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1.  Expression Level of Quiescin Sulfhydryl Oxidase 1 (Qsox1) in Neuroblastomas 
Neuroblastoma is the most common extracranial solid malignant tumor observed during childhood. Although these tumors can sometimes regress spontaneously or respond well to treatment in infants, genetic alterations that influence apoptosis can, in some cases, confer resistance to chemotherapy or result in relapses and adversely affect prognosis for these patients. The aim of this study was to correlate immunohistochemical expression of the protein quiescin sulfhydryl oxidase 1 (QSOX1) in samples obtained from untreated neuroblastomas with the patients’ clinical and pathological prognostic factors and clinical course. Neuroblastoma samples (n=23) obtained from histology blocks were arrayed into tissue microarrays and analysed by immunohistochemistry. The cases were classified according to the following clinical and pathological prognostic factors: age at diagnosis greater or less than/equal to 18 months; location of the lesion at diagnosis (abdominal or extra-abdominal); presence or absence of bone-marrow infiltration; tumor differentiation (well or poorly differentiated); Shimada histopathologic classification (favourable or unfavourable); state of the tumor extracellular matrix (Schwannian-stroma rich or poor); amplification of the MYCN oncogene; and clinical course (dead or alive with or without relapses/residual lesions). Twelve of the cases were female, 9 children were over 18 months old, 9 cases presented with extra-abdominal tumors and 9 cases exhibited tumors with unfavourable histologies. Fifteen patients underwent bone-marrow biopsy, and 4 of these were positive for metastasis. Nine patients died. The higher immunohistochemical expression of QSOX1 was more common in well-differentiated samples (P=0.029), in stroma-rich samples (P=0.029) and in samples from patients with a high prevalence of relapses/residual disease. The functions of QSOX1 include extracellular matrix maturation and the induction of apoptosis. Therefore, QSOX1 may be involved in neuroblastoma differentiation and regression and may thus function as a biomarker for identifying risk groups for this neoplasm.
doi:10.4081/ejh.2014.2228
PMCID: PMC3980203  PMID: 24704990
neuroblastoma; QSOX1; proliferation; apoptosis; prognostic factors
2.  Neuroblastoma occurring in a 38-year old Nigerian man: a rare finding 
Rare Tumors  2009;1(1):e15.
Neuroblastoma (NB) is a common malignancy in children, but rarely occurs in adults. Accepted unfavorable prognostic factors include age over one year, low histological grade and advanced stage, MYCN amplification, chromosomal aberrations, elevations of neuron specific enolase and lactate dehydrogenase, and increased catecholamine metabolites in urine or serum. In adults, abdomen/retroperitoneum are the primary sites and in children the adrenal gland. We report a 38-year old civil servant who presented at our urology clinic on the 21st of December 2007 with a six month history of right flank dull pain which was worse on walking and relieved by rest, hypertension and a large right retroperitoneal mass. Tumor resection revealed a grade III NB. Chemotherapy using a combination of vincristine, adriamycin and cyclophosphamide was started. Follow-up showed regression of the mass initially with a relapse after patient absconded for three months. He resurfaced with new masses and he had a repeat chemotherapy with disappearance of the masses and is currently undergoing further treatment. To our knowledge this is the only report of NB in an adult registered so far in Nigeria and perhaps the whole of Africa. Currently, there are no standard treatment guidelines for patients with NB in adulthood. This study emphasizes the need for a standard treatment regime for adult onset neuroblastoma and its recognition as a possible differential in intra-abdominal mass in adults.
doi:10.4081/rt.2009.e15
PMCID: PMC2994447  PMID: 21139886
neuroblastoma; adult.
3.  Lung Metastases in Neuroblastoma at Initial Diagnosis: A Report from the International Neuroblastoma Risk Group (INRG) Project 
Pediatric blood & cancer  2008;51(5):589-592.
Background
Neuroblastoma is the most common extracranial pediatric solid cancer. Lung metastasis is rarely detected in children with newly diagnosed neuroblastoma. We aimed to describe the incidence, clinical characteristics, and outcome of patients with lung metastasis at initial diagnosis using a large international database.
Procedure
The subset of patients from the International Neuroblastoma Risk Group database with INSS stage 4 neuroblastoma and known data regarding lung metastasis at diagnosis was selected for analysis. Clinical and biological characteristics were compared between patients with and without lung metastasis. Survival for patients with and without lung metastasis was estimated by Kaplan-Meier methods. Cox proportional hazards methods were used to determine the independent prognostic value of lung metastasis at diagnosis.
Results
Of the 2,808 patients with INSS stage 4 neuroblastoma diagnosed between 1990 and 2002, 100 patients (3.6%) were reported to have lung metastasis at diagnosis. Lung metastasis was more common among patients with MYCN amplified tumors, adrenal primary tumors, or elevated lactate dehydrogenase (LDH) levels (p < 0.02 in each case). Five-year overall survival ± standard error for patients with lung metastasis was 34.5% ± 6.8% compared to 44.7% ± 1.3% for patients without lung metastasis (p=0.0002). However, in multivariable analysis, the presence of lung metastasis was not independently predictive of outcome.
Conclusions
Lung metastasis at initial diagnosis of neuroblastoma is associated with MYCN amplification and elevated LDH levels. Although lung metastasis at diagnosis was not independently predictive of outcome in this analysis, it remains a useful prognostic marker of unfavorable outcome.
doi:10.1002/pbc.21684
PMCID: PMC2746936  PMID: 18649370
Neuroblastoma; Lung Metastases; Pulmonary; MYCN
4.  Decreased aortic growth and middle aortic syndrome in patients with neuroblastoma after radiation therapy 
Pediatric Radiology  2009;39(11):1194-1202.
Background
Long-term CT follow-up studies are required in pediatric patients who have received intraoperative radiation therapy (IORT) and external beam radiation therapy (EBRT) to assess vascular toxicities and to determine the exact complication rate.
Objective
To analyze with CT the effects of radiation therapy (RT) on the growth of the aorta in neuroblastoma patients.
Materials and methods
Abdominal CT scans of 31 patients with intraabdominal neuroblastoma (stage II–IV), treated with RT (20 IORT±EBRT, 11 EBRT alone), were analyzed retrospectively. The diameter of the abdominal aorta was measured before and after RT. These data were compared to normal and predicted normal aortic diameters of children, according to the model of Fitzgerald, Donaldson and Poznanski (aortic diameter in centimeters = 0.844 + 0.0599 × age in years), and to the diameters of a control group of children who had not undergone RT. Statistical analyses for the primary aims were performed using the chi-squared test, t-test, Mann-Whitney test, nonparametric Wilcoxon matched-pairs test and analysis of variance for repeated measures. Clinical files and imaging studies were evaluated for signs of late vascular complications of neuroblastoma patients who had received RT.
Results
The mean diameter before and after RT and the growth of the aorta were significantly lower than expected in patients with neuroblastoma (P<0.05 for each) and when compared to the growth in a control group with normal and nonirradiated aortas. Among the patients who had received RT, there was no difference due to the type of RT. Seven patients from the IORT±EBRT group developed vascular complications, which included hypertension (five), middle aortic syndrome (two), death due to mesenteric ischemia (one) and critical aortic stenosis, which required aortic bypass surgery (two).
