Comparing presentations and outcomes of children with cancer: a study between a lower-middle-income country and a high-income country.

BACKGROUND: Substantial progress has been achieved in managing childhood cancers in many high-income countries (HICs). In contrast, survival rates in lower-middle-income countries (LMICs) are less favorable. Here, we aimed to compare outcomes and associated factors between two large institutions; Egypt (LMIC) and Germany (HIC). METHODS: A retrospective review was conducted on newly diagnosed children with cancer between 2006 and 2010 in the departments of pediatric oncology at the South Egypt Cancer Institute (SECI) (n = 502) and the University Hospital of Cologne-Uniklinik Köln (UKK) (n = 238). Characteristics including age, sex, diagnosis, travel time from home to the cancer center, the time interval from initial symptoms to the start of treatment, treatment-related complications, compliance, and outcome were analyzed. A Cox proportional hazards regression model was applied to investigate the influence of risk factors. RESULTS: The most common diagnoses in SECI were leukemia (48.8%), lymphomas (24.1%), brain tumors (1%), and other solid tumors (24.7%), compared to 22.3%, 19.3%, 28.6%, and 26.5% in UKK, respectively. Patients from SECI were younger (5.2 vs. 9.0 years, P < 0.001), needed longer travel time to reach the treatment center (1.44 ± 0.07 vs. 0.53 ± 0.03 h, P < 0.001), received therapy earlier (7.53 ± 0.59 vs. 12.09 ± 1.01 days, P = 0.034), showed less compliance (85.1% vs. 97.1%, P < 0.001), and relapsed earlier (7 vs. 12 months, P = 0.008). Deaths in SECI were more frequent (47.4% vs. 18.1%) and caused mainly by infection (60% in SECI, 7% in UKK), while in UKK, they were primarily disease-related (79% in UKK, 27.7% in SECI). Differences in overall and event-free survival were observed for leukemias but not for non-Hodgkin lymphoma. CONCLUSIONS: Outcome differences were associated with different causes of death and other less prominent factors.

Differences of hemiarthroplasty and total hip replacement in orthogeriatric treated elderly patients: a retrospective analysis of the Registry for Geriatric Trauma DGU®.

PURPOSE: Medial femoral neck fractures are typically managed with hemiarthroplasty (HA) or total hip arthroplasty (THA) in elderly patients. There is a debate as to which treatment predominates. The literatures have reported better outcomes for those patients with proximal femur fracture who were treated in an orthogeriatric centres compared to standard orthopaedic hospitals. Therefore, we have analysed the differences of outcome between HA and THA on patients, exclusively treated in orthogeriatric co-management and compared the results with the available literature. METHODS: We conducted a retrospective registry analysis of the Registry for Geriatric Trauma DGU®. Between 2016 and 2018, data for 16,236 patients from 78 different hospitals were available: they were analysed univariably, and differences between HA and THA were examined using propensity score matching, according to the American Society of Anesthesiologists (ASA) grade, Identification-of-Seniors-At-Risk (ISAR) Score, anticoagulation level, sex, age, and walking ability prefracture. RESULTS: There were 4,662 patients treated with HA and 892 with THA, meeting inclusion criteria. Patients in the HA group were older (84 years (IQR 80-89) vs. 79 years (IQR 75-83); p < 0.001), with more severe preexisting conditions, with an ASA grade ≥ 3 in 79% vs. 57% in the THA group (p < 0.001). After matching, the mortality rate, in-house revision rate, and quality of life (QoL) 7 days postoperatively were not significantly different by group. After 120 days, the HA group presented a lower rate of surgical complications (4% vs. 10%; p = 0.006), while the THA group had a higher rate of independent walking (18% vs. 28%; p = 0.001) and a higher QoL, measured by the EQ-5D-3L (0.81 (IQR 0.7-1.0) vs. 0.9 (IQR 0.72-1.0); p = 0.01). CONCLUSIONS: Due to better walking ability and QoL, THA might be the better choice in healthier and more mobile patients, while HA would be better for multimorbid patients to avoid additional complication-associated treatments. Not the age of the patient but the preoperative condition might be important for the choice between THA and HA.

