SPELEMAN, PARK, AND HENDERSON

Neuroblastoma: A Tough Nut to Crack

Frank Speleman, PhD, Julie R. Park, MD, and Tara O. Henderson, MD, MPH

OVERVIEW

Neuroblastoma, an embryonal tumor arising from neural crest–derived progenitor cells, is the most common solid tumor in
childhood, with more than 700 cases diagnosed per year in the United States. In the past several decades, significant
advances have been made in the treatment of neuroblastoma. Treatment advances reflect improved understanding of the
biology of neuroblastoma. Although amplification of MYCN was discovered in the early 1980s, our understanding of
neuroblastoma oncogenesis has advanced in the last decade as a result of high-throughput genomic analysis, exome and
whole-genome sequencing, genome-wide association studies, and synthetic lethal drug screens. Our refined understanding
of neuroblastoma biology and genetics is reflected in improved prognostic stratification and appropriate tailoring of therapy
in recent clinical trials. Moreover, for high-risk neuroblastoma, a disease that was uniformly fatal 3 decades ago, recent
clinical trials incorporating autologous hematopoietic transplant and immunotherapy utilizing anti-GD2 antibody plus
cytokines have shown improved event-free and overall survival. These advances have resulted in a growing population of
long-term survivors of neuroblastoma. Examination of the late effects and second malignant neoplasms (SMNs) in both older
generations of survivors and more recently treated survivors will inform both design of future trials and surveillance
guidelines for long-term follow-up. As a consequence of advances in understanding of the biology of neuroblastoma,
successful clinical trials, and refined understanding of the late effects and SMNs of survivors, the promise of precision
medicine is becoming a reality for patients with neuroblastoma.

N euroblastoma is undoubtedly one of the most enigmatic

tumors, with remarkable heterogeneous clinical be-
havior ranging from spontaneous regression to metastatic
disease that is refractory to therapy (see the therapy update
section). Progress in understanding the molecular basis of
the biologic and clinical behavior of neuroblastoma has
moved forward at a slower pace compared with many other
tumor entities, such as childhood leukemias. Although am-
plification of the MYCN oncogene was discovered as early
as 1983,1 the finding of further genes implicated in neu-
roblastoma oncogenesis took much longer. Low-resolution
whole-genome analyses revealed further highly recurrent
and large genomic DNA copy-number alterations, such as
1p and 11q deletions and 17q gain.2 In the past decade,
this picture has dramatically changed by virtue of high-
throughput genomic analysis such as transcriptome pro-
filing, exome and whole-genome sequencing, genome-wide
association studies, and synthetic lethal drug screens.
As a result, step by step, the promise of precision oncology is
now also approaching patients with neuroblastoma suf-
fering from aggressive tumors at diagnosis or relapsed tu-
mors with limited further treatment options.3 Interestingly,
many of the novel findings connect directly or indirectly to
regulatory pathways controlling MYCN activity, bringing the
old enemy into the spotlight of our current and future
targeted drug efforts. Fortunately, our increasing knowledge
of neuroblastoma biology and genetics, together with access
to a rapidly increasing number of actionable drugs, is now
offering new hope for significantly increased cure rates and
reduced toxicity.
NEUROBLASTOMA BIOLOGY UPDATE
Neuroblastoma Biology and Genetics: Progress in
Brief
In the recent past, several excellent reviews have described
progress in understanding neuroblastoma biology.3-8 Neu-
roblastoma, an embryonal tumor arising from neural
crest–derived progenitor cells, has been considered as a
developmental disorder that develops through deregulation
of signaling pathways governing sympathetic nervous sys-
tem development, such as neurothrophin receptor signal-
ing, and several key transcription factors orchestrating
the complex developmental lineage commitment and
differentiation. 6,9-11
As for other cancers, a search for recurrent genetic alterations
was a major path toward understanding neuroblastoma

From the Center for Medical Genetics Ghent, Cancer Research Institute Ghent, Ghent, Belgium; Seattle Children’s Hospital, Seattle, WA; Department of Pediatrics, University of
Washington School of Medicine, Seattle, WA; University of Chicago Comer Children’s Hospital, Chicago, IL.