Conclusion
Patients with neuroblastoma who had received RT showed impaired growth of the abdominal aorta. Significant long-term vascular complications occurred in seven patients who received IORT±EBRT. Thus, CT evaluation of patients with neuroblastoma who receive RT should include not only reports of changes in tumor extension, but also documentation of perfusion, and the size and growth of the aorta and its branches over time.
doi:10.1007/s00247-009-1351-1
PMCID: PMC2765626  PMID: 19763559
Neuroblastoma; Middle aortic syndrome; Therapy complications; Intraoperative irradiation; Children
5.  Extra luminal colonic gastrointestinal stromal tumor: a case report 
Cases Journal  2009;2:7525.
Introduction
Gastrointestinal stromal tumors are the commonest mesenchymal tumors of the gastrointestinal tract, the stomach and small intestine are the favored sites of occurrence. They rarely occur in the colon, rectum and esophagus. GIST is neoplasm of mesenchymal origin originating from precursors of the interstitial cells of cajal. The symptoms of gastrointestinal stromal tumor depend on the site and size of the tumor, and may include abdominal pain, gastrointestinal bleeding or signs of obstruction; small tumors may, however, be asymptomatic. Majority of the patients with gastrointestinal stromal tumor have bloody stools and abdominal pain as the commonest manifestation. We describe a young female with extra luminal colonic gastrointestinal stromal tumor presenting as mass abdomen.
Case presentation
We describe 34-year-old female from north Indian state of Jammu and Kashmir who had presented with history of slowly increasing epigastric lump associated with abdominal discomfort of 4 months duration. She had no features of luminal obstruction. Her contrast enhanced computed tomography abdomen revealed a large extra-colonic mass in relation to transverse colon. The tumor was resected and histology was suggestive of gastrointestinal stromal tumor.
Conclusion
Extra luminal colonic gastrointestinal stromal tumors are very rare and can present as mass abdomen. Resection is the treatment of choice.
doi:10.1186/1757-1626-2-7525
PMCID: PMC2740148  PMID: 19829995
6.  Survival-Related Profile, Pathways, and Transcription Factors in Ovarian Cancer 
PLoS Medicine  2009;6(2):e1000024.
Background
Ovarian cancer has a poor prognosis due to advanced stage at presentation and either intrinsic or acquired resistance to classic cytotoxic drugs such as platinum and taxoids. Recent large clinical trials with different combinations and sequences of classic cytotoxic drugs indicate that further significant improvement in prognosis by this type of drugs is not to be expected. Currently a large number of drugs, targeting dysregulated molecular pathways in cancer cells have been developed and are introduced in the clinic. A major challenge is to identify those patients who will benefit from drugs targeting these specific dysregulated pathways.The aims of our study were (1) to develop a gene expression profile associated with overall survival in advanced stage serous ovarian cancer, (2) to assess the association of pathways and transcription factors with overall survival, and (3) to validate our identified profile and pathways/transcription factors in an independent set of ovarian cancers.
Methods and Findings
According to a randomized design, profiling of 157 advanced stage serous ovarian cancers was performed in duplicate using ∼35,000 70-mer oligonucleotide microarrays. A continuous predictor of overall survival was built taking into account well-known issues in microarray analysis, such as multiple testing and overfitting. A functional class scoring analysis was utilized to assess pathways/transcription factors for their association with overall survival. The prognostic value of genes that constitute our overall survival profile was validated on a fully independent, publicly available dataset of 118 well-defined primary serous ovarian cancers. Furthermore, functional class scoring analysis was also performed on this independent dataset to assess the similarities with results from our own dataset. An 86-gene overall survival profile discriminated between patients with unfavorable and favorable prognosis (median survival, 19 versus 41 mo, respectively; permutation p-value of log-rank statistic = 0.015) and maintained its independent prognostic value in multivariate analysis. Genes that composed the overall survival profile were also able to discriminate between the two risk groups in the independent dataset. In our dataset 17/167 pathways and 13/111 transcription factors were associated with overall survival, of which 16 and 12, respectively, were confirmed in the independent dataset.
Conclusions
Our study provides new clues to genes, pathways, and transcription factors that contribute to the clinical outcome of serous ovarian cancer and might be exploited in designing new treatment strategies.
Ate van der Zee and colleagues analyze the gene expression profiles of ovarian cancer samples from 157 patients, and identify an 86-gene expression profile that seems to predict overall survival.
Editors' Summary
Background.
Ovarian cancer kills more than 100,000 women every year and is one of the most frequent causes of cancer death in women in Western countries. Most ovarian cancers develop when an epithelial cell in one of the ovaries (two small organs in the pelvis that produce eggs) acquires genetic changes that allow it to grow uncontrollably and to spread around the body (metastasize). In its early stages, ovarian cancer is confined to the ovaries and can often be treated successfully by surgery alone. Unfortunately, early ovarian cancer rarely has symptoms so a third of women with ovarian cancer have advanced disease when they first visit their doctor with symptoms that include vague abdominal pains and mild digestive disturbances. That is, cancer cells have spread into their abdominal cavity and metastasized to other parts of the body (so-called stage III and IV disease). The outlook for women diagnosed with stage III and IV disease, which are treated with a combination of surgery and chemotherapy, is very poor. Only 30% of women with stage III, and 5% with stage IV, are still alive five years after their cancer is diagnosed.
Why Was This Study Done?
If the cellular pathways that determine the biological behavior of ovarian cancer could be identified, it might be possible to develop more effective treatments for women with stage III and IV disease. One way to identify these pathways is to use gene expression profiling (a technique that catalogs all the genes expressed by a cell) to compare gene expression patterns in the ovarian cancers of women who survive for different lengths of time. Genes with different expression levels in tumors with different outcomes could be targets for new treatments. For example, it might be worth developing inhibitors of proteins whose expression is greatest in tumors with short survival times. In this study, the researchers develop an expression profile that is associated with overall survival in advanced-stage serous ovarian cancer (more than half of ovarian cancers originate in serous cells, epithelial cells that secrete a watery fluid). The researchers also assess the association of various cellular pathways and transcription factors (proteins that control the expression of other proteins) with survival in this type of ovarian carcinoma.
What Did the Researchers Do and Find?
The researchers analyzed the gene expression profiles of tumor samples taken from 157 patients with advanced stage serous ovarian cancer and used the “supervised principal components” method to build a predictor of overall survival from these profiles and patient survival times. This 86-gene predictor discriminated between patients with favorable and unfavorable outcomes (average survival times of 41 and 19 months, respectively). It also discriminated between groups of patients with these two outcomes in an independent dataset collected from 118 additional serous ovarian cancers. Next, the researchers used “functional class scoring” analysis to assess the association between pathway and transcription factor expression in the tumor samples and overall survival. Seventeen of 167 KEGG pathways (“wiring” diagrams of molecular interactions, reactions and relations involved in cellular processes and human diseases listed in the Kyoto Encyclopedia of Genes and Genomes) were associated with survival, 16 of which were confirmed in the independent dataset. Finally, 13 of 111 analyzed transcription factors were associated with overall survival in the tumor samples, 12 of which were confirmed in the independent dataset.
What Do These Findings Mean?
These findings identify an 86-gene overall survival gene expression profile that seems to predict overall survival for women with advanced serous ovarian cancer. However, before this profile can be used clinically, further validation of the profile and more robust methods for determining gene expression profiles are needed. Importantly, these findings also provide new clues about the genes, pathways and transcription factors that contribute to the clinical outcome of serous ovarian cancer, clues that can now be exploited in the search for new treatment strategies. Finally, these findings suggest that it might eventually be possible to tailor therapies to the needs of individual patients by analyzing which pathways are activated in their tumors and thus improve survival times for women with advanced ovarian cancer.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000024.