Internal fixation versus hip arthroplasty in patients with nondisplaced femoral neck fractures: short-term results from a geriatric trauma registry.

PURPOSE: To determine whether internal fixation (IF) or hip arthroplasty (HA) is associated with superior outcomes in geriatric nondisplaced femoral neck fracture (FNF) patients. METHODS: Data from the Registry for Geriatric Trauma of the German Trauma Society (ATR-DGU) were analyzed (IF Group 449 and HA Group 1278 patients). In-hospital care and a 120-day postoperative follow-up were conducted. Primary outcomes, including mobility, residential status, reoperation rate, and a generic health status measure (EQ-5D score), and the secondary outcome of mortality were compared between groups. Multivariable analyses were performed to assess independent treatment group associations (odds ratios, ORs) with the primary and secondary end points. RESULTS: Patients in the HA group were older (83 vs. 81 years, p < 0.001) and scored higher on the Identification of Seniors at Risk screening (3 vs. 2, p < 0.001). We observed no differences in residential status, reoperation rate, EQ-5D score, or mortality between groups. After adjusting for key covariates, including prefracture ambulatory capacity, the mobility of patients in the HA group was more frequently impaired at the 120-day follow-up (OR 2.28, 95% confidence interval = 1.11-4.74). CONCLUSION: Treatment with HA compared to treatment with IF led to a more than twofold increase in the adjusted odds of impaired ambulation at the short-term follow-up, while no significant associations with residential status, reoperation rate, EQ-5D index score, or mortality were observed. Thus, IF for geriatric nondisplaced FNFs was associated with superior mobility 120 days after surgery. However, before definitive treatment recommendations can be made, prospective, randomized, long-term studies must be performed to confirm our findings.

Four-month outcome after proximal femur fractures and influence of early geriatric rehabilitation: data from the German Centres of Geriatric Trauma DGU.

This study analyzed the outcome of orthogeriatric patients with hip fracture 4 months after surgery. The overall mortality rate was 12.2%. Sixty-five percent presented a degradation in walking ability, and 16% had to move to a nursing home. Early geriatric rehabilitation reduces the mortality rate and increases the rate of anti-osteoporotic treatment. PURPOSE: Hip fractures are increasingly common with severe consequences. Therefore, the German Trauma Society (DGU) implemented an orthogeriatric co-management and developed the concept for certified Centre for Geriatric Trauma DGU. The patients' treatment data and the optional 120 days of follow-up were collected in the Registry for Geriatric Trauma DGU (ATR-DGU). This study analyzed these 4-month treatment results. METHODS: A retrospective analysis of the ATR-DGU was conducted. Outcome parameters were the rate of readmission, rate of re-surgery, anti-osteoporotic therapy, housing, mortality, walking ability, and quality of life (QoL) 120 days post-surgery. The influence of the early geriatric rehabilitation (EGR) was evaluated using a regression analysis. RESULTS: The follow-up data from 9780 patients were included. After 120 days, the mortality rate was 12.2%, the readmission rate 4%, and the re-surgery rate 3%. The anti-osteoporotic treatment increased from 20% at admission to 32%; 65% of the patients had a degradation in walking ability, and 16% of the patients who lived in their domestic environment pre-surgery had to move to a nursing home. QoL was distinctly reduced. The EGR showed a positive influence of anti-osteoporotic treatment (p<0.001) and mortality (p=0.011) but led to a slight reduction in QoL (p=0.026). CONCLUSION: The 4-month treatment results of the ATR-DGU are comparable to international studies. The EGR led to a significant rise in anti-osteoporotic treatment and a reduction in mortality with a slight reduction in QoL.

Effect of time-to-surgery on in-house mortality during orthogeriatric treatment following hip fracture: A retrospective analysis of prospectively collected data from 16,236 patients of the AltersTraumaRegister DGU®.