Disclosures of potential conflicts of interest provided by the authors are available with the online article at asco.org/edbook.

Corresponding author: Julie R. Park, MD, Seattle Children’s Hospital, 4800 Sandpoint Way NE, Seattle, WA 98105; email: julie.park@seattlechildrens.org.

© 2016 by American Society of Clinical Oncology.

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formation. Roughly three major subgroups were identified
using DNA copy-number analyses: favorable tumors among
children younger than 18 months without MYCN amplifi-
cation with typically whole chromosome imbalances, and
high-risk tumors among older children with either MYCN
amplification and 1p deletions or 11q deletions in the
absence of MYCN amplifications, with both high-risk
groups exhibiting almost invariably 17q gain.2,12,13 In view
of the high frequency and large size of these segmental
aberrations, it has been proposed that dosage effects of
multiple genes located on the involved chromosomal
regions are implicated in tumor formation. Unfortunately,
the large size of these segments has precluded the identi-
fication of the culprit genes on 11q and 17q, whereas a few
genes are now considered to be involved for 1p, including
CHD5, CAMTA1, and CASZ1.14-16
In addition to MYCN, two other oncogenes, ALK and
LIN28B, were found to be amplified, albeit in very low
frequency.17,18 Furthermore, activating ALK mutations were
identified as the major cause of familial neuroblastomas,
although somatic mutations were discovered in less than
10% of neuroblastomas, opening the way for targeted
therapies.19-21 A remarkable productive approach was taken
by Maris et al using genome-wide association studies to
genetic variants predisposing to neuroblastoma and pointing
toward involvement of multiple loci, including LINC00340,
BARD1, LMO1, DUSP12, DDX4, LIN28B, HACE1, NEFL, and
TP53.22-28
KEY POINTS
• Recent high-throughput genomics analyses have
provided a wealth of novel data that shed new light on
complex neuroblastoma tumor biology and clinical
behavior.
• Novel insights into tumor biology are opening the way
for precision medicine among patients with high-risk
and relapsed neuroblastoma.
• Tumor biology and clinical characteristics determine
prognosis and treatment recommendations.
• Therapy reduction has proven possible for patients
without high-risk neuroblastoma; for patients with
high-risk neuroblastoma, dose-intensive multimodality
therapy, including dose-intensive induction
chemotherapy, high-dose chemotherapy with
autologous stem cell rescue, external beam
radiotherapy, and immunotherapy has improved
outcomes.
• Understanding of the late effects and second
malignancies of survivors is essential for ensuring the
long-term health of survivors with neuroblastoma as
well as informing the design of future neuroblastoma
treatment trials aimed at improved survival along with a
concurrent reduction in late effects.
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NEUROBLASTOMA BIOLOGY, THERAPY, AND SURVIVORSHIP
Untangling the MYCN Regulatory Network
MYCN biology has been intensively studied for many years
using in vitro model systems and a TH-MYCN–driven mouse
model, among others. More recently, new mouse and
zebrafish models were generated18,29-31 and novel pros-
pects for drug MYCN activity have brought MYCN further
into the picture.32 MYCN controls multiple essential cellular
processes, including cell cycle, apoptosis, differentiation,
and metabolism, and it is involved in basic processes
connected to replication, transcription, and splicing.33-35
To further unravel the underlying molecular basis of MYCN
transcriptional control, chromatin immunoprecipitation
sequencing has been performed and many bona fide target
genes have been identified, although MYC(N) overall can
bind to thousands of promotors. The nature of these target
genes appears to be context dependent, and recent studies
provided evidence of a so-called amplifier role for MYC and
MYCN, boosting the transcription of already active genes, a
process that might be distinctly different between normal
and malignant cells. 36,37 MYCN both activates and re-
presses certain gene sets through promotor binding and
association of activator or repressor protein complexes,
respectively. In this context, the binding of MYCN to EZH2,
which is overexpressed in neuroblastoma cells and is a core
component of the PRC2 repressive complex, may play a key