This study is further discussed in a PLoS Medicine Perspective by Simon Gayther and Kate Lawrenson
See also a related PLoS Medicine Research Article by Huntsman and colleagues
The US National Cancer Institute provides a brief description of what cancer is and how it develops, and information on all aspects of ovarian cancer for patients and professionals (in English and Spanish)
The UK charity Cancerbackup provides general information about cancer, and more specific information about ovarian cancer
MedlinePlus also provides links to other information about ovarian cancer (in English and Spanish)
The KEGG Pathway database provides pathway maps of known molecular networks involved in a wide range of cellular processes
doi:10.1371/journal.pmed.1000024
PMCID: PMC2634794  PMID: 19192944
7.  Transcribed-ultra conserved region expression is associated with outcome in high-risk neuroblastoma 
BMC Cancer  2009;9:441.
Background
Neuroblastoma is the most common, pediatric, extra-cranial, malignant solid tumor. Despite multimodal therapeutic protocols, outcome for children with a high-risk clinical phenotype remains poor, with long-term survival still less than 40%. Hereby, we evaluated the potential of non-coding RNA expression to predict outcome in high-risk, stage 4 neuroblastoma.
Methods
We analyzed expression of 481 Ultra Conserved Regions (UCRs) by reverse transcription-quantitative real-time PCR and of 723 microRNAs by microarrays in 34 high-risk, stage 4 neuroblastoma patients.
Results
First, the comparison of 8 short- versus 12 long-term survivors showed that 54 UCRs were significantly (P < 0.0491) over-expressed in the former group. For 48 Ultra Conserved Region (UCRs) the expression levels above the cut-off values defined by ROC curves were strongly associated with good-outcome (OS: 0.0001

Conclusions
Our pilot study suggests that a deregulation of the microRNA/T-UCR network may play an important role in the pathogenesis of neuroblastoma. After further validation on a larger independent set of samples, such findings may be applied as the first T-UCR prognostic signature for high-risk neuroblastoma patients.
doi:10.1186/1471-2407-9-441
PMCID: PMC2804711  PMID: 20003513
Genome Biology  2008;9(10):R150.
Differences in MYCN/c-MYC target gene expression are associated with distinct neuroblastoma subtypes and clinical outcome.
Background
Amplified MYCN oncogene resulting in deregulated MYCN transcriptional activity is observed in 20% of neuroblastomas and identifies a highly aggressive subtype. In MYCN single-copy neuroblastomas, elevated MYCN mRNA and protein levels are paradoxically associated with a more favorable clinical phenotype, including disseminated tumors that subsequently regress spontaneously (stage 4s-non-amplified). In this study, we asked whether distinct transcriptional MYCN or c-MYC activities are associated with specific neuroblastoma phenotypes.
Results
We defined a core set of direct MYCN/c-MYC target genes by applying gene expression profiling and chromatin immunoprecipitation (ChIP, ChIP-chip) in neuroblastoma cells that allow conditional regulation of MYCN and c-MYC. Their transcript levels were analyzed in 251 primary neuroblastomas. Compared to localized-non-amplified neuroblastomas, MYCN/c-MYC target gene expression gradually increases from stage 4s-non-amplified through stage 4-non-amplified to MYCN amplified tumors. This was associated with MYCN activation in stage 4s-non-amplified and predominantly c-MYC activation in stage 4-non-amplified tumors. A defined set of MYCN/c-MYC target genes was induced in stage 4-non-amplified but not in stage 4s-non-amplified neuroblastomas. In line with this, high expression of a subset of MYCN/c-MYC target genes identifies a patient subtype with poor overall survival independent of the established risk markers amplified MYCN, disease stage, and age at diagnosis.
Conclusions
High MYCN/c-MYC target gene expression is a hallmark of malignant neuroblastoma progression, which is predominantly driven by c-MYC in stage 4-non-amplified tumors. In contrast, moderate MYCN function gain in stage 4s-non-amplified tumors induces only a restricted set of target genes that is still compatible with spontaneous regression.
doi:10.1186/gb-2008-9-10-r150
PMCID: PMC2760877  PMID: 18851746
Pediatric blood & cancer  2012;60(3):363-370.
Background
Of 4,706 peripheral neuroblastic tumors (pNTs) registered on the Children’s Cancer Group and Children’s Oncology Group Neuroblastoma Study between 1989 and 2010, 51 cases (1.1%) had genotype-phenotype discordance characterized by MYCN amplification (indicating poor prognosis) and Favorable Histology (indicating better prognosis).
Procedure
To distinguish prognostic subgroups in the genotype-phenotype discordant pNTs, two subgroups, “conventional” and “bull’s eye”, were identified based on the nuclear morphology. The “conventional” tumors (35 cases) included: Neuroblastoma, Poorly differentiated subtype (NB-PD, 26 cases) with “salt-and-pepper” nuclei; Neuroblastoma, Differentiating subtype (4 cases); Ganglioneuroblastoma, Intermixed (3 cases); and Ganglioneuroma, Maturing subtype (2 cases). The “bull’s eye” tumors included NB-PD with prominent nucleoli (16 cases). Clinicopathologic characteristics of these two subgroups were analyzed. N-myc protein expression was tested immunohistochemically on available tumors.
Results
No significant difference was found between these two subgroups in the distribution of prognostic factors such as age at diagnosis, clinical stage, histopathology category/subtype, mitosis-karyorrhexis index, ploidy, 1p LOH, and unbalanced 11qLOH. However, prognosis of the patients with “conventional” tumors (5-year EFS 85.7±12.2%; OS 89.3±10.3%) was significantly better than those with “bull’s eye” tumors (EFS 31.3±13.0%; OS 42.9±16.2%) (P=0.0010 and 0.0008, respectively). Immunohistochemically all (11/11) tested “conventional” tumors were negative, and 10/11 tested “bull’s eye” tumors were positive for N-myc protein expression.
Conclusions
Based on the presence or absence of prominent nucleoli (the putative site of RNA synthesis/accumulation leading to N-myc protein expression), two prognostic subgroups, “conventional” with a better prognosis and “bull’s eye” with a poor prognosis, were distinguished among the genotype-phenotype discordant pNTs.
doi:10.1002/pbc.24238
PMCID: PMC3397468  PMID: 22744966
neuroblastoma; International Neuroblastoma Pathology Classification; MYCN; genotype-phenotype correlation; prognosis; immunohistochemistry
Apart from the biochemical parameters routinely used like Vanillyl Mandellic Acid for the patients with neuroblastoma the parameters like neuron specific enolase, ferritin, lactate dehydrogenase, gamma glutamyl transferase were also studied to assess the utility in diagnosing the patients with neuroblastoma. The study involved 40 healthy ambulatory subjects and 30 untreated cases of histologically proved neuroblastoma referred to the Tata Memorial Hospital for further management and treatment. The urinary Vanillyl Mandellic Acid levels and the serum levels of neuron specific enolase, ferritin, lactate dehydrogenase had increased significantly, p<0.001 whereas the gamma glutamyl transferase had decreased significantly p<0.001, as compared to the normal. Serum neuron specific enolase, ferritin, lactate dehydrogenase alongwith urinary Vanillyl Mandellic Acid could be of help in diagnosing the patients with neuroblastoma.
doi:10.1007/s12291-008-0066-7
PMCID: PMC3453444  PMID: 23105774
Biochemical Parameters; Neuroblastoma; Vanillyl Mandellic Acid; Neuron Specific Enolase
Journal of Clinical Oncology  2009;27(3):365-370.
