3-year EFS rate, [11, 87-89]. This improvement is thought to be due to
whereas those with amplified MYCN had a 10% ± 7% 3-year intensification of induction chemotherapy, megatherapy
EFS rate (p < 0.0001). These results emphasize the clinical consolidation, and improved supportive care [90]. Dose-
significance of NB tumor biology. intensity has been shown to correlate strongly with both
284 Diagnosis and Treatment of Neuroblastoma

response and progression-free survival, and response rates

1
from 70%-80% have been seen with intensive multiagent
induction regimens [11, 91]. Furthermore, several single-

Probability of event-free survival

0.8
armed studies have suggested that intensification of
consolidation therapy with autologous stem cell trans- 0.6
plantation following myeloablative doses of chemother-
apy with or without total body irradiation also contributes 0.4
Bone marrow
to improved overall survival [88, 89, 92, 93]. A report transplantation

0.2
from the European Group for Blood and Marrow Continuation chemotherapy

Transplant of 1,070 myeloablative procedures followed

0
by stem cell rescue performed during the past 17 years 0 1 2 3 4 5 6 7 8
Years after first randomization
found a 2-year posttransplant survival rate of 49% and a
5-year survival rate of 33% [94]. Recently, the superiority
of myeloablative therapy and autologous bone marrow Figure 4. Kaplan-Meier EFS curves from the time of first random-
transplant over conventional dose chemotherapy was ization into the CCG 3891 study for high-risk NB patients treated
definitively demonstrated in a randomized study con- with myeloablative therapy plus autologous stem cell rescue versus
continuous chemotherapy. Reprinted with permission [11].
ducted by the CCG [11]. In that study, the 3-year EFS rate
was significantly better for patients randomized to the
1
transplant arm than for patients randomized to continuous
chemotherapy (34% ± 4% versus 22% ± 4%, respectively,
Probability of event-free survival

0.8
p = 0.034) (Fig. 4).
In an effort to further dose intensify consolidation ther- 0.6
apy, some investigators have treated patients with tandem
13-cis-retinoic acid
cycles of high-dose therapy in conjunction with stem cell 0.4

rescue. Grupp and colleagues conducted a single-arm trial No 13-cis-retinoic acid

0.2
of peripheral blood stem cell (PBSC)-supported tandem
transplantation for high-risk NB patients, demonstrating
0
that tandem transplant was feasible in this patient cohort 0 1 2 3 4 5 6 7 8
Years after second randomization
and that toxicity was acceptable [95]. The estimated 3-year
EFS rate from the date of diagnosis was promising at 58%
(90% confidence interval, 40%-72%). Another pilot study Figure 5. Kaplan-Meier EFS curves from the time of second ran-
conducted at Children’s Memorial Hospital in Chicago uti- domization into the CCG 3891 study for high-risk NB patients
lized triple-tandem cycles of high-dose therapy with PBSC treated with 13-cis-retinoic acid following consolidation therapy
rescue [96]. With a median of 32 months follow-up, the versus no further therapy. Reprinted with permission [11].
estimated 3-year EFS rate from the time of diagnosis in that
study was 57% ± 11%. TREATMENT OF SPINAL CORD COMPRESSION
Unfortunately, despite intensive multimodality treat- Approximately 7%-15% of NB patients present with
ment, more than 50% of children with high-risk disease paraspinal tumors that extend through vertebral foramina
will relapse due to drug-resistant residual disease [11, 97]. either with or without associated spinal cord compression
Eradication of refractory microscopic disease remains one [98-101]. Prompt resolution of spinal cord compression
of the most significant challenges in the treatment of high- may prevent the development of permanent neurologic
risk NB. In an effort to treat chemotherapy-resistant tumor impairment in these children. Current therapeutic strate-
cells, the differentiation agent 13-cis-retinoic acid (RA) gies to relieve spinal cord compression include surgical
has been administered to high-risk patients following resection either with or without laminectomy, chemother-
completion of consolidation therapy. A recently com- apy, and radiation therapy [99, 102-105]. The optimal
pleted CCG study demonstrated that administration of this treatment approach for cord decompression, however,
differentiation agent in the setting of minimal residual dis- remains unknown. In a retrospective review of the POG
ease was clinically effective and resulted in a greater 3- experience, similar rates of neurologic recovery were
year EFS rate (Fig. 5) [11]. Preliminary data suggest that observed in symptomatic patients following treatment with
other biologic agents may also be clinically effective in chemotherapy or laminectomy, although more orthopedic
the setting of minimal residual disease (see below). sequelae were observed in the children treated with
Weinstein, Katzenstein, Cohn 285