role in MYCN-controlled gene repression of neuronal dif-
ferentiation genes. Further dissection of the regulatory
protein complexes that are acting in concert with MYCN in
oncogenic regulation of DNA replication, transcription,
splicing, and so forth will be pivotal.38,39 Moreover, MYCN
also controls expression of many microRNAs, most nota-
bly the miR-17-92 cluster, targeting transforming growth
factor-beta pathway components and DKK3, among
others.40-42
The Novel Neuroblastoma Oncogenes, ALK and
LIN28B, Are Wired Into the MYCN Regulatory
Network
Given the central role of MYCN in neuroblastoma biology,
understanding upstream regulators is also of key impor-
tance. LIN28B has been shown to positively regulate MYCN
levels through let-7 binding. In keeping with its impor-
tant upstream regulator role for MYCN, LIN28B itself
has been recognized as a bona fide driver gene by mouse
modeling. 18 In addition, using an unbiased LIN28B-39
untranslated region reporter screen, we found that miR-
26a-5p and miR-26b-5p regulate LIN28B expression and
that MYCN indirectly affects the expression of miR-26a-5p,
hence regulating LIN28B. Furthermore, MYCN directly
regulates LIN28B expression through LIN28B promoter
binding. 43 Taken together, these data point to a com-
plex regulatory relationship between both genes.44 Other
MYCN upstream regulators include SIRT1, SIRT2, and
PRMT5. 45-47
The finding of ALK mutations and rare amplifications in
neuroblastomas was exciting to neuroblastoma researchers
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SPELEMAN, PARK, AND HENDERSON
and pediatric oncologists because this represented an im-
portant novel druggable target. Several small molecules
are now under clinical testing; although resistance to
such compounds has been reported, further in-depth in-
vestigation of the optimal design and potential powerful
combination therapies must be explored to exploit the full
potential of this molecular target.48,49 In this context, we
performed an in-depth analysis of downstream mutant ALK
signaling to gain a deeper understanding of the rewired
oncogenic signaling in ALK mutant neuroblastoma cells and
to provide a molecular basis to gain insights into possible
drug-resistance mechanisms and drug-induced compen-
satory pathways. This study provided a rich data set for
exploration and showed mutant ALK-driven upregulation
of mitogen-activated protein kinase negative feedback
regulators, among others, and upregulation of RET and RET-
driven sympathetic neuronal markers of the cholinergic
lineage.50 Although this most likely connects ALK and RET
signaling in a developmental context (in keeping with
other observations),51,52 this observation also offers novel
venues for drug treatments that are currently under
investigation.
ALK has been connected to MYCN through multiple
mechanisms. ALK was shown to drive MYCN expression
by promotor activation53 and activation through ERK5.54
In addition, activated ALK downstream signaling through
phosphoinositide 3-kinase/AKT controls glycogen synthase
kinase 3 beta activity and MYCN protein stabilization. These
mechanisms explain the observed cooperative effect of
mutant ALK accelerated tumor formation in MYCN trans-
genic mice and zebrafish.29,31,55
The Whole Genome and Nothing But the Whole
Genome
In keeping with recent findings in other embryonal tumors,
the overall mutation burden was low, with an average
of fewer than 10 mutations. 56-59 No additional recur-
rent mutations with significant frequency, such as ALK-
activating mutations, were found; however, Molenaar
et al56 collectively demonstrated that an increase in im-
plication of low-frequency mutations of neuritogenesis
genes was observed overall. In addition, chromothripsis,
a complex pattern of interchromosomal and/or intra-
chromosomal rearrangements believed to arise through
a single time-point event, was also demonstrated in sev-
eral cases. Perhaps the main power of whole-genome se-
quencing was the possibility to combine both mutation
and copy-number events at single base-pair resolution. By
combining such data, further recurrent events emerged,
including the ARID1A and ARID1B epigenetic components
of the SWI/SNF remodeling complex and, most notably,
ATRX inactivating events (mainly deletions) and hTERT
activating structural rearrangements. ATRX encodes a SWI/
SNF chromatin-remodeling ATP-dependent helicase; re-