Purpose
Treatment of patients with localized neuroblastoma with unfavorable biologic features is controversial. To evaluate the outcome of children with low-stage MYCN-amplified neuroblastoma and develop a rational treatment strategy, data from the International Neuroblastoma Risk Group (INRG) database were analyzed.
Patients and Methods
The database is comprised of 8,800 patients. Of these, 2,660 patients (30%) had low-stage (International Neuroblastoma Staging System stages 1 and 2) neuroblastoma, known MYCN status, and available follow-up data. Eighty-seven of these patients (3%) had MYCN amplified tumors.
Results
Patients with MYCN-amplified, low-stage tumors had less favorable event-free survival (EFS) and overall survival (OS) than did patients with nonamplified tumors (53% ± 8% and 72% ± 7% v 90% ± 1% and 98% ± 1%, respectively). EFS and OS were statistically significantly higher for patients whose tumors were hyperdiploid rather than diploid (EFS, 82% ± 20% v 37% ± 21%; P = .0069; OS, 94% ± 11% v 54% ± 15%; P = .0056, respectively). No other variable had prognostic significance. Initial treatment consisted of surgery alone for 29 (33%) of 87 patients. Details of additional therapy were unknown for 14 patients. Twenty-two patients (25%) underwent surgery and moderate-intensity chemotherapy; another 22 underwent surgery, intensive chemotherapy, and radiation therapy. Nine of the latter 22 underwent stem cell transplantation. Survival in patients who received transplantation did not differ from survival in those who did not receive transplantation.
Conclusion
Among patients with low-stage, MYCN-amplified neuroblastoma, outcomes of patients with hyperdiploid tumors were statistically, significantly better than those with diploid tumors. The data suggest that tumor cell ploidy could potentially be used to identify candidates for reductions in therapy. Further study of MYCN-amplified, low-stage neuroblastoma is warranted.
doi:10.1200/JCO.2008.17.9184
PMCID: PMC2651034  PMID: 19047282
BMC Cancer  2014;14(1):840.
Background
Segmental genomic copy number alterations, such as loss of 11q or 3p and gain of 17q, are well established markers of poor outcome in neuroblastoma, and have been suggested to comprise tumor suppressor genes or oncogenes, respectively. The gene forkhead box P1 (FOXP1) maps to chromosome 3p14.1, a tumor suppressor locus deleted in many human cancers including neuroblastoma. FoxP1 belongs to a family of winged-helix transcription factors that are involved in processes of cellular proliferation, differentiation and neoplastic transformation.
Methods
Microarray expression profiles of 476 neuroblastoma specimens were generated and genes differentially expressed between favorable and unfavorable neuroblastoma were identified. FOXP1 expression was correlated to clinical markers and patient outcome. To determine whether hypermethylation is involved in silencing of FOXP1, methylation analysis of the 5′ region of FOXP1 in 47 neuroblastomas was performed. Furthermore, FOXP1 was re-expressed in three neuroblastoma cell lines to study the effect of FOXP1 on growth characteristics of neuroblastoma cells.
Results
Low expression of FOXP1 is associated with markers of unfavorable prognosis like stage 4, age >18 months and MYCN amplification and unfavorable gene expression-based classification (P < 0.001 each). Moreover, FOXP1 expression predicts patient outcome accurately and independently from well-established prognostic markers. Array-based CGH analysis of 159 neuroblastomas revealed that heterozygous loss of the FOXP1 locus was a rare event (n = 4), but if present, was associated with low FOXP1 expression. By contrast, DNA methylation analysis in 47 neuroblastomas indicated that hypermethylation is not regularly involved in FOXP1 gene silencing. Re-expression of FoxP1 significantly impaired cell proliferation, viability and colony formation in soft agar. Furthermore, induction of FOXP1 expression led to cell cycle arrest and apoptotic cell death of neuroblastoma cells.
Conclusions
Our results suggest that down-regulation of FOXP1 expression is a common event in high-risk neuroblastoma pathogenesis and may contribute to tumor progression and unfavorable patient outcome.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2407-14-840) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2407-14-840
PMCID: PMC4251948  PMID: 25406647
FoxP1; Neuroblastoma; Tumor suppressor; Cell proliferation; Disease progression
BMC Cancer  2009;9:422.
Background
Neuroblastoma is a pediatric tumor of neural crest cells that is clinically characterized by its variable evolution, from spontaneous regression to malignancy. Despite many advances in neuroblastoma research, 60% of neuroblastoma, which are essentially metastatic cases, are associated with poor clinical outcome due to the lack of effectiveness of current therapeutic strategies. Membrane-type 1 matrix metalloproteinase (MT1-MMP, MMP-14), an enzyme involved in several steps in tumor progression, has previously been shown to be associated with poor clinical outcome for neuroblastoma. Based on our recent demonstration that MT1-MMP phosphorylation is involved in the growth of fibrosarcoma tumors, we examined the potential role of phosphorylated MT1-MMP in neuroblastoma progression.
Methods
Tyrosine phosphorylated MT1-MMP was immunostained on tissue microarray samples from 55 patients with neuroblastoma detected by mass screening (known to be predominantly associated with favourable outcome), and from 234 patients with standard diagnosed neuroblastoma. In addition, the effects of a non phosphorylable version of MT1-MMP on neuroblastoma cell migration and proliferation were investigated within three-dimensional collagen matrices.
Results
Although there is no correlation between the extent of tyrosine phosphorylation of MT1-MMP (pMT1-MMP) and MYCN amplification or clinical stage, we observed greater phosphorylation of pMT1-MMP in standard neuroblastoma, while it is less evident in neuroblastoma from mass screening samples (P = 0.0006) or in neuroblastoma samples from patients younger than one year (P = 0.0002). In vitro experiments showed that overexpression of a non-phosphorylable version of MT1-MMP reduced MT1-MMP-mediated neuroblastoma cell migration and proliferation within a three-dimensional type I collagen matrix, suggesting a role for the phosphorylated enzyme in the invasive properties of neuroblastoma cells.
Conclusion
Overall, these results suggest that tyrosine phosphorylated MT1-MMP plays an important role in neuroblastoma progression and that its expression is preferentially observed in tumor specimens from neuroblastoma patients showing poor clinical outcome.
doi:10.1186/1471-2407-9-422
PMCID: PMC2796679  PMID: 19961596
The New England journal of medicine  2010;363(14):1313-1323.
BACKGROUND
The survival rate among patients with intermediate-risk neuroblastoma who receive dose-intensive chemotherapy is excellent, but the survival rate among patients who receive reduced doses of chemotherapy for shorter periods of time is not known.
METHODS
We conducted a prospective, phase 3, nonrandomized trial to determine whether a 3-year estimated overall survival of more than 90% could be maintained with reductions in the duration of therapy and drug doses, using a tumor biology-based therapy assignment. Eligible patients had newly diagnosed, intermediate-risk neuroblastoma without MYCN amplification; these patients included infants (<365 days of age) who had stage 3 or 4 disease, children (≥365 days of age) who had stage 3 tumors with favorable histopathological features, and infants who had stage 4S disease with a diploid DNA index or unfavorable histopathological features. Patients who had disease with favorable histopathological features and hyperdiploidy were assigned to four cycles of chemotherapy, and those with an incomplete response or either unfavorable feature were assigned to eight cycles.