BACKGROUND: Time-to-surgery in geriatric hip fractures remains of interest. The majority of the literature reports a significantly decreased mortality rate after early surgery. Nevertheless, there are some studies presenting no effect of time-to-surgery on mortality. The body of literature addressing the effect of an orthogeriatric co-management is growing. Here we investigate the effect of time-to-surgery on in-house mortality in a group of patients treated under the best possible conditions in certified orthogeriatric treatment units. METHODS: We conducted a retrospective cohort registry analysis from prospectively collected data of the AltersTraumaRegister DGU®. Data were analyzed univariably, and the association of early surgery with in-house mortality was assessed with multivariable logistic regression while controlling for specified patient characteristics. Additionally, propensity score matching for time-to-surgery was applied to examine its effect on the in-house mortality rate. FINDINGS: A total of 15,099 patients met the inclusion criteria. The median age was 85 years (IQR 80-89), and 72.1% were female. The overall in-house mortality rate was 5.5%. Most (71.2%) of the patients were treated within 24 h, and 91.6% within 48 h. Neither the multivariable logistic regression model nor the propensity score matching indicated that early surgery was associated with a decreased mortality rate. The most important indicators for mortality were ASA ≥ 3 [Odds ratio (OR) 3.4, 95% confidence interval (CI) 2.35-5.11], fracture event during inpatient stay (OR 2.6, 95% CI 1.48-4.3), ISAR ≥ 2 (OR 1.88, 95% CI 1.33-2.76), and male gender (OR 1.71, 95% CI 1.39-2.09). INTERPRETATION: Our results suggest that for those patients, who were treated in an orthogeriatric co-management under the best possible conditions, there are no significant differences regarding in-house mortality rate between the time-to-surgery intervals of 24 and 48 h or slightly above. This and the comparatively small number of patients who underwent surgery after 24 h show that an extension of the pre-surgery interval, justified by an orthogeriatric treatment team, will not be detrimental to the affected patients.

Management of children with fever and neutropenia: results of a survey in 51 pediatric cancer centers in Germany, Austria, and Switzerland.

PURPOSE: Investigation of the current practice of diagnostics and treatment in pediatric cancer patients with febrile neutropenia. METHODS: On behalf of the German Society for Pediatric Oncology and Hematology and the German Society for Pediatric Infectious Diseases, an Internet-based survey was conducted in 2016 concerning the management of febrile neutropenia in pediatric oncology centers (POC). This survey accompanied the release of the corresponding German guideline to document current practice before its implementation in clinical practice. RESULTS: In total, 51 POCs participated (response rate 73%; 43 from Germany, and 4 each from Austria and Switzerland). Identified targets for antimicrobial stewardship concerned blood culture diagnostics, documentation of the time to antibiotics, the use of empirical combination therapy, drug monitoring of aminoglycosides, the time to escalation in patients with persisting fever, minimal duration of IV treatment, sequential oral treatment in patients with persisting neutropenia, indication for and choice of empirical antifungal treatment, and the local availability of a pediatric infectious diseases consultation service. CONCLUSION: This survey provides useful information for local antibiotic stewardship teams to improve the current practice referring to the corresponding national and international guidelines.

Evaluation of new quality indicators for the TraumaRegister DGU® using the systematic QUALIFY methodology.