markably, ATRX mutations occur mainly in older children,
with a frequency rising to greater than 40% in children
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older than age 14. It was shown that most of the tumors
with ATRX loss showed evidence of alternative lengthening
of telomeres. Two recent articles further showed mutual
exclusivity for ATRX inactivating events versus hTERT ac-
tivating rearrangements. hTERT is a known MYCN target
gene and previous lower-resolution DNA copy-number
analyses revealed recurrent gains and rearrangements
affecting the hTERT locus.60 This type of alteration was
studied in more detail using whole-genome sequencing
approaches and revealed that 5p15.33 rearrangements
juxtapose the TERT coding sequence to strong enhancer
elements, resulting in massive chromatin remodeling and
DNA methylation of the affected region and transcriptional
upregulation of hTERT.61,62 TERT rearrangements (23%),
ATRX deletions (11%), and MYCN amplifications (37%) iden-
tified three almost nonoverlapping groups of high-stage
neuroblastoma, each associated with very poor prognosis.62
Of further interest, sequencing whole genomes of di-
agnostic and relapsed tumors has provided both insight into
the nature of mutations driving therapy resistance and
molecular evidence for the existence of minor subclones
that emerge during therapy (e.g., ALK mutant subclones
in otherwise ALK wild-type tumors at diagnosis, among
others). 63,64
NEUROBLASTOMA THERAPY UPDATE
Because of the heterogeneous biology of neuroblastoma, its
clinical behavior and prognosis range from near uniform
survival to high risk for fatal demise. Significant advances in
our knowledge of neuroblastoma biology have led to im-
proved prognostic stratification and appropriate tailoring of
therapy, although our evolving molecular understanding has
yet to translate fully into novel therapies. The International
Risk Group (INRG) classification system uses clinical and
biologic factors that have been shown to predict progno-
sis and risk of recurrence, including age, International
Neuroblastoma Staging System stage histopathology, DNA
index (ploidy), segmental chromosomal gains or losses, and
MYCN amplification,65 to classify patients as having low-risk,
intermediate-risk, and high-risk neuroblastoma. In addition, a
National Cancer Institute–sponsored Clinical Trials Planning
Meeting has proposed revisions to the International Response
Criteria. These revised criteria will integrate tumor response
in the primary tumor, soft tissue and bone metastases, and
bone marrow. Primary and metastatic soft tissue sites will
be assessed using RECIST and 123I-metaiodobenzylguanidine
(MIBG) or 18F-fluorodeoxyglucose (FDG)–PET scans if the
tumor is MIBG nonavid. 123I-MIBG or FDG-PET scans, for
MIBG nonavid disease, replace 99technetium bone scans for
osteomedullary metastases assessment. Bone marrow
will be assessed by histology/immunohistochemistry and
cytology/immunocytology. Urinary catecholamine levels
will not be included in response assessment. Overall re-
sponse will be defined as complete response, partial re-
sponse, minor response, stable disease, and progressive
disease. These international collaborations provide the

opportunity for comparison across international clinical
trials and have opened the door for international collab-
orative trials.
Neuroblastoma: When Less Is More
Low-risk disease is characterized by a localized primary
tumor (INRGSS L1) or INRGSS stage MS without the pres-
ence of MYCN amplification. Survival rates for patients
with low-risk neuroblastoma are excellent with surgery
alone and rare recurrences can often be cured with sal-
vage chemotherapy, resulting in survival rates of greater
than 95%. 66-68 Chemotherapy is reserved for patients
with localized neuroblastoma who have life- or organ-
threatening symptoms or the minority of patients who
experience recurrence or progressive disease. Several
clinical trials have further established the potential for
spontaneous regression of localized neuroblastoma, es-
pecially among patients who are diagnosed at younger
than age 12 months.69-71 In addition, recent clinical trials
support a continued reduction of chemotherapy expo-
sure and surgery for the majority of low-risk asymp-
tomatic patients, and studies to examine strategies to
biologically identify the rare patient with localized dis-
ease who will have a poor outcome are underway.