laminectomy [106]. Plantaz and colleagues similarly in a subsequent randomized phase III study, 13-cis-RA
reported that chemotherapy effectively relieved neurologic was shown to improve the 3-year EFS rate when it was
symptoms from cord compression due to NB [107]. Taken administered to patients with minimal residual disease fol-
together, these results support a primary medical approach lowing completion of consolidation therapy (Fig. 4) [11].
for the initial treatment of children with intraspinal NB Thus, 13-cis-RA appears to be most effective in the setting
tumors, with laminectomy reserved for those that fail of minimal residual disease.
chemotherapy. The synthetic retinoid fenretinide (4-HPR) has also
been shown to inhibit NB growth in vitro, and it is highly
TREATMENT OF OPSOCLONUS/MYOCLONUS SYNDROME active against RA-resistant NB cell lines [117]. In contrast
The opsoclonus/myoclonus syndrome (OMS) that to 13-cis-RA and ATRA, 4-HPR induces apoptosis and
occurs coincident with NB is believed to be immune medi- necrosis [122]. Furthermore, a recent report indicates that
ated. Although approximately 60% of patients respond to 4-HPR may also inhibit NB-induced angiogenesis [123].
adrenocorticotropic hormone or corticosteroid therapy, Phase I and II trials are being conducted to determine the
most patients have recurrences of their neurologic symp- clinical activity of this compound against NB.
toms and develop developmental delays or mental retarda-
tion [108, 109]. Several retrospective studies suggest that Immunotherapy
the administration of chemotherapy may improve the long- Another promising approach for the treatment of
term neurologic outcome of this group of patients [110, multidrug-resistant microscopic disease is targeted
111]. There have also been several case reports indicating immunotherapy, which exploits tumor selectivity and has
good responses to treatment with i.v. gammaglobulin [112]. minimal cross-resistance and overlapping toxicities with
Recently, the COG designed a prospective study to deter- chemotherapy. Disialoganglioside (GD2) is a particularly
mine if the addition of i.v. gammaglobulin to chemotherapy suitable target for immunotherapy because this antigen is
and steroids would improve the neurologic outcome for expressed at a high density in the majority of human NB
patients with NB tumors and coincident OMS. tumors [124]. Several anti-GD2 monoclonal antibodies
have been developed and tested in clinical trials [125].
NEW THERAPEUTIC AGENTS Initial studies were performed with murine monoclonal
antibodies (3F8 and 14G.2a), and more recently, a human-
Cytotoxic Agents murine chimeric antibody (ch14.18) was developed and
Responses to topotecan, a topoisomerase I inhibitor, tested [126]. Therapeutic responses have been observed in
have been observed in patients with refractory or recurrent phase I and phase II studies with both the murine and
NB [113]. Combination therapy with topotecan plus chimeric antibodies [127-130]. In small series of patients,
cyclophosphamide or carboplatin has also been shown to responses have been reported with radiolabelled 131I-3F8
have activity against recurrent NB [114, 115]. These antibody (8-28 mCi/kg) followed by autologous bone
promising results led to the development of a COG pilot marrow rescue [126, 131].
study designed to test the clinical efficacy of incorporating In an effort to enhance response rates, cytokines have
topotecan into an intensive induction regimen in newly been combined with anti-GD2 antibodies to increase anti-
diagnosed high-risk NB patients. The clinical efficacy of body-dependent cellular cytotoxicity (ADCC). GM-CSF
another topoisomerase I inhibitor, irinotecan, is currently has been shown to increase leukocyte number and enhance
being tested in COG phase I trials. their anti-GD2 mediated ADCC [132], and therapeutic
responses have been observed in trials using ch14.18 anti-
Retinoids GD2 antibody plus GM-CSF in patients with recurrent/
Retinoids are natural and synthetic derivatives of vita- refractory NB [125]. Interleukin-2 (IL-2) has also been
min A. Treatment with all-trans-RA (ATRA) and 13-cis- shown to augment lymphocyte-mediated ADCC [133].
RA induces NB differentiation in vitro, downregulates Enhancement of natural killer cell activity by IL-2 was
MYCN mRNA expression, and leads to a sustained arrest observed in some patients treated with the combination of
of tumor cell proliferation [116-119]. These laboratory anti-GD2 and IL-2 [134, 135]. The COG is currently con-
observations prompted the development of clinical trials ducting a randomized phase III trial that has been designed
designed to test the clinical utility of 13-cis-RA in children to determine if the addition of ch14.18 anti-GD2 antibody
with relapsed NB. In phase I and II trials, the overall activ- and cytokines to 13-cis-RA in the setting of minimal resid-
ity of 13-cis-RA in patients with high tumor burdens was ual disease will improve the outcome of high-risk NB
disappointing [120, 121]. However, as mentioned above, patients.
286 Diagnosis and Treatment of Neuroblastoma

