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

Abstract

BackgroundAlthough 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.MethodsPatients 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.ResultsA 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.ConclusionsIn 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.

Efficacy of proton therapy in children with high‐risk and locally recurrent neuroblastoma

“…Achieving GTR has been reported to improve outcomes in some studies of high‐risk neuroblastoma and is influenced by several factors including the site and extent of primary disease, patient comorbidities, and surgical expertise . In the NB97 trial, GTR did not improve OS or local control; however, in the same study, some patients with STR received 36 Gy RT to the tumor bed, whereas none of the GTR patients received RT.…”

High-Risk Neuroblastoma Treatment Review

“…Similar results were reported from a German study, which showed that the extent of best operation had no impact on EFS [ 11 ]. In patients older than 18 months old with localized HRNBL, however, patients who underwent complete resection had superior local-progression-free survival (LPFS), EFS, and OS compared with patients who had gross total resections, incomplete surgery, or biopsy only [ 12 ]. Thus, in patients with metastatic high-risk disease, surgical morbidity should be carefully considered when planning resection and should not occur at the expense of a complete resection.…”

Anti-GD2-IRDye800CW as a targeted probe for fluorescence-guided surgery in neuroblastoma

“…Over 75% of patients are categorized as high-risk with a poor overall 5-year survival of less than 50%, despite intensive treatment with high-dose chemotherapy followed by surgery, autologous stem cell transplantation, radiotherapy and immunotherapy 2 , 3 . Resection of high-risk NB is associated with a risk for serious surgical complications, since the tumor often encases major blood vessels leading to severe hemorrhage and/or unplanned organ damage 4 , 5 . Discriminating cancerous tissue from healthy tissue is challenging, but of great importance to achieve optimal tumor resection, while preserving healthy tissue, which can thereby increase survival 6 , 7 .…”