Intermediate-risk classification encompasses a wide
spectrum of disease for which surgical resection and
moderate-dose multi-agent chemotherapy are the back-
bone of therapy. Intermediate risk includes subsets of
patients with locoregional disease (INRGSS L2) without
MYCN amplification and infants (younger than 18 months
at diagnosis) with metastatic disease and favorable tumor
biologic features including no MCYNA. Survival after
moderate-dose chemotherapy including carboplatin or
cisplatin, doxorubicin, etoposide, and cyclophosphamide is
greater than 90% for patients whose tumors exhibit fa-
vorable clinical and biologic characteristics, including in-
fants with stage M who lack MYCN amplification. 72,73
Extent of surgical resection does not affect prognosis.72
Ongoing studies are investigating whether further reduction
(and, in some cases, elimination) of therapy for the majority
of patients with favorable histology and genomics can be
achieved.
Despite the overall excellent prognosis for the majority of
patients with intermediate-risk neuroblastoma, the prog-
nosis is less favorable for patients older than 18 months with
locoregional disease (INRGSS L2) and unfavorable histology
or segmental chromosomal aberrations or those infants
with metastatic disease with unfavorable biologic charac-
teristics. Event-free survival for this rare cohort of patients
ranges from 40% to 70%72,74-76 with a wide range of therapy
intensity used. Improved understanding of the underlying
tumor biology and international collaborative clinical trials
are needed to better define optimal therapy for this rare
cohort of patients.
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NEUROBLASTOMA BIOLOGY, THERAPY, AND SURVIVORSHIP
High-Risk Neuroblastoma: Beyond Chemotherapy
Dose Intensity
High-risk neuroblastoma is defined by presence of tumor
MYCN amplification or children with metastatic disease
older than age 18 months at diagnosis. High-risk neuroblas-
toma is largely chemotherapy responsive, but approxi-
mately one-half of patients still experience disease relapse
despite improvements in overall response rates. Standard
therapy for patients with high-risk neuroblastoma has
evolved through the results of randomized clinical trials
performed by international cooperative groups and in-
volves three components: multi-agent chemotherapy in-
duction and surgical resection, consolidation using high-
dose chemotherapy with autologous hematopoietic stem
cell rescue, and postconsolidation/maintenance treatment
of minimal residual disease using a biologic differentiating
agent (isotretinoin) and immunotherapy with antiganglioside
(GD2) antibody plus cytokines.
Dose intensity of chemotherapy is an important factor
in successful treatment of high-risk neuroblastoma. Dose-
intensive multi-agent induction chemotherapy provided im-
proved event-free survival compared with a less-intensive
chemotherapy regimen.77 Additional randomized trials
demonstrated that the use of myeloablative therapy and
autologous hematopoietic stem cell rescue further im-
proved outcomes for high-risk neuroblastoma compared
with use of conventionally dosed chemotherapy or
observation.78-80 More recently, randomized clinical trials
demonstrated that the specific agents used for consolidation
chemotherapy (busulfan/melphalan)81 or the intensity of
consolidation therapy (tandem transplant; J. Park, personal
communication, April 2016) may further improve outcomes
for high-risk neuroblastoma.
Randomized clinical trials have also highlighted the role
of treating minimal residual disease to improve outcomes
for patients with high-risk neuroblastoma. Isotretinoin, a
noncytotoxic differentiating agent, led to improved event-
free survival from high-risk neuroblastoma. Furthermore,
the addition of immunotherapy utilizing anti-GD2 antibody
plus cytokines improved event-free and overall survival,
becoming the first example of the benefits of immune-
targeted therapy for treatment of a solid tumor in
childhood.
Although outcomes for patients with high-risk neuro-
blastoma have markedly improved over the past 2 decades,
our current therapies for these patients remain subop-
timal. Chemotherapy and radiotherapy resistance remain
the hallmark of failure. However, optimism remains as our
expanding knowledge of tumor biology provides ample
opportunities for the introduction of novel molecularly
targeted agents into an optimized backbone of chemo-
therapy and radiotherapy. Novel therapeutic approaches
may target more generalizable features of neuroblastoma,
including surface epitopes such as GD2 for immuno-
therapy 82 and targeted radionuclide delivery. Alterna-
tively, the molecularly targeted therapy paradigm includes
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SPELEMAN, PARK, AND HENDERSON
identification and pharmacologic antagonism of an onco-
genic driver as a novel therapeutic.