RESULTS
Between 1997 and 2005, a total of 479 eligible patients were enrolled in this trial (270 patients with stage 3 disease, 178 with stage 4 disease, and 31 with stage 4S disease). A total of 323 patients had tumors with favorable biologic features, and 141 had tumors with unfavorable biologic features. Ploidy, but not histopathological features, was significantly predictive of the outcome. Severe adverse events without disease progression occurred in 10 patients (2.1%), including secondary leukemia (in 3 patients), death from infection (in 3 patients), and death at surgery (in 4 patients). The 3-year estimate (±SE) of overall survival for the entire group was 96±1%, with an overall survival rate of 98±1% among patients who had tumors with favorable biologic features and 93±2% among patients who had tumors with unfavorable biologic features.
CONCLUSIONS
A very high rate of survival among patients with intermediate-risk neuroblastoma was achieved with a biologically based treatment assignment involving a substantially reduced duration of chemotherapy and reduced doses of chemotherapeutic agents as compared with the regimens used in earlier trials. These data provide support for further reduction in chemotherapy with more refined risk stratification. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT00003093.)
doi:10.1056/NEJMoa1001527
PMCID: PMC2993160  PMID: 20879880
PLoS ONE  2010;5(9):e12825.
Background
Neuroblastoma is a childhood malignancy of sympathetic embryonal origin. A high potential for differentiation is a hallmark of neuroblastoma cells. We have previously presented data to suggest that in situ differentiation in tumors frequently proceeds along the chromaffin lineage and that decreased oxygen (hypoxia) plays a role in this. Here we explore the utility of Neuro-Endocrine Secretory Protein 55 (NESP55), a novel member of the chromogranin family, as a marker for this process.
Methodology/Principal Findings
Immunohistochemical analyses and in situ hybridizations were performed on human fetal tissues, mouse xenografts of human neuroblastoma cell lines, and on specimens of human neuroblastoma/ganglioneuroma. Effects of anaerobic exposure on gene expression by cultured neuroblastoma cells was analyzed with quantitative real-time PCR. Fetal sympathetic nervous system expression of NESP55 was shown to be specific for chromaffin cell types. In experimental and clinical neuroblastoma NESP55 immunoreactivity was specific for regions of chronic hypoxia. NESP55 expression also correlated strikingly with morphological evidence of differentiation and with other chromaffin-specific patterns of gene expression, including IGF2 and HIF2α. Anaerobic culture of five neuroblastoma cell lines resulted in an 18.9-fold mean up-regulation of NESP55.
Conclusions/Significance
The data confirms that chronic tumor hypoxia is a key microenvironmental factor for neuroblastoma cell differentiation, causing induction of chromaffin features and NESP55 provides a reliable marker for this neuronal to neuroendocrine transition. The hypoxia-induced phenotype is the predominant form of differentiation in stroma-poor tumors, while in stroma-rich tumors the chromaffin phenotype coexists with ganglion cell-like differentiation. The findings provide new insights into the biological diversity which is a striking feature of this group of tumors.
doi:10.1371/journal.pone.0012825
PMCID: PMC2941466  PMID: 20862257
PLoS ONE  2013;8(12):e82457.
Neuroblastoma is the most common extracranial tumor and a major cause of infant cancer mortality worldwide. Despite its importance, little is known about its molecular mechanisms. A striking feature of this tumor is its clinical heterogeneity. Possible outcomes range from aggressive invasion to other tissues, causing patient death, to spontaneous disease regression or differentiation into benign ganglioneuromas. Several efforts have been made in order to find tumor progression markers. In this work, we have reconstructed the neuroblastoma regulatory network using an information-theoretic approach in order to find genes involved in tumor progression and that could be used as outcome predictors or as therapeutic targets. We have queried the reconstructed neuroblastoma regulatory network using an aggressive neuroblastoma metastasis gene signature in order to find its master regulators (MRs). MRs expression profiles were then investigated in other neuroblastoma datasets so as to detect possible clinical significance. Our analysis pointed MAX as one of the MRs of neuroblastoma progression. We have found that higher MAX expression correlated with favorable patient outcomes. We have also found that MAX expression and protein levels were increased during neuroblastoma SH-SY5Y cells differentiation. We propose that MAX is involved in neuroblastoma progression, possibly increasing cell differentiation by means of regulating the availability of MYC:MAX heterodimers. This mechanism is consistent with the results found in our SH-SY5Y differentiation protocol, suggesting that MAX has a more central role in these cells differentiation than previously reported. Overexpression of MAX has been identified as anti-tumorigenic in other works, but, to our knowledge, this is the first time that the link between the expression of this gene and malignancy was verified under physiological conditions.
doi:10.1371/journal.pone.0082457
PMCID: PMC3857773  PMID: 24349289
Clinical Cancer Research  2012;18(10):2740-2753.
Neuroblastoma, the most common extra- cranial solid tumor in children, is derived from neural crest cells. Nearly half of patients present with metastatic disease, and have 5-year EFS of less than 50%. New approaches with targeted therapy may improve efficacy without increased toxicity. The current review will evaluate three promising targeted therapies, including 131I-metaiodobenzylguanidine (MIBG), a radiopharmaceutical taken up by the human norepinephrine transporter expressed in 90% of neuroblastomas, immunotherapy with monoclonal antibodies targeting the GD2 ganglioside, expressed on 98% of neuroblastoma cells, and inhibitors of ALK, a tyrosine kinase which is mutated or amplified in approximately 10% of neuroblastoma and expressed on the surface of most neuroblastoma cells. Early phase trials have confirmed the activity of 131I-MIBG in relapsed neuroblastoma, with response rates of about 30%, but the technical aspects of administration of large amounts of radioactivity in young children and the limited access have hindered incorporation into treatment of newly diagnosed patients. Anti-GD2 antibodies have also demonstrated activity in relapsed disease, and a recent phase III randomized trial showed a significant improvement in event-free survival for patients receiving chimeric anti-GD2 (ch14.18) combined with cytokines and isotretinoin after myeloablative consolidation therapy. A recently approved small molecule inhibitor of ALK has promising pre-clinical activity for neuroblastoma, and is currently in phase I and II trials. This is the first agent directed to a specific mutation in neuroblastoma, and marks a new step toward personalized therapy for neuroblastoma. Further clinical development of targeted treatments offers new hope for children with neuroblastoma.
doi:10.1158/1078-0432.CCR-11-1939
PMCID: PMC3382042  PMID: 22589483
BMJ Case Reports  2011;2011:bcr1220103674.
A full term otherwise healthy, 4-months-old male infant presented with progressive distension of abdomen from 2 months. The clinical examination showed shifting dullness only but no definite lump palpable. The abdominal radiography revealed calcification in right hypochondrium. Serum α-feto protein (AFP), neuron specific enolase, β human chorionic gonadotrophin and urinary vanillymandelic acid (VMA) were appropriate for age-range. Contrast enhanced abdominal CT showed predominantly multicystic lesion in right hypochondrium with central solid component and calcification, but no definite organ of origin determined. The exploratory laparotomy showed extra gastric multilobulated cystic mass sized 23×15×8 cm lesion arising from the lesser curvature of body of stomach. The tumour was feeding through short pedicle based on left gastric artery. There was no infiltration to adjacent areas. Histopathology of excised specimen showed immature teratoma. The child was discharged with appropriate advice and had no recurrence in 1 year of follow-up.
doi:10.1136/bcr.12.2010.3674
PMCID: PMC3070927  PMID: 22700350
Journal of Clinical Oncology  2011;29(33):4358-4364.
