Molecular Pathogenesis of Peripheral Neuroblastic Tumors
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Oncogene (2010) 29, 1566–1579 & 2010 Macmillan Publishers Limited All rights reserved 0950-9232/10 $32.00 www.nature.com/onc REVIEW Molecular pathogenesis of peripheral neuroblastic tumors I Janoueix-Lerosey1, G Schleiermacher1,2 and O Delattre1,3 1INSERM U830, Laboratoire de Ge´ne´tique et Biologie des Cancers, Institut Curie, Paris Cedex 05, France; 2De´partement de Pe´diatrie, Institut Curie, Paris Cedex 05, France and 3Unite´ de Ge´ne´tique Somatique, Institut Curie, Paris Cedex 05, France Neuroblastoma (NB) is an embryonal cancer of the thetic nervous system (Brodeur, 2003; Maris et al., sympathetic nervous system observed in early childhood, 2007). Although most primary tumors occur in the characterized by a broad spectrum of clinical behaviors, abdomen (65%), often in the adrenal medulla, other ranging from spontaneous regression to fatal outcome develop in the paraspinal sympathic ganglia, at various despite aggressive therapies. NB accounts for 8–10% of sites including neck (5%), chest (20%) and pelvis (5%). pediatric cancers and 15% of the deaths attributable to The clinical presentation of NB can be very hetero- malignant conditions in children. Interestingly, NB may geneous as reported more than 30 years ago (Evans occur in various contexts, being mostly sporadic but also et al., 1971). Until recently, the most widely used staging familial or syndromic. This review focuses on recent system was the international NB staging system (INSS) advances in the identification of the genes and mechanisms that classified NB tumors into five stages according to implicated in NB pathogenesis. Although the extensive the clinical presentation and age. This INSS classifica- characterization of the genomic aberrations recurrently tion distinguished localized (stages 1 and 2), advanced observed in sporadic NBs provides important insights locoregional disease (stage 3) or metastatic (stage 4 or into the understanding of the clinical heterogeneity of this 4s) tumors (Brodeur et al., 1993) (Figure 1). A new neoplasm, analysis of familial and syndromic cases also system called International Neuroblastoma Risk Group unravels essential clues on the genetic bases of NB. Staging System (INRGSS), based on clinical criteria and Recently, the ALK gene emerged as an important NB image-defined risk factors, now classifies NB into L1 gene, being implicated both in sporadic and familial cases. (localized disease without image-defined risk factors The identification of gene expression signatures associated precluding surgical resection), L2 (localized disease with with patient’s outcome points out the potential of using image-defined risk factors), M (metastatic tumors) and gene expression profiling to improve clinical management Ms (metastatic tumors with metastases confined to the of patients suffering from NB. Finally, based on recent skin, liver and/or bone marrow in children younger than observations integrating genomic analyses, biological data 18 months of age) (Cohn et al., 2009; Monclair et al., and clinical information, we discuss possible evolution/ 2009). The signs and symptoms of NB are extremely progression schemes in NB. variable, depending on age, primary tumor site, presence Oncogene (2010) 29, 1566–1579; doi:10.1038/onc.2009.518; of metastasis and occasionally on associated paraneo- published online 25 January 2010 plastic syndromes. Heterogeneity also characterizes the clinical course and outcome of NB patients: whereas a Keywords: neuroblastoma; genetic alterations; suscept- subset of tumors will undergo spontaneous regression, ibility; ALK mutations; expression profiling; progression others show relentless progression in spite of multi- modal treatment. The outcome of children with NB is extremely different according to the INSS stage, with long-term survival rates still lower than 40% for patients Neuroblastoma clinical features with a high-risk clinical phenotype (Figure 1). Clinical presentation Histology Neuroblastoma (NB) was first described more than one An International Pathology Classification System century ago, by three physicians including Robert (INPC), based on the Shimada classification, distin- Hutchison, William Pepper and James Homer Wright guishes favorable and unfavorable tumors depending on who recognized the neural nature of the tumor the degree of neuroblastic differentiation, the amount of (Rothenberg et al., 2009). NB is indeed a disease of Schwannian stromal content, the mitosis-karyorrhexis the sympaticoadrenal lineage of the neural crest and index (MKI) and the age at diagnosis (Shimada et al., tumors may develop at various sites along the sympa- 1999). Schematically, the unfavorable group includes undifferentiated tumors or high MKI cases at