Ongoing and planned clinical trials will exploit the ra-
diosensitivity of neuroblastoma by incorporating 131I-MIBG
targeted radiotherapy. Neuroblastoma is one of the most
radiosensitive tumors of childhood, resulting in a marked
decreased in primary site-specific recurrence, yet 50% of
patients have recurrence in bone marrow and/or cortical
bone.83 Efforts to radiate all sites of metastatic disease
using conventional total body irradiation (TBI) have not
clearly benefited patients, in part because of toxicity-
associated limitations of TBI beyond a dose of 1,000 to
1,200 cGy and associated second malignancies.84 MIBG,
a norepinephrine analog, is concentrated selectively in sym-
pathetic tissues. Clinical trials have demonstrated the
safety of 131I-MIBG (12–18 mCi/kg) administered with
chemotherapy, and objective response rates of up to 25%
have been documented among patients with recurrent and
refractory disease.85-87 131I-MIBG can be safely combined
with myeloablative chemotherapy for patients with a poor
response to induction chemotherapy with additional an-
titumor efficacy.88
Future therapies must also build on the success of anti-
GD2 monoclonal antibody immunotherapy and develop
novel approaches to enhance antibody efficacy, such as the
addition of lenolidomide,89 which increases cytokine levels
and activates natural killer cells, combination with cytotoxic
therapy that may alter the inhibitory tumor microenviron-
ment (R. Mody, personal communication, April 2016) or
active immunization with anti-idiotype antibodies are being
studied among patients with relapsed disease.90 Promising
novel immunotherapies genetically modify a patient’s own
T cells to be redirected against tumor-associated antigens
(e.g., GD2, L1CAM). Autologous T cells engineered to over-
express chimeric antigen receptors are infused and have
been shown to persist and demonstrate antitumor activity
among patients with neuroblastoma.91,92
Translation of our evolving understanding of neuroblas-
toma biology and the increasing availability of active clinical
compounds has greatly enhanced the availability of mo-
lecularly targeted agents. However, these remain in early-
phase clinical trials for patients with recurrent high-risk
neuroblastoma, with the ultimate goal to bring those with
the most encouraging activity into front-line therapy. For
patients with MYCN-amplified neuroblastoma, preclinical
studies suggest that BET bromodomain inhibitors can induce
cell death by interfering with MYCN transcription.93 Other
drugs that have effects on MYCN stability (aurora kinase A
and mTOR inhibitors)5 as well as those that target MYC-
dependent metabolic changes (difluoromethylornithine)94
are being studied. ALK is a pharmacologically tractable target
and early experience suggests that its inhibition can induce
responses in pediatric tumors with activating ALK muta-
tions.95,96 Emergent resistance to targeted therapeutics
is a concern.97,98 A major issue is that ALK mutations
confer differential sensitivity to available ALK inhibitors.98
The combination of an ALK inhibitor with cytotoxic
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chemotherapy may augment activity and will be studied in
up-front treatment of children whose neuroblastoma har-
bors ALK aberrations. Genetic studies of relapsed neuro-
blastoma demonstrate genetic evolution of tumors and
further support combination of molecularly targeted agents
for treatment of relapsed disease.64
NEUROBLASTOMA SURVIVORSHIP
As described, there has been tremendous success in the
treatment of neuroblastoma. Five-year relative survival has
increased from 54% among patients diagnosed between
1975 and 1984 to 78% for those diagnosed between 2005
and 2011.99 Subsequently, there has been a growing pop-
ulation of survivors of neuroblastoma. Consistent with other
childhood cancer survivors, these advances have not come
without a cost.