BACKGROUND: The TraumaRegister DGU® (TR-DGU) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) enables the participating hospitals to perform quality management. For that purpose, nine so-called audit filters have existed, since its foundation, which, inter alia, is listed in the Annual Report. The objective of this study effort is a revision of these quality indicators with the aim of developing pertinent new and reliable quality indicators for the management of severely injured patients. MATERIALS AND METHODS: Apart from indicators already used at national and international levels, a systematic review of the literature revealed further potential key figures for quality of the management of severely injured patients. The latter were evaluated by an interdisciplinary and interprofessional group of experts using a standardized QUALIFY process to assess their suitability as a quality indicator. RESULTS: By means of the review of the literature, 39 potential indicators could be identified. 9 and 14 indicators, respectively, were identified in existing trauma registries (TR-DGU and TARN), 17 in the ATLS® training concept, and 57 in the S3 guideline on the treatment of polytrauma/severe injuries. The exclusion of duplicates and the limitation to indicators that can be collected using the TR-DGU Version 2015 data set resulted in a total of 43 indicators to be reviewed. For each of the 43 indicators, 13 quality criteria were assessed. A consensus was achieved in 305 out of 559 individual assessments. With 13 quality criteria assessed and 43 indicators correspond this to a relative consensus value of 54.6%. None of the indicators achieved a consensus in all 13 quality criteria assessed. The following 13 indicators achieved a consensus in at least 9 quality criteria: time between hospital admission and WBCT, mortality, administration of tranexamic acid to bleeding patients, use of CCT with GCS <14, time until first emergency surgical intervention (7-item list in the TR-DGU), time until surgical intervention for penetrating trauma, application of pelvic sling belt (prehospital), capnometry (etCO2) in intubated patients, time until CCT with GCS < 15, time until surgery for hemorrhagic shock, time until craniotomy for severe TBI, prehospital airway management in unconscious patients (GCS < 9), and complete basic diagnostics available. Two indicators achieved a consensus in 11 criteria and thus represent the maximum consensus achieved within the group of experts. Four indicators only achieved a consensus in three quality criteria. 17 indicators had a mean value for the 3 relevance criteria of ≥ 3.5 and were, therefore, assessed by the group of experts as being highly relevant. CONCLUSION: Not all the key figures published for the management of severely injured patients are suitable for use as quality indicators. It remains to be seen whether the quality indicators identified by experts using the QUALIFY process will meet the requirements in practice. Prior to the implementation of the assessed quality indicators in standardized quality assurance programs, a scientific evaluation based on national data will be required.

Correction to: Evaluation of new quality indicators for the TraumaRegister DGU® using the systematic QUALIFY methodology.

The original version of this article unfortunately contained some mistakes.

[120-day follow-up after proximal femoral fractures-first results from the Geriatric Trauma Registry DGU®]. / 120-Tage-Follow-up nach hüftgelenknahen Frakturen ­ erste Daten aus dem AltersTraumaRegister DGU®.

BACKGROUND: Geriatric trauma centers which are certified to the status of a Geriatic Trauma Center DGU® based on the criteria catalogue as outlined by the German Trauma Society (DGU), are required to participate in the Geriatric Trauma Register (ATR-DGU) for quality management and outcome analyses. The evaluation is pseudoanonymous and includes data on all treated hip fracture patients over 70 years old. This has been in regular use since 2016. This study analyzed the postoperative evaluation of gait, mortality, quality of life, hospital readmission and treatment of osteoporosis after 120 days. METHODS: A voluntary retrospective data evaluation of the ATR-DGU 120-day follow-up from 2017 was carried out. Written consent for the analysis and publication of the data was obtained from six clinics that already participated in the follow-up. The primary target parameters were mortality rate, readmission and revision rates, gait quality, osteoporosis treatment and quality of life according to EQ-5D-3L. The patient data were completely pseudonymized and a descriptive analysis was carried out. RESULTS: In this study 957 patients from the 6 hospitals were included. The average age was 84.5 years (±6.8 years). The mortality rate during the acute treatment phase was 5%. The 120-day follow-up could be evaluated in 412 patients, 10% of these required hospital readmission due to complications oft he same fracture and of these 6% required revision surgery. The mortality rate at 120 days was 12%. In 54% of the patients the fracture led to deterioration of mobility and 49% of patients received osteoporosis treatment after 120 days. The results of the EQ-5D-3L at 120 days revealed improvement as compared to the values on postoperative day 7; however, the preoperative status with respect to mobility and quality of life could not be regained. CONCLUSION: Despite the clear advantages of interdisciplinary treatment, the results are still limited concerning mobilization and quality of life. Further analysis of causative and influencing factors is necessary.

A new risk score for patients after first recurrence of stage 4 neuroblastoma aged ≥18 months at first diagnosis.

