Neuroblastoma

Neuroblastoma A tumor of postganglionic sympathetic neuroblasts The sympathetic chain extends from the neck to the sacrum The adrenal gland Neurotransmitter- Catecholamines

Neuroblastoma - Epidemiology Most common extracranial solid tumor Incidence – 10/million per year ~10% of pediatric tumors Peak age – 2-3 years >90% cases before 5 years Mostly sporadic – rare genetic associations Most common neonatal tumor

Neuroblastoma - Genetics Mostly sporadic – rare (2%) genetic associations (NF1, Hirschsprung, congenital central hypoventilation syndrome) Mutations in ALK (tyrosine kinase) Environment??

Neuroblastoma – Biology Neuroblastoma is a tumor of undifferentiated (embryonal) neuroectodermal cells, derived from the neural crest An aberration of normal differentiation An abnormal response to normal neurotropic signals (TRK-A, NGF) Spontaneous regression Differentiation – Ganglioneuroma, ganglioneuroblastoma

Neuroblastoma – Clinical features I Tumor originates from sympathetic ganglia/adrenal gland Lymphatic and hematogenous spread Metastases to bone, liver, bone marrow, skin Most patients present with advanced disease (40% of all patients, 55% of patients over 1 year)

Neuroblastoma-Clinical features - II Abdominal mass (65%) Thoracic mass (Infants) Bone pain Fever Weight loss “Sick looking child”

Neuroblastoma – Clinical Features - III Lower limb paresis – 20 to spinal epidural tumor (4%) Severe diarrhea 20 to secretion of VIP (vasoactive intestinal peptide) (4%) Horner syndrome - patients with cervical or upper thoracic sympathetic ganglia (1.7%) Hypertension, flushing, sweating (0.2%) Raccoon eyes Pallor, bleeding diathesis (Bone marrow involvement)

Neuroblastoma Raccoon eyes

Neuroblastoma – Clinical features - IV Opsoclonus-Myoclonus syndrome Acute cerebellar encephalopathy characterized by cerebellar ataxia, rapid and random eye movements (opsoclonus) and myoclonic jerks (2.8%) Good oncological but poor neurological outcome

Laboratory Features Catecholamines (Dopamine, epinephrine, VMA, HVA) Serum markers - LDH, ferritin, NSE (Neuron specific enolase) Blood count (BM involvement) Coagulation (Liver involvement)

Metabolism of Catecholamines

Pathology Small round blue cell tumor Neuroblastic differentiation: From very undifferentiated to differentiated Degree of anaplasia – Shimada index Biological parameters

Neuroblastoma biology II N-MYC – Oncogene on chromosome 2 amplification – worse prognosis DI (DNA Index= ploidy) – hyperdiploid – better outcome in infants 1p deletion – putative tumor suppressor genes – worse prognosis 17q gain – oncogene?

N-Myc amplification Amplification – A localized genomic change that results in increased dosage of a gene or genes affected Homogeneously staining regions (HSR’s) - are areas on the native chromosome with multiple 100-200 kB copies of the region containing the amplified gene Double minutes (DM) – Extrachromosomal fragments containing the amplified gene >10 copies are associated with a worse prognosis

Mechanisms of N-myc amplification

N-MYC amplification- Homogeneously staining region

N-MYC amplification- Double minutes

Neuroblastoma- 1p deletion

Neuroblastoma - Staging CT/MRI MIBG (Meta-iodo-benzyl-guanidine) Bone scan Bone marrow aspirate and biopsy Surgery

MIBG scan

Neuroblastoma - Staging Stage Tumor confined to organ of origin and completely resected I Tumor extending beyond organ of origin, ipsilateral nodes+ II Tumor crosses midline, contralateral nodes+ III Metastatic disease IV <1.5 year; metastases to liver, skin, BM IV-S

Neuroblastoma - INSS Staging System Stage 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) Stage 2A – Localized tumor with incomplete gross resection; representative ipsilateral non-adherent lymph nodes negative for tumor microscopically Stage 2B- Localized tumor with or without complete gross excision, with ipsilateral non-adherent lymph nodes positive for tumor’ enlarged contralateral lymph nodes must be negative microscopically Stage 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 Stage 4 – Any primary tumor with dissemination to distant lymph nodes, bone, bone marrow, liver, skin, and/or other organs (except as defined for stage 4s) Stage 4s – Localized primary tumor (as defined for stage 1, 2A or 2B) with dissemination limited skin, liver, and or bone marrow (limited to infants<1 year)

International Neuroblastoma Staging System (INSS) 1 4 2b 4S 3 2a

Age (<18m – favorable) Prognostic Factors Age (<18m – favorable) Stage Histology (Shimada) Biology N-MYC, DI, 17q+, 1p-

Neuroblastoma - Treatment Risk adapted Low risk NB – Minimal therapy – excellent outcome High NB – Intensive therapy – poor outcome

INRG – International Neuroblastoma Risk Group Classification System Age Stage N-MYC status