The long-term outcomes of 954 survivors of neuroblas-
toma diagnosed between 1970 and 1986 who are partici-
pants in the North American cohort, the Childhood Cancer
Survivor Study (CCSS), were reported in 2009.100 The 25-year
cumulative late mortality was 6%. Compared with the sex-
and age-matched general population, the risk of death was
almost sixfold higher (standardized mortality ratio [SMR],
5.6; 95% CI, 4.4–6.9). The most common cause of late
mortality was recurrence, followed by an SMN (SMR, 10.9;
95% CI, 5.8–18.7), pulmonary complications (SMR,
11.4; 95% CI, 3.1–29.3), and cardiac complications (SMR, 5.0;
95% CI, 1.0–14.5). The 20-year cumulative incidence of
a chronic health condition was 41.1%. Compared with
their siblings, survivors had an 8.3-fold risk of developing a
chronic health condition. Survivors of neuroblastoma were
at increased risk for at least one of the following health
complications: neurologic, musculoskeletal, endocrine, and
sensory complications, with 20-year cumulative incidences
of 30%, 8%, 8%, and 9%, respectively. In the CCSS cohort,
30 survivors of neuroblastoma developed an SMN 5 years
or later after the neuroblastoma diagnosis. Of the patients
with SMNs, eight had thyroid cancer, five had renal cell
carcinoma, three had soft tissue sarcomas, two had AML,
two had breast cancer, one had a brain tumor, one had
Hodgkin lymphoma, and seven had other SMNs. The risk of
developing an SMN was eightfold higher among survivors of
neuroblastoma than the general population (standardized
incidence ratio, 8.0; 95% CI, 5.4–11.4). Similar to other
childhood cancer survivors, risks of late effects and SMNs
were attributable to radiation exposure (e.g., SMN, thyroid
disease, or cardiac disease), cisplatin exposure (e.g., hearing
loss or renal disease), alkylator exposure (e.g., renal dis-
ease, infertility, or risk of treatment-related acute myeloid
leukemia/myelodysplastic syndrome), and other treatment
exposures.
Notably, the outcomes reported from the CCSS reflect
outcomes associated with the treatment and survival suc-
cess of an earlier era for neuroblastoma. Although data on
stage and/or risk group were not available in the CCSS
analysis, only 20 survivors had undergone bone marrow

transplantation, suggesting that most of the participants did
not have high-risk disease.100 Thus, these data do not reflect
the late effects or SMNs experienced by patients with re-
cently treated neuroblastoma, such as high-risk patients
who received more modern therapies such as tandem he-
matopoietic stem cell transplantation, biologic therapies,
and immunotherapy. Currently, survivorship researchers are
focused on the questions of whether risk-adapted therapies
improve the late effect profiles of low- and intermediate-risk
survivors and, importantly, identifying the long-term out-
comes of high-risk survivors exposed to therapies never
given alone or in combination to any other population of
childhood cancer survivors.
Regarding the effects of risk-based therapy on the long-
term outcomes of survivors of neuroblastoma, a recent
study examined second cancers in the Surveillance, Epide-
miology, and End Results database across treatment eras.
Among 2,801 patients with neuroblastoma treated between
1973 and 2006 (era 1, 1973 to 1989; era 2, 1990 to 1996;
and era 3, 1997 to 2006), 34 patients developed an SMN
(14 developed a carcinoma and 10 had a hematologic malig-
nancy). Importantly, there was no difference in the incidence of
SMNs in era 1 compared with era 3. Consistent with other
institutional studies reporting a high incidence of SMNs in
high-risk survivors,101 the 30-year cumulative incidence of
SMNs among high-risk patients was 10.4% (95% CI, 4.0–20.5)
compared with 3.6% among lower-risk patients.102 A large,
comprehensive analysis of SMNs among these high-risk
survivors is necessary to examine the effect of modern
regimens and exposures (including the combination of ra-
diotherapy, chemotherapy, cis-retinoic acid, immunother-
apy, as well as 131I-MIBG) on risk for SMNs.
Current knowledge regarding the long-term outcomes of
high-risk survivors of neuroblastoma treated with more
modern approaches is limited to small institutional series.
These studies suggest a high burden of multiple late effects
for these survivors (summarized in Table 1).103-108 Endocrine
late effects are prominent, with most series identifying
growth failure and short stature even in the absence of
TABLE 1. Prevalence of Late Effects Among Survivors of High-Risk Neuroblastoma
Late Effect Cohen, 2014103 Laverdière, 2005104
No. of Survivors 51 63
Late Effect
Cardiac 10 (20) 5 (8)
Pulmonary — 12 (19)
Hypertension/Renal — 6 (9)
Growth Abnormality 10 (20) 6 (9)
Gonadal Failure 9 (12) 13 (41)*
Hypothyroid 29 (49) 15 (24)
Hearing Loss 37 (73) 39 (62)
Neurocognitive 11 (38) 8 (13)
Data are given as numbers (percentages).