BACKGROUND: The prognosis of patients with recurrences from stage 4 neuroblastoma is not uniformly dismal. The evaluation of new therapies therefore needs to consider the individual risks of the treated patients. This study aims to define clinically useful risk criteria. PATIENTS AND METHODS: Inclusion criteria were: first recurrence of neuroblastoma stage 4 aged ≥18 months and enrollment in first line trials between 1997 and 2016. Patients were randomized into a training set (N = 310) and an independent validation set (N = 159). The primary endpoint was secondary event-free survival. The individual treatment elements the patients received during initial and recurrent disease were analyzed as binary and time-dependent variables. A five-step multiple time-dependent Cox regression analysis was performed on the training set to identify prognostic variables adjusted for the individual frontline treatment. The selected variables resulted in a prognostic index (PI) and were used to build a risk score system. The score was validated with the validation set. RESULTS: Of the 469 patients, 372 were treated with curative intent and 97 with palliative intent. The PI included the variables number of recurrence organs (hazard ratio [HR] = 2.27), time to recurrence (HR = 2.03), liver metastasis at diagnosis (HR = 1.77), first recurrence at site of the primary tumor (HR = 1.55), and age (HR = 1.29). Three risk groups were built and confirmed in the validation set. The scoring system was likewise useful for the curatively or palliatively treated subgroups. CONCLUSION: A new risk score system for patients with first recurrence of stage 4 neuroblastoma aged ≥18 months at diagnosis is proposed.

A mechanistic classification of clinical phenotypes in neuroblastoma.

Neuroblastoma is a pediatric tumor of the sympathetic nervous system. Its clinical course ranges from spontaneous tumor regression to fatal progression. To investigate the molecular features of the divergent tumor subtypes, we performed genome sequencing on 416 pretreatment neuroblastomas and assessed telomere maintenance mechanisms in 208 of these tumors. We found that patients whose tumors lacked telomere maintenance mechanisms had an excellent prognosis, whereas the prognosis of patients whose tumors harbored telomere maintenance mechanisms was substantially worse. Survival rates were lowest for neuroblastoma patients whose tumors harbored telomere maintenance mechanisms in combination with RAS and/or p53 pathway mutations. Spontaneous tumor regression occurred both in the presence and absence of these mutations in patients with telomere maintenance-negative tumors. On the basis of these data, we propose a mechanistic classification of neuroblastoma that may benefit the clinical management of patients.

Sense-Antisense lncRNA Pair Encoded by Locus 6p22.3 Determines Neuroblastoma Susceptibility via the USP36-CHD7-SOX9 Regulatory Axis.

Trait-associated loci often map to genomic regions encoding long noncoding RNAs (lncRNAs), but the role of these lncRNAs in disease etiology is largely unexplored. We show that a pair of sense/antisense lncRNA (6p22lncRNAs) encoded by CASC15 and NBAT1 located at the neuroblastoma (NB) risk-associated 6p22.3 locus are tumor suppressors and show reduced expression in high-risk NBs. Loss of functional synergy between 6p22lncRNAs results in an undifferentiated state that is maintained by a gene-regulatory network, including SOX9 located on 17q, a region frequently gained in NB. 6p22lncRNAs regulate SOX9 expression by controlling CHD7 stability via modulating the cellular localization of USP36, encoded by another 17q gene. This regulatory nexus between 6p22.3 and 17q regions may lead to potential NB treatment strategies.

Retrospective analysis of relapsed abdominal high-risk neuroblastoma.

BACKGROUND/PURPOSE: The impact of abdominal topography and surgical technique on resectability and local relapse pattern of relapsed abdominal high-risk neuroblastoma (R-HR-NB) is not clearly defined. METHODS: A sample of thirty-nine patients with R-HR-NB enrolled in the German neuroblastoma trials between 2001 and 2010 was analyzed retrospectively using surgical and imaging reports. We evaluated resectability and local relapse pattern within 6 standardized abdominal regions, impact of extent of the first resective surgery on overall survival (OS), and of number of operations and a higher cumulative surgical assessment score (C-SAS) on OS after the first event. RESULTS: In the left upper abdomen, rates for tumor persistence and relapse were 45.9% and 13.5% and in the left lower abdomen 27.7% and 8.3%, respectively. OS in months did not differ between complete and incomplete first resections (median (interquartile range): 35 (45.6) vs. 40 (65.4), P=.649). Better OS after the first event was associated with repeated as compared to single surgery (47.7 (64.7) vs. 4.3 (12.5), P=.000), and with higher as compared to lower C-SAS (47.7 (64.3) vs. 7.6 (14.7), P=.002). CONCLUSIONS: OS after relapse/progression was not dependent on the extent of first resection. The number of operations was associated with better outcome after event. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: LEVEL III Retrospective comparative study.