Purpose
Patients with neuroblastoma younger than 12 months of age with a 4S pattern of disease (metastases limited to liver, skin, bone marrow) have better outcomes than infants with stage 4 disease. The new International Neuroblastoma Risk Group (INRG) staging system extends age to 18 months for the 4S pattern. Our aim was to determine which prognostic features could be used for optimal risk classification among patients younger than 18 months with metastatic disease.
Methods
Event-free survival (EFS) and overall survival were analyzed by log-rank tests, Cox models, and survival tree regression for 656 infants with stage 4S neuroblastoma younger than 12 months of age and 1,019 patients with stage 4 disease younger than 18 months of age in the INRG database.
Results
Unfavorable biologic features were more frequent in infants with stage 4 disease than in infants with 4S tumors and higher overall in those age 12 to 18 months (although not different for stage 4 v 4S pattern). EFS was significantly better for infants younger than 12 months with 4S pattern than with stage 4 disease (P < .01) but similar for toddlers age 12 to 18 months with stage 4 versus 4S pattern. Among 717 patients with stage 4S pattern, patients age 12 to 18 months had worse EFS than those age younger than 12 months (P < .01). MYCN, 11q, mitosis-karyorrhexis index (MKI), ploidy, and lactate dehydrogenase were independently statistically significant predictors of EFS and more highly predictive than age or metastatic pattern. MYCN, 11q, MKI, histology, and 1p were combined in a survival tree for improved risk stratification.
Conclusion
Tumor biology is more critical than age or metastatic pattern for prognosis of patients age younger than 18 months with metastatic neuroblastoma and should be considered for risk stratification.
doi:10.1200/JCO.2011.35.9570
PMCID: PMC3221520  PMID: 21969516
PLoS Medicine  2008;5(6):e123.
Background
The complexity and heterogeneity of the human plasma proteome have presented significant challenges in the identification of protein changes associated with tumor development. Refined genetically engineered mouse (GEM) models of human cancer have been shown to faithfully recapitulate the molecular, biological, and clinical features of human disease. Here, we sought to exploit the merits of a well-characterized GEM model of pancreatic cancer to determine whether proteomics technologies allow identification of protein changes associated with tumor development and whether such changes are relevant to human pancreatic cancer.
Methods and Findings
Plasma was sampled from mice at early and advanced stages of tumor development and from matched controls. Using a proteomic approach based on extensive protein fractionation, we confidently identified 1,442 proteins that were distributed across seven orders of magnitude of abundance in plasma. Analysis of proteins chosen on the basis of increased levels in plasma from tumor-bearing mice and corroborating protein or RNA expression in tissue documented concordance in the blood from 30 newly diagnosed patients with pancreatic cancer relative to 30 control specimens. A panel of five proteins selected on the basis of their increased level at an early stage of tumor development in the mouse was tested in a blinded study in 26 humans from the CARET (Carotene and Retinol Efficacy Trial) cohort. The panel discriminated pancreatic cancer cases from matched controls in blood specimens obtained between 7 and 13 mo prior to the development of symptoms and clinical diagnosis of pancreatic cancer.
Conclusions
Our findings indicate that GEM models of cancer, in combination with in-depth proteomic analysis, provide a useful strategy to identify candidate markers applicable to human cancer with potential utility for early detection.
Samir Hanash and colleagues identify proteins that are increased at an early stage of pancreatic tumor development in a mouse model and may be a useful tool in detecting early tumors in humans.
Editors' Summary
Background.
Cancers are life-threatening, disorganized masses of cells that can occur anywhere in the human body. They develop when cells acquire genetic changes that allow them to grow uncontrollably and to spread around the body (metastasize). If a cancer is detected when it is still small and has not metastasized, surgery can often provide a cure. Unfortunately, many cancers are detected only when they are large enough to press against surrounding tissues and cause pain or other symptoms. By this time, surgical removal of the original (primary) tumor may be impossible and there may be secondary cancers scattered around the body. In such cases, radiotherapy and chemotherapy can sometimes help, but the outlook for patients whose cancers are detected late is often poor. One cancer type for which late detection is a particular problem is pancreatic adenocarcinoma. This cancer rarely causes any symptoms in its early stages. Furthermore, the symptoms it eventually causes—jaundice, abdominal and back pain, and weight loss—are seen in many other illnesses. Consequently, pancreatic cancer has usually spread before it is diagnosed, and most patients die within a year of their diagnosis.
Why Was This Study Done?
If a test could be developed to detect pancreatic cancer in its early stages, the lives of many patients might be extended. Tumors often release specific proteins—“cancer biomarkers”—into the blood, a bodily fluid that can be easily sampled. If a protein released into the blood by pancreatic cancer cells could be identified, it might be possible to develop a noninvasive screening test for this deadly cancer. In this study, the researchers use a “proteomic” approach to identify potential biomarkers for early pancreatic cancer. Proteomics is the study of the patterns of proteins made by an organism, tissue, or cell and of the changes in these patterns that are associated with various diseases.
What Did the Researchers Do and Find?
The researchers started their search for pancreatic cancer biomarkers by studying the plasma proteome (the proteins in the fluid portion of blood) of mice genetically engineered to develop cancers that closely resemble human pancreatic tumors. Through the use of two techniques called high-resolution mass spectrometry and acrylamide isotopic labeling, the researchers identified 165 proteins that were present in larger amounts in plasma collected from mice with early and/or advanced pancreatic cancer than in plasma from control mice. Then, to test whether any of these protein changes were relevant to human pancreatic cancer, the researchers analyzed blood samples collected from patients with pancreatic cancer. These samples, they report, contained larger amounts of some of these proteins than blood collected from patients with chronic pancreatitis, a condition that has similar symptoms to pancreatic cancer. Finally, using blood samples collected during a clinical trial, the Carotene and Retinol Efficacy Trial (a cancer-prevention study), the researchers showed that the measurement of five of the proteins present in increased amounts at an early stage of tumor development in the mouse model discriminated between people with pancreatic cancer and matched controls up to 13 months before cancer diagnosis.
What Do These Findings Mean?
These findings suggest that in-depth proteomic analysis of genetically engineered mouse models of human cancer might be an effective way to identify biomarkers suitable for the early detection of human cancers. Previous attempts to identify such biomarkers using human samples have been hampered by the many noncancer-related differences in plasma proteins that exist between individuals and by problems in obtaining samples from patients with early cancer. The use of a mouse model of human cancer, these findings indicate, can circumvent both of these problems. More specifically, these findings identify a panel of proteins that might allow earlier detection of pancreatic cancer and that might, therefore, extend the life of some patients who develop this cancer. However, before a routine screening test becomes available, additional markers will need to be identified and extensive validation studies in larger groups of patients will have to be completed.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050123.
The MedlinePlus Encyclopedia has a page on pancreatic cancer (in English and Spanish). Links to further information are provided by MedlinePlus
The US National Cancer Institute has information about pancreatic cancer for patients and health professionals (in English and Spanish)
The UK charity Cancerbackup also provides information for patients about pancreatic cancer
The Clinical Proteomic Technologies for Cancer Initiative (a US National Cancer Institute initiative) provides a tutorial about proteomics and cancer and information on the Mouse Proteomic Technologies Initiative
doi:10.1371/journal.pmed.0050123
PMCID: PMC2504036  PMID: 18547137
Journal of Clinical Investigation  1990;85(5):1555-1559.