Other targeted immunotherapy studies are being con- long-term issues. Musculoskeletal abnormalities, including
ducted with cytokine-modified NB cells, cytotoxic T lym- scoliosis, osteoporosis, and bony and soft tissue hypoplasia,
phocytes, modified dendritic cells, and recombinant IL-2 may occur as a result of surgery and/or radiotherapy. The
[136-139]. IL-2 has been infused following myeloablative chemotherapeutic regimens used in the treatment of NB
therapy and stem cell rescue in several small series [140- include many agents with known long-term toxicities.
142]. To target delivery of cytokine therapy and achieve Cardiopulmonary sequelae can result from anthracyclines
more effective concentrations of IL-2 in the tumor microen- or thoracic radiotherapy [157-159]. Ototoxicity is a well-
vironment, a ch14.18-IL-2 fusion protein has recently been established toxicity of cisplatin. Renal-tubule-damaging
generated [143]. Preclinical studies have demonstrated that chemotherapy, including ifosfamide and cisplatin, may lead
this fusion protein induces a cellular immune response that to chronic electrolyte abnormalities, and these symptoms
results in inhibited tumor growth. A COG phase I study may be further exacerbated by abdominal radiotherapy and
testing the ch14.18-IL-2 fusion protein in relapsed NB nephrectomy [159, 160]. Alkylating agents and radiation
patients is ongoing. clearly impair gonadal function, and thereby, negatively
impact sexual maturation and fertility [159, 161]. Other
Radioiodinated mIBG endocrine consequences of intensive multimodality anti-
Radiolabelled mIBG has been used to target delivery of cancer therapy include growth hormone deficiency, prema-
radiotherapy, and responses have been observed [144, 145]. ture menopause, thyroid and pituitary dysfunction, and
Promising results have also been reported with combination obesity [159, 161, 162]. Late effects of chemotherapy and
radiolabelled mIBG and myeloablative chemotherapy fol- radiation also include second malignant neoplasms.
lowed by autologous stem cell rescue [146]. Additional Treatment-related myelodysplasia and leukemia have been
clinical trials are ongoing in North America and Europe that seen in NB patients following dose-intensive therapy [96,
will hopefully determine the optimal dose, schedule, and 163]. Solid tumors are also observed in NB patients, and
timing of mIBG therapy. one study indicated that NB was the most common first
neoplasm among 23 patients with radiation-induced thyroid
Antiangiogenic Therapy cancer [164]. Some childhood cancer survivors also suffer
Angiogenesis plays an important role in the growth and chronically from the psychological effects of cancer, its
metastasis of malignant tumors [147]. In NB, high-level treatment, and treatment-related cosmetic, functional, or
expression of angiogenesis activators and high tumor vas- other consequences [161]. As the outcomes of high-risk NB
cularity have been shown to correlate with advanced-staged patients improve, it becomes increasingly important to
disease, whereas low vascular tumor density correlates with develop new therapeutic strategies that will lead to higher
localized disease and favorable outcome [148, 149]. rates of survival as well as enhanced quality of life.
Furthermore, preclinical studies have demonstrated that
antiangiogenic agents effectively inhibit NB growth in vivo CONCLUSION
and that the optimal response may be in the setting of min- Although substantial progress has been made in the
imal residual disease [150-154]. These observations sug- treatment of children with low- and intermediate-risk NB,
gest that angiogenesis inhibitors may be effective in the cure rates for high-risk patients remain low. Research
treatment of patients with highly vascular NB tumors. aimed at discovering new genes and pathways critical to
Phase I studies testing a number of angiogenesis inhibitors NB tumorigenesis and drug resistance should be prioritized
are ongoing. in an effort to identify new targets for therapeutic strategies.
Hopefully, further development of innovative, biologically
Late Effects of Therapy based treatment approaches will prove to be effective in the
Although intensive multimodality treatment has treatment of NB and result in improved survival of children
resulted in improved survival of children with various types with clinically aggressive NB.
of cancer, including high-risk NB, follow-up of these sur-
vivors has uncovered notable adverse long-term sequelae ACKNOWLEDGMENTS
related to treatment [24]. These so-called “late effects” The work from S.L.C.’s laboratory was supported in
have diverse manifestations that can significantly impair part by the Neuroblastoma Children’s Cancer Society,
quality of life and lead to a greater rate of premature mor- Friends for Steven Pediatric Cancer Research Fund, the
tality [155, 156]. Because of the complex nature of these Elise Anderson Neuroblastoma Research Fund, the Robert
late effects, it is imperative to follow cancer survivors in a H. Lurie Comprehensive Cancer Center, and the NIH, NCI
comprehensive clinic that has a clear emphasis on these Core Grant 5P30CA60553.
Weinstein, Katzenstein, Cohn 287

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