Molecular Classification Substitutes for the Prognostic Variables Stage, Age, and MYCN Status in Neuroblastoma Risk Assessment.

BACKGROUND: Current risk stratification systems for neuroblastoma patients consider clinical, histopathological, and genetic variables, and additional prognostic markers have been proposed in recent years. We here sought to select highly informative covariates in a multistep strategy based on consecutive Cox regression models, resulting in a risk score that integrates hazard ratios of prognostic variables. METHODS: A cohort of 695 neuroblastoma patients was divided into a discovery set (n=75) for multigene predictor generation, a training set (n=411) for risk score development, and a validation set (n=209). Relevant prognostic variables were identified by stepwise multivariable L1-penalized least absolute shrinkage and selection operator (LASSO) Cox regression, followed by backward selection in multivariable Cox regression, and then integrated into a novel risk score. RESULTS: The variables stage, age, MYCN status, and two multigene predictors, NB-th24 and NB-th44, were selected as independent prognostic markers by LASSO Cox regression analysis. Following backward selection, only the multigene predictors were retained in the final model. Integration of these classifiers in a risk scoring system distinguished three patient subgroups that differed substantially in their outcome. The scoring system discriminated patients with diverging outcome in the validation cohort (5-year event-free survival, 84.9±3.4 vs 63.6±14.5 vs 31.0±5.4; P<.001), and its prognostic value was validated by multivariable analysis. CONCLUSION: We here propose a translational strategy for developing risk assessment systems based on hazard ratios of relevant prognostic variables. Our final neuroblastoma risk score comprised two multigene predictors only, supporting the notion that molecular properties of the tumor cells strongly impact clinical courses of neuroblastoma patients.

Complete surgical resection improves outcome in INRG high-risk patients with localized neuroblastoma older than 18 months.

BACKGROUND: Although several studies have been conducted on the role of surgery in localized neuroblastoma, the impact of surgical timing and extent of primary tumor resection on outcome in high-risk patients remains controversial. METHODS: Patients from the German neuroblastoma trial NB97 with localized neuroblastoma INSS stage 1-3 age > 18 months were included for retrospective analysis. Imaging reports were reviewed by two independent physicians for Image Defined Risk Factors (IDRF). Operation notes and corresponding imaging reports were analyzed for surgical radicality. The extent of tumor resection was classified as complete resection (95-100%), gross total resection (90-95%), incomplete resection (50-90%), and biopsy (<50%) and correlated with local control rate and outcome. Patients were stratified according to the International Neuroblastoma Risk Group (INRG) staging system. Survival curves were estimated according to the method of Kaplan and Meier and compared by the log-rank test. RESULTS: A total of 179 patients were included in this study. 77 patients underwent more than one primary tumor operation. After best surgery, 68.7% of patients achieved complete resection of the primary tumor, 16.8% gross total resection, 14.0% incomplete surgery, and 0.5% biopsy only. The cumulative complication rate was 20.3% and the surgery associated mortality rate was 1.1%. Image defined risk factors (IDRF) predicted the extent of resection. Patients with complete resection had a better local-progression-free survival (LPFS), event-free survival (EFS) and OS (overall survival) than the other groups. Subgroup analyses showed better EFS, LPFS and OS for patients with complete resection in INRG high-risk patients. Multivariable analyses revealed resection (complete vs. other), and MYCN (non-amplified vs. amplified) as independent prognostic factors for EFS, LPFS and OS. CONCLUSIONS: In patients with localized neuroblastoma age 18 months or older, especially in INRG high-risk patients harboring MYCN amplification, extended surgery of the primary tumor site improved local control rate and survival with an acceptable risk of complications.