*Of 32 female survivors, 13 had ovarian failure.
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NEUROBLASTOMA BIOLOGY, THERAPY, AND SURVIVORSHIP
treatment with TBI.103,108 Survivors with growth failure
often exhibit suboptimal responses to growth hormone (GH)
therapy.109,110 The etiology of this striking growth failure
and inadequate GH response is unclear and may be at-
tributable to compromised spine growth after radiation.
Recent data have suggested that it may also be a conse-
quence of premature epiphyseal closure caused by 13-cis-
retinoic acid exposure.103,111 Other prevalent endocrine late
effects include hypothyroidism, abnormal glucose meta-
bolism, and delayed/abnormal pubertal development and
maturation.103,111,112 The high prevalence of hypothyroid-
ism in survivors of neuroblastoma reflects damage from
diagnostic exposure to radioactive iodine tracers (131I-MIBG)
and, in some cases, therapeutic radiation therapy that
involves the thyroid.113 A number of investigators reported
laboratory evidence of diabetes and metabolic syndrome
among survivors of high-risk neuroblastoma.112,114 Female
survivors may demonstrate abnormal pubertal progression
and premature ovarian failure; puberty and gonadal func-
tion has not been characterized in male individuals.103 In
addition to endocrine late effects, studies of survivors of
high-risk neuroblastoma suggest elevated rates of sensori-
neural hearing loss,104-108 cardiac dysfunction,103,104,108
hypertension/renal dysfunction,104-108 and neurocognitive
deficits including behavioral problems as well as speech
and/or learning disabilities.103,105 Importantly, these studies
were small institutional studies limiting investigators to
have the power to describe true incidence and risk of late
effects and identify the risk factors associated with their
development.
Recognizing the gap in knowledge regarding the com-
bined effects on morbidity and quality of life of high-dose
chemotherapy, radiation, and non-TBI–based stem cell
transplantation in combination with cis-retinoic acid, im-
munocytokines, and immunotherapy in high-risk survivors
of neuroblastoma, researchers have identified a cohort
of 5-year survivors (. 700) of high-risk neuroblastoma
treated between 2000 and 2011 who were enrolled in the
Children’s Oncology Group (COG) Neuroblastoma Biology
Moreno, 2013105 Perwein, 2011106 Hobbie, 2008108 Trahair, 2007107
57 16 13 23
— — 1 (8) —
— 4 (25) 7 (54) —
8 (14) 10 (63) 8 (61) 10 of 21 (47)
4 (7) 7 (44) 7 (54) 13 of 13 (100)
2 (4) 2 (13) 2 (15) 5 of 6 (83)
1 (2) 8 (50) 7 (54) 4 of 14 (29)
28 (49) 6 (38) 12 (92) 11 of 15 (73)
12 (21) — — —
asco.org/edbook | 2016 ASCO EDUCATIONAL BOOK e553
SPELEMAN, PARK, AND HENDERSON
Study ANBL00B1.115 The COG LEAHRN (Late Effects After High
Risk Neuroblastoma) study (ALTE 15N2) plans to open in 2016
and will recruit almost 400 of these survivors for a cross-
sectional study to characterize the survivors’ late effects and
SMNs, assess for predictors of these late effects and SMNs,
and identify factors predictive of decreased health-related
quality of life. Furthermore, ALTE 15N2 will serve to es-
tablish a cohort of high-risk survivors of neuroblastoma, with
stored peripheral blood samples, as a resource for future
investigation.
Understanding of the late effects and SMNs of survivors is
essential for both ensuring the long-term health of survivors
of neuroblastoma as well as informing the design of future
neuroblastoma treatment trials aimed at improved survival
along with a concurrent reduction in late effects. While we
continue to refine our understanding of the late effects
of modern neuroblastoma treatments, all neuroblastoma
survivors should continue to participate in lifelong risk-
based health care with surveillance and early intervention
of late effects and SMNs, as recommended by the Institute
of Medicine and the COG.116,117
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EPILOGUE: NEW TECHNIQUES, NEW
DISCOVERIES, NEW IDEAS...IN THAT ORDER
Referencing the quote of Nobel prize winner Sydney Brenner
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