Chromogranin A is an acidic protein costored and coreleased with catecholamines from storage vesicles. Its serum concentration is elevated in patients with peptide-producing endocrine neoplasia. We measured serum chromogranin A at the time of diagnosis in 34 children with all stages of neuroblastoma. With a sensitivity of 91% and specificity of 100%, serum chromogranin A emerged as a useful diagnostic tool for neuroblastoma, comparable to or better than other measurements such as neuron-specific enolase, ferritin, or dopamine-beta-hydroxylase. Mean serum chromogranin A correlated with disease stage (r = 0.76, P less than 0.01). The relationship of prognosis (progression-free survival) to baseline serum chromogranin A, age, and disease stage was determined in 34 patients at risk for relapse, with a median followup period of 18 mo (range, 1-48 mo). The survival rate for patients with lower serum chromogranin A levels (less than 190 ng/ml at the time of diagnosis) was 69%, whereas it was 30% for those with higher chromogranin A levels (P less than 0.05). Furthermore, when subjects were additionally stratified by either age or stage, chromogranin A was an effective prognostic tool in patients who either were older than 1 yr (P less than 0.005) or had more advanced disease (stage III or IV; P less than 0.05). We conclude that serum chromogranin A in neuroblastoma is (a) a valuable (sensitive and specific) diagnostic tool, (b) a correlate of tumor burden, and (c) a useful predictor of survival.
PMCID: PMC296605  PMID: 2332506
Gynecological Surgery  2012;9(3):237-245.
The aim of this study was to provide a single site resource for investigators, clinicians, and others seeking preclinical, animal, and human investigational studies concerning the postsurgical, anti-adhesion barrier Seprafilm™ (Genzyme Corporation, Cambridge, MA). All published preclinical, animal, human extra-abdominal research as of July 2011 have been summarized and included in this document. Searches of Medline and EMBASE Drugs and Pharmaceuticals databases were conducted for original preclinical, animal, and human extra-abdominal studies involving Seprafilm. Preclinical, animal, and extra-abdominal human investigational studies are the study selection for this manuscript. Intraabdominal use is discussed in the accompanying manuscript. Data extraction includes systematic manuscript review. Summary of preclinical, animal, and extra-abdominal human investigational use of Seprafilm by surgical discipline were gathered for data synthesis. The clinical use of Seprafilm, which was approved by the FDA for intra-abdominal procedures, is supported by preclinical and animal studies relating to general surgical and obstetrical/gynecological applications. Findings from preclinical, animal, and human investigational studies at other sites throughout the body raises the potential for additional human clinical trials to assess efficacy and safety following surgical procedures at non-abdominal locations.
doi:10.1007/s10397-012-0741-9
PMCID: PMC3401296  PMID: 22837732
Postoperative adhesions; Seprafilm; Anti-adhesion adjuvant; Adhesiolysis
Background:
Gastrointestinal stromal tumors (GISTs) rarely develop outside the digestive tract and such tumors are designated extra-GISTs (EGISTs). The majority of EGISTs are located in the mesentery, omentum, and retroperitoneum, and the primary localization in the pancreas has been reported in only about six cases. We describe a patient with a large metastatic pancreatic EGIST that had metastasized to the liver at time of presentation.
Case:
An 84-year-old male presented with worsening confusion and agitation for the past few days. He also reported progressively increasing abdominal distension for the past 3 years, more so in the past few months. He denied any abdominal pain, nausea, or vomiting. He mentioned one episode of melena 2 months ago. There was a history of unintentional weight loss of 30 pounds over the past few months. Review of systems was otherwise negative. Past medical history was significant for diabetes mellitus and lactose intolerance. Pertinent examination findings included a cachectic appearance, altered mentation without any focal neurologic deficit, and marked abdominal distension with dullness on percussion. Investigations were significant for elevated ammonia level (168 ug/dL), AST/ALT/Alk. phosphatase (424/153/102 U/L), and total bilirubin of 1.7 mg/dL. CEA and CA19-9 were within normal limits. Computed tomography (CT) scan of the abdomen showed an extremely large central heterogeneous mass of 34 × 24 × 27 cm replacing the entire pancreatic tissue and multiple hepatic metastases. Subsequently, a CT-guided liver biopsy demonstrated a spindle cell neoplasm with CD117 (c-kit), CD34, and vimentin-positive cells, consistent with liver metastasis from an EGIST. On day 3, he had massive hematemesis, for which he was transferred to the intensive care unit. His condition rapidly deteriorated with hemodynamic instability and further worsening of mental status. After a thorough discussion about treatment options and prognosis, his family concluded to limit care to comfort measures only. He passed away the next day, day 5 of admission. The family refused an autopsy.
Discussion:
EGISTs are usually asymptomatic depending on the location, tumor size, and mucosal involvement. The usual clinical symptoms include abdominal pain, early satiety, ileus, bleeding, anemia, and weight loss. This is the first reported case of pancreatic EGIST presenting with abdominal distension due to massive size of the tumor and hepatic encephalopathy secondary to hepatic metastasis.
GISTs originate from the interstitial cells of Cajal (ICC), which express the c-kit protein (CD117), CD34, and vimentin. An EGIST or metastatic disease may mimic a sarcoma or myoma on gross and microscopic appearance. The definite diagnosis is based on the immunohistochemical examination. CD117 expression is the most sensitive marker, found in 95% of GISTs. Frequent mitotic activity (2/50 HPF), high cellularity, and the presence of necrosis indicate a potentially aggressive clinical course for EGIST. The current definitive treatment for GIST, including EGIST, is surgical. Adjuvant therapy appears to be warranted because of high recurrence rates. Imatinib mesylate, a tyrosine kinase inhibitor, is a current treatment of choice for advanced GIST. It has also proven to be of benefit as adjuvant therapy with surgery to prevent recurrences.
PMCID: PMC3047023
EXECUTIVE SUMMARY
The Medical Advisory Secretariat conducted a systematic review of the evidence on the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysm in comparison to open surgical repair. An abdominal aortic aneurysm [AAA] is the enlargement and weakening of the aorta (major blood artery) that may rupture and result in stroke and death. Endovascular abdominal aortic aneurysm repair [EVAR] is a procedure for repairing abdominal aortic aneurysms from within the blood vessel without open surgery. In this procedure, an aneurysm is excluded from blood circulation by an endograft (a device) delivered to the site of the aneurysm via a catheter inserted into an artery in the groin. The Medical Advisory Secretariat conducted a review of the evidence on the effectiveness and cost-effectiveness of this technology. The review included 44 eligible articles out of 489 citations identified through a systematic literature search. Most of the research evidence is based on non-randomized comparative studies and case series. In the short-term, EVAR appears to be safe and comparable to open surgical repair in terms of survival. It is associated with less severe hemodynamic changes, less blood transfusion and shorter stay in the intensive care and hospital. However, there is concern about a high incidence of endoleak, requiring secondary interventions, and in some cases, conversion to open surgical repair. Current evidence does not support the use of EVAR in all patients. EVAR might benefit individuals who are not fit for surgical repair of abdominal aortic aneurysm and whose risk of rupture of the aneurysm outweighs the risk of death from EVAR. The long-term effectiveness and cost-effectiveness of EVAR cannot be determined at this time. Further evaluation of this technology is required.
OBJECTIVE
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysms (EVAR) in comparison to open surgical repair (OSR).