Lack of immunocytological GD2 expression on neuroblastoma cells in bone marrow at diagnosis, during treatment, and at recurrence.

BACKGROUND: Loss of disialoganglioside 2 (GD2) expression in neuroblastoma (NB) bone marrow cells has been reported in rare cases. This study investigated prospectively the frequency and the patterns of visible GD2 loss at diagnosis, during treatment, and at recurrence. METHODS: Bone marrow aspirates of patients with new or recurrent stage 4 and 4S NB diagnosed between January 1, 2002 and August 31, 2013 were investigated in parallel by cytology and GD2 immunocytology. Complete negative immunostaining was defined if staining was absent in all and partial if absent in a portion and/or in case of atypical faint staining. RESULTS: Of 1,261 investigated trial patients of all stages, 474 had unequivocal cytological bone marrow infiltration at initial diagnosis. Thirty-seven patients had tumor cells with complete or partial negative GD2 staining at initial diagnosis, nine during chemotherapy, and 11 at recurrence (altogether 12.0%). The percentage of GD2 negativity in stages 4 and 4S were similar (13% and 9%, respectively). Complete negativity was seen in 14 and partial in 43 cases. Twenty-one cases changed from positive to negative (15 to partial and six to complete) and three cases from negative to positive staining (two to partial and one to complete). The GD2 negative and positive groups were not different regarding tumor sites, molecular characteristics, histology, and tumor markers. Children with stage 4 and GD2 negativity tended to be older at diagnosis (42 vs. 32 months, P = 0.056). Event-free survival and overall survival comparing negative versus positive staining did not show any differences. CONCLUSIONS: Complete or partial lack of GD2 staining on NB cells in bone marrow is more frequent than currently recognized.

MYCN and HDAC5 transcriptionally repress CD9 to trigger invasion and metastasis in neuroblastoma.

The systemic and resistant nature of metastatic neuroblastoma renders it largely incurable with current multimodal treatment. Clinical progression stems mainly from the increasing burden of metastatic colonization. Therapeutically inhibiting the migration-invasion-metastasis cascade would be of great benefit, but the mechanisms driving this cycle are as yet poorly understood. In-depth transcriptome analyses and ChIP-qPCR identified the cell surface glycoprotein, CD9, as a major downstream player and direct target of the recently described GRHL1 tumor suppressor. CD9 is known to block or facilitate cancer cell motility and metastasis dependent upon entity. High-level CD9 expression in primary neuroblastomas correlated with patient survival and established markers for favorable disease. Low-level CD9 expression was an independent risk factor for adverse outcome. MYCN and HDAC5 colocalized to the CD9 promoter and repressed transcription. CD9 expression diminished with progressive tumor development in the TH-MYCN transgenic mouse model for neuroblastoma, and CD9 expression in neuroblastic tumors was far below that in ganglia from wildtype mice. Primary neuroblastomas lacking MYCN amplifications displayed differential CD9 promoter methylation in methyl-CpG-binding domain sequencing analyses, and high-level methylation was associated with advanced stage disease, supporting epigenetic regulation. Inducing CD9 expression in a SH-EP cell model inhibited migration and invasion in Boyden chamber assays. Enforced CD9 expression in neuroblastoma cells transplanted onto chicken chorioallantoic membranes strongly reduced metastasis to embryonic bone marrow. Combined treatment of neuroblastoma cells with HDAC/DNA methyltransferase inhibitors synergistically induced CD9 expression despite hypoxic, metabolic or cytotoxic stress. Our results show CD9 is a critical and indirectly druggable suppressor of the invasion-metastasis cycle in neuroblastoma.

Transcription factor activating protein 2 beta (TFAP2B) mediates noradrenergic neuronal differentiation in neuroblastoma.