any age, Correspondence: Dr I Janoueix-Lerosey, INSERM U830, Laboratoire poorly differentiated tumors or intermediate MKI in de Ge´ne´tique et Biologie des Cancers, Institut Curie, 26 rue d’Ulm, children older than 18 months, differentiating tumor or Paris Cedex 05 75248, France. E-mail: [email protected] low MKI over 60 months. The favorable group includes Received 14 September 2009; revised 10 December 2009; accepted 18 all the other cases as well as ganglioneuroma (GN) or December 2009; published online 25 January 2010 ganglioneuroblastoma intermixed. The last category is Molecular pathogenesis of peripheral neuroblastic tumors I Janoueix-Lerosey et al 1567 Stages 1, 2 or 4s (n=248) 100 ≤ 18 months (n=340) 100 80 80 Stage 3 (n=87) 60 60 40 40 > 18 months (n=153) Stage 4 (n=151) Overall survival (%) Overall survival (%) 20 20 0 0 0 40 80 120 160 200 240 0 40 80 120 160 200 240 Time (months) Time (months) Figure 1 NB is a heterogeneous disease with respect to clinical presentation and outcome. (a) Metastatic NB revealed by an MIBG scintigraphy; (b) localized thoracic NB; (c) example of NB unfavorable histology; (d, e) overall survival of NB patients according to the INSS stage or age at diagnosis, respectively. The Kaplan–Meier survival curves correspond to the series of 493 NB patients reported in our recent paper (Janoueix-Lerosey et al., 2009). nodular ganglioneuroblastoma, with well-defined areas program in Japan, in which more than 15 million children of ganglioneuromatous and neuroblastic components, were screened at 6 months between 1984 and 2003, may be the prognosis of which is determined by evaluating more encouraging (Hiyama et al., 2008). Indeed, though differentiation and MKI of the neuroblastic component. this report confirms the higher incidence of favorable NB in the screened cohort as compared with the unscreened, it also reports a decreased mortality in the screened group Mass screening associated with a decreased incidence of stage 4 tumors. Most of NBs secrete catecholamine whose metabolites can This therefore suggests that screening at 6 months may be found in the urine including dopamine, vanillylmandelic detect some cases that would otherwise evolve toward acid and homovanillic acid. This property has an more aggressive tumors at a later age. Given these results important diagnostic value and is also extremely useful and with the goal of decreasing overdiagnosis and for patient’s follow-up. In the 1980–1990s it provided a increasing effectiveness, pilot screening programs at 18 rationale to propose mass screening programs for NB months have recently been launched in Japan. Although detection at birth or at 6–12 months of age, mainly in encouraging it has to be kept in mind that the Hiyama Japan, Quebec and Germany (Schilling et al., 2002; study is retrospective and should hence be confirmed by a Yamamoto et al., 2002; Barrette et al., 2006). Quite prospective, case–control study to fully document the disappointingly, the main early observation of these benefit of screening (Maris and Woods, 2008). programs was an overall increased incidence of NB without significant decrease in mortality. This therefore indicated that screening mainly detected NB that would Epidemiology otherwise have regressed spontaneously but was relatively NB prevalence is about one case in 7000–10 000 live inefficient for an early detection of clinically relevant high- births. There is no strong evidence for difference in risk cases. However, the recent results of a nationwide disease occurrence according to ethnical origin. No Oncogene Molecular pathogenesis of peripheral neuroblastic tumors I Janoueix-Lerosey et al 1568 major risk factor was identified with respect to the (Figure 2) (Mosse et al., 2004; McConville et al., 2006; potential role of parental occupation and of environ- Raabe et al., 2007). A recent survey of the genotype– mental factors in the pre- and perinatal periods phenotype correletions performed on 174 patients affec- (reviewed in (Heck et al., 2009)). More convincingly, a ted with Congenital Central Hypoventilation Syndrome, recent study investigating the role of birth character- either isolated or associated with Hirschsprung’s disease istics, congenital malformations and maternal reproduc- and/or neuroblastic tumors confirmed that NB predis- tive history reported a very significant association of NB position was mainly linked to missense and frame- with congenital malformation in children less than 1 shift mutations (Trochet et al., 2005b). Although the year (Munzer et al., 2008). involvement of PHOX2B in familial cases of NB is compelling, its contribution to the development of sporadic NB is much less obvious as somatic mutations are extremely rare (van Limpt et al., 2004; McConville Hereditary predisposition to NB et al., 2006; Raabe et al., 2007). Several