Neuroblastoma -Protocol assignment by risk group Study Risk Group DNA Ploidy Shimada histology N-MYC status Age INSS stage Low risk Low Any 0-21 y 1 High risk High - Fav Unfav Non-Amp Amp <365/547 d >365 d >365 2A/2B IM risk High-risk Intermediate <365 d 3 4 >1 =1 <365 4s

Low/Intermediate risk Neuroblastoma Watch and wait (No treatment=no toxicity) Surgery- Minimize damage Low intensity chemotherapy Radiation – emergency only (rarely used)

Improving Survival for Stage 4 Neuroblastoma Patients > 1 Year of Age at Diagnosis 0.8 Childrens Cancer Group Data Probability of Overall Survival 0.6 0.4 1986-1995 N = 675 0.2 1978-1985 N = 507 P < 0.001 1 2 3 4 5 6 7 8 9 10 Years from Diagnosis

Treatment – High Risk Neuroblastoma Induction chemotherapy Surgery High dose chemotherapy with stem cell rescue (Eradication of residual disease) Radiation Retinoic Acid Immunotherapy

High-risk Neuroblastoma – Treatment Roadmap █████ ███ ███ █ ██ ██ Induction Surgery Consolidation XRT Cis-RA Immunorx. Chemotherapy ABMT Anti GD2 IL-2 GM-CSF (Differentiation therapy) Immunotherapy

Chemotherapy in Neuroblastoma Platinum (Cis, carbo) VP-16 Doxorubicin Cyclophosphamide/Ifosfamide Vincristine Topotecan

High Dose Chemotherapy Myeloablative doses Eradication of tumor Rescue with autologous stem cells MEC (Melphalan, etoposide, carboplatinum) BM (Busulfan, Melphalan)

Neuroblastoma – Radiation Therapy Local consolidation (In high-risk disease) Massive hepatomegaly in infants with 4S Cord compression? Metastatic disease - palliation

Neuroblastoma – Differentiation therapy Cis-retinoic acid (Roaccutane) Induces differentiation of neuroblastoma cells in vitro and decreases proliferative capacity Shown in randomized clinical trial to improve outcome

High-Dose, Pulse Retinoic Acid Induces Neuroblastoma Differentiation Control 10 mM Retinoic Acid

Neuroblastoma – Immunotherapy Anti GD-2 antibodies Interleukin 2 GM-CSF

Accrual of 386 randomized patients needed

COG-ANBL0032 Phase III 2/17/09 Status: DATA AND SAFETY MONITORING COMMITTEE With ~61 % of accrual in, and ~ 2 year median follow up, the Immunotherapy arm shows: Superior EFS (p = 0.0115) Superior OS (p = 0.0223)

Neuroblastoma - Outcome Stage I – 95% 5y EFS Stage II – 90% 5y EFS Stage III+IV – 10-40% 5y EFS Stage IV-S - 95% 5y EFS

4s Neuroblastoma NOT BONE Under 18 months Primary tumor stage I/II Metastatic disease limited to: Bone marrow(<10%) Skin(Subcutaneous nodules) Liver NOT BONE

Bone and Bone Marrow

Neuroblastoma - Staging Stage Tumor confined to organ of origin and completely resected I Tumor extending beyond organ of origin, ipsilateral nodes+ II Tumor crosses midline, contralateral nodes+ III Metastatic disease IV <18months; metastases to liver, skin, BM IV-S

4s Neuroblastoma Spontaneous regression Cure with minimal therapy Exception: Massive hepatomegaly in <2 months (May require chemotherapy, RT)

Neuroblastoma – Spontaneous regression Occurs mainly in 4s disease But - may occur in all stages (overall ~ 10% of cases) Screening studies detect a 2-fold increase in incidence of neuroblastoma compared to clinically detected cases Cases detected in utero by ultrasound are being reported more frequently, and most are expected to resolve without treatment Spontaneous maturation to ganglioneuroma is apparently less common, but there is little data

Neuroblastoma – Outcome by stage

MYCN Amplification Correlates With Poor Survival in Infants with Stage 4 Neuroblastoma P < 0.0001 Schmidt, JCO 2000

Potential Therapy Radioactive MIBG Anti-GD2 antibodies Allogeneic BMT Sequential auto-BMT x2-3 Rapid sequence induction Early detection Targeted therapy - ALK inhibition

Neuroblastoma - Screening Rationale: Poor results in advanced-stage tumors Early stage – better outcome Available tumor marker (CA) Method Universal screening by urinary CA at 6 months

Neuroblastoma Screening - Results More early stage tumors No increase in detection of advanced tumors No improvement in overall cure Do advanced tumors evolve from early stage less aggressive tumors? Or are they rapidly evolving metastatic tumors that occur after 1 year of age?

Perinatal Neuroblastoma Tumors discovered during routine antenatal ultrasound as adrenal masses Differential diagnosis: Adrenal hemorrhage, pulmonary sequestration Traditional approach: Surgery Most tumors – stage 1, favorable histology, N-MYC non-amp Postnatal MIBG scan. If positive: Close observation; surgery for growing tumors Excellent outcome

Neuroblastoma A tumor of sympathetic neuroblasts that arises along the sympathetic chain and in the adrenal gland Heterogeneous clinical behavior and prognosis Different subtypes present different challenges