Neuroblastoma is an embryonal pediatric tumor that originates from the developing sympathetic nervous system and shows a broad range of clinical behavior, ranging from fatal progression to differentiation into benign ganglioneuroma. In experimental neuroblastoma systems, retinoic acid (RA) effectively induces neuronal differentiation, and RA treatment has been therefore integrated in current therapies. However, the molecular mechanisms underlying differentiation are still poorly understood. We here investigated the role of transcription factor activating protein 2 beta (TFAP2B), a key factor in sympathetic nervous system development, in neuroblastoma pathogenesis and differentiation. Microarray analyses of primary neuroblastomas (n = 649) demonstrated that low TFAP2B expression was significantly associated with unfavorable prognostic markers as well as adverse patient outcome. We also found that low TFAP2B expression was strongly associated with CpG methylation of the TFAP2B locus in primary neuroblastomas (n = 105) and demethylation with 5-aza-2'-deoxycytidine resulted in induction of TFAP2B expression in vitro, suggesting that TFAP2B is silenced by genomic methylation. Tetracycline inducible re-expression of TFAP2B in IMR-32 and SH-EP neuroblastoma cells significantly impaired proliferation and cell cycle progression. In IMR-32 cells, TFAP2B induced neuronal differentiation, which was accompanied by up-regulation of the catecholamine biosynthesizing enzyme genes DBH and TH, and down-regulation of MYCN and REST, a master repressor of neuronal genes. By contrast, knockdown of TFAP2B by lentiviral transduction of shRNAs abrogated RA-induced neuronal differentiation of SH-SY5Y and SK-N-BE(2)c neuroblastoma cells almost completely. Taken together, our results suggest that TFAP2B is playing a vital role in retaining RA responsiveness and mediating noradrenergic neuronal differentiation in neuroblastoma.

Boolean modeling identifies Greatwall/MASTL as an important regulator in the AURKA network of neuroblastoma.

Aurora Kinase A (AURKA) is often overexpressed in neuroblastoma (NB) with poor outcome. The causes of AURKA overexpression in NB are unknown. Here, we describe a gene regulatory network consisting of core regulators of AURKA protein expression and activation during mitosis to identify potential causes. This network was transformed to a dynamic Boolean model. Simulated activation of the serine/threonine protein kinase Greatwall (GWL, encoded by MASTL) that attenuates the pivotal AURKA inhibitor PP2A, predicted stabilization of AURKA. Consistent with this notion, gene set enrichment analysis showed enrichment of mitotic spindle assembly genes and MYCN target genes in NB with high GWL/MASTL expression. In line with the prediction of GWL/MASTL enhancing AURKA, elevated expression of GWL/MASTL was associated with NB risk factors and poor survival of patients. These results establish Boolean network modeling of oncogenic pathways in NB as a useful means for guided discovery in this enigmatic cancer.

The number of removed lymph nodes by inguinofemoral lymphadenectomy: impact on recurrence rates in patients with vulva carcinoma.

OBJECTIVE: Inguinal lymph node (LN) metastasis is a crucial prognostic factor in vulva carcinoma. The aim of this study was to determine the prognostic value of the number of resected LNs in patients with vulvar carcinoma on recurrence rates. METHODS: This retrospective study includes patients with vulvar squamous cell carcinoma who underwent inguinofemoral lymphadenectomy (IFL) between 1998 and 2011. Dissected groins were stratified by the number of removed lymph nodes (<6 LNs versus ≥6 LNs) or inguinal LN metastasis (pN- versus pN+) and analyzed according to groin, local and distance recurrence rates. RESULTS: In total 45 patients were identified and 79 groins were eligible for this analysis. 11 patients underwent ipsilateral IFL and 34 bilateral IFL. The median age was 58 years (range 31-80). The median tumor size was 2 cm (range 0.1-7.9). A median of 8 (range 0-19) LNs were resected per groin. Overall in 11 groins LN metastases were found. Groin recurrences occurred in four patients, local recurrence in six patients and distant metastasis in one patient. We did not observe any significant improvement in groin recurrence rates, local recurrence rates and distant recurrence rates if more than six LNs were removed per groin. Notably, patients with LN metastasis did not show higher recurrence rates compared to unaffected LNs. CONCLUSION: In this cohort we demonstrated that resection of more than six LNs per groin does not improve the recurrence rates in patients with carcinoma of the vulva. Further prospective studies with more individuals are needed to evaluate the role of resected LNs in vulvar carcinoma.