BACKGROUND
Clinical Need
An abdominal aortic aneurysm (AAA) is a localized, abnormal dilatation of the aorta greater than 3 cm or 50% of the aortic diameter at the diaphragm. (1) A true AAA involves all 3 layers of the vessel wall. If left untreated, the continuing extension and thinning of the vessel wall may eventually result in rupture of the AAA. The risk of death from ruptured AAA is 80% to 90%. (61) Heller et al. (44) analyzed information from a national hospital database in the United States. They found no significant change in the incidence rate of elective AAA repair or ruptured AAA presented to the nation’s hospitals. The investigators concluded that technologic and treatment advances over the past 19 years have not affected the outcomes of patients with AAAs, and the ability to identify and to treat patients with AAAs has not improved.
Classification of Abdominal Aortic Aneurysms
At least 90% of the AAAs are affected by atherosclerosis, and most of these aneurysms are below the level of the renal arteries.(1)
An abdominal aortic aneurysm may be symptomatic or asymptomatic. An AAA may be classified according to their sizes:(7)
Small aneurysms: less than 5 cm in diameter.
Medium aneurysms: 5-7cm.
Large aneurysms: more than 7 cm in diameter.
Small aneurysms account for approximately 50% of all clinically recognized aneurysms.(7)
Aortic aneurysms may be classified according to their gross appearance as follows (1):
Fusiform aneurysms affect the entire circumference of a vessel, resulting in a diffusely dilated lesion
Saccular aneurysms involve only a portion of the circumference, resulting in an outpouching (protrusion) in the vessel wall.
Prevalence of Abdominal Aortic Aneurysms
In community surveys, the prevalence of AAA is reported to be between 1% and 5.4%. (61) The prevalence is related to age and vascular risk factors. It is more common in men and in those with a positive family history.
In Canada, Abdominal aortic aneurysms are the 10th leading cause of death in men 65 years of age or older. (60) Naylor (60) reported that the rate of AAA repair in Ontario has increased from 38 per 100,000 population in 1981/1982 to 54 per 100,000 population in 1991/1992. For the period of 1989/90 to 1991/92, the rate of AAA repair in Ontarians age 45 years and over was 53 per 100,000. (60) In the United States, about 200,000 new cases are diagnosed each year, and 50,000 to 60,000 surgical AAA repairs are performed. (2) Ruptured AAAs are responsible for about 15,000 deaths in the United States annually. One in 10 men older than 80 years has some aneurysmal change in his aorta. (2)
Symptoms of Abdominal Aortic Aneurysms
AAAs usually do not produce symptoms. However, as they expand, they may become painful. Compression or erosion of adjacent tissue by aneurysms also may cause symptoms. The formation of mural thrombi, a type of blood clots, within the aneurysm may predispose people to peripheral embolization, where blood vessels become blocked. Occasionally, an aneurysm may leak into the vessel wall and the periadventitial area, causing pain and local tenderness. More often, acute rupture occurs without any prior warning, causing acute pain and hypotension. This complication is always life-threatening and requires an emergency operation.
Diagnosis of Abdominal Aortic Aneurysms
An AAA is usually detected on routine examination as a palpable, pulsatile, and non-tender mass. (1)
Abdominal radiography may show the calcified outline of the aneurysms; however, about 25% of aneurysms are not calcified and cannot be visualized by plain x-ray. (1) An abdominal ultrasound provides more accurate detection, can delineate the traverse and longitudinal dimensions of the aneurysm, and is useful for serial documentation of aneurysm size. Computed tomography and magnetic resonance have also been used for follow-up of aortic aneurysms. These technologies, particularly contrast-enhanced computer tomography, provide higher resolution than ultrasound.
Abdominal aortography remains the gold standard to evaluate patients with aneurysms for surgery. This technique helps document the extent of the aneurysms, especially their upper and lower limits. It also helps show the extent of associated athereosclerotic vascular disease. However, the procedure carries a small risk of complications, such as bleeding, allergic reactions, and atheroembolism. (1)
Prognosis of Abdominal Aortic Aneurysms
The risk of rupture of an untreated AAA is a continuous function of aneurysm size as represented by the maximal diameter of the AAA. The annual rupture rate is near zero for aneurysms less than 4 cm in diameter. The risk is about 1% per year for aneurysms 4 to 4.9 cm, 11% per year for aneurysms 5 to 5.9 cm, and 25% per year or more for aneurysms greater than 6 cm. (7)
The 1-year mortality rate of patients with AAAs who do not undergo surgical treatment is about 25% if the aneurysms are 4 to 6 cm in diameter. This increases to 50% for aneurysms exceeding 6 cm. Other major causes of mortality for people with AAAs include coronary heart disease and stroke.
Treatment of Abdominal Aortic Aneurysms
Treatment of an aneurysm is indicated under any one of the following conditions:
The AAA is greater than 6 cm in diameter.
The patient is symptomatic.
The AAA is rapidly expanding irrespective of the absolute diameter.
Open surgical repair of AAA is still the gold standard. It is a major operation involving the excision of dilated area and placement of a sutured woven graft. The surgery may be performed under emergent situation following the rupture of an AAA, or it may be performed electively.
Elective OSR is generally considered appropriate for healthy patients with aneurysms 5 to 6 cm in diameter. (7) Coronary artery disease is the major underlying illness contributing to morbidity and mortality in OSR. Other medical comorbidities, such as chronic renal failure, chronic lung disease, and liver cirrhosis with portal hypertension, may double or triple the usual risk of OSR.
Serial noninvasive follow-up of small aneurysms (less than 5 cm) is an alternative to immediate surgery.
Endovascular repair of AAA is the third treatment option and is the topic of this review.
PMCID: PMC3387737  PMID: 23074438
Neuroblastoma is the most common extra cranial solid tumor in childhood and the most frequently diagnosed neoplasm during the infancy. MYCN amplification and overexpression occur in about 25% of total neuroblastoma cases and this percentage increases at 30% in advanced stage neuroblastoma. So far, MYCN expression profile is still one of the most robust and significant prognostic markers for neuroblastoma outcome. MYCN is a transcription factor that belongs to the family of MYC oncoproteins, comprising c-MYC and MYCL genes. Deregulation of MYC oncoprotein expression is a crucial event involved in the occurrence of different types of malignant tumors. MYCN, as well as c-MYC, can heterodimerize with its partner MAX and activate the transcription of several target genes containing E-Box sites in their promoter regions. However, recent several lines of evidence have revealed that MYCN can repress at least as many genes as it activates, thus proposing a novel function of this protein in neuroblastoma biology. Whereas the mechanism by which MYCN can act as a transcriptional activator is relatively well known, very few studies has been done in the attempt to explain how MYCN can exert its transcription repression function. Here, we will review current knowledge about the mechanism of MYCN-mediated transcriptional repression and will emphasize its role as a repressor in the recruitment of a precise set of proteins to form complexes capable of down-regulating specific subsets of genes whose function is actively involved in apoptosis, cell differentiation, chemosensitivity, and cell motility. The finding that MYCN can also act as a repressor has widen our view on its role in oncogenesis and has posed the bases to search for novel therapeutic drugs that can specifically target its transcriptional repression function.
doi:10.3389/fonc.2013.00042
PMCID: PMC3593680  PMID: 23482921
MYCN; neuroblastoma; transcriptional repression; cell differentiation; apoptosis; cell cycle

Results 1-25 (1490596)