Neuroblastoma

Diagnosis

Indications for Testing

• Clinical presentation of disease – mass identified with imaging; presence of an associated syndrome

Laboratory Testing

• Initial testing – increased urinary excretion of vanillylmandelic acid (VMA) and homovanillic acid (HVA)
  • VMA/creatinine and HVA/creatinine ratios are used for diagnosis 
  • Elevations >10 times the reference limit are highly predictive of a neuroendocrine tumor
• Paraneoplastic opsoclonus-myoclonus syndrome frequently associated with anti-Hu (ANNA1)
• PHOX2B, ALK genetic mutation testing
  • Patients with sporadic or familial neuroblastoma in conjunction with congenital central hypoventilation syndrome or Hirschsprung syndrome

Histology

• Characteristic pathologic appearance of tissue specimens using the International Neuroblastoma Staging System (also called the Shimada system)
  • Protocol for examination of neuroblastoma specimens (College of American Pathologists [CAP])
  • Bone marrow biopsy – required for staging of disease
• Recent use of flow cytometry for bone marrow studies
  • Positive for CD44, CD56, CD81, CD9
  • Negative for CD45

Imaging Studies

• CT or MRI
• MIBG (metaiodobenzylguanidine) scintigraphy – if CT scan is not revealing
• Technetium bone scan – if bone disease suspected and MIBG scan is negative

Prognosis

• Markers
  • N-MYC – amplification associated with advanced stage disease, rapid tumor progression, and poor prognosis
  • DNA index – aneuploidy associated with poor prognosis
  • Others – not used in initial risk staging
    • Neuron-specific enolase – >100 ng/mL indicates worse prognosis
    • Ferritin – >142 ng/mL indicates worse prognosis
    • Lactate dehydrogenase – 1,500 u/L indicates worse prognosis
    • Chromosome additions/deletions – 17q, 1p;11q
      • Commonly associated with MYC amplification
    • TrKA, B, C
      • TrKA tends to have a favorable prognosis; TrKB does not
• Children's Oncology Group risk group classification

  Risk Group Classification
  Risk Group	INSS*	Age	N-MYC	DNA index	Shimada histopathology
  Low	1 2A, 2B 2A, 2B 2A, 2B 4S	Any <1 ≥1 ≥1 <1	Any Any Nonamplified Amplified Nonamplified	Any Any Any Any >1.0	Any Any Any Favorable Favorable
  Intermediate	3 3 4 4S 4S	<1 ≥1 <1 <1 <1	Nonamplified Nonamplified Nonamplified Nonamplified Nonamplified	Any Any Any 1.0 Any	Any Favorable Any Favorable Unfavorable
  High	2A, 2B 3 3 3 4 4 4S	≥1 <1 ≥1 ≥1 <1 ≥1 <1	Amplified Amplified Nonamplified Amplified Amplified Any Amplified	Any Any Any Any Any Any Any	Unfavorable Any Unfavorable Any Any Any Any
  * International Neuroblastoma Staging System

Differential Diagnosis

• Nephroblastoma (Wilms tumor)
• Clear-cell sarcoma of the kidney
• Rhabdoid tumor of the kidney
• Renal or adrenal cyst/hemorrhage
• Renal-cell carcinoma
• Adrenocortical neoplasm
• Non-Hodgkin lymphoma (especially Burkitt lymphoma)
• Ewing sarcoma/primary neuroendocrine tumor
• Desmoplastic small round-cell tumor

Screening

Clinical Background

Neuroblastomas are solid tumors of the autonomic nervous system and the most common extracranial solid tumor in infants and children.

Epidemiology

• Incidence – 10.5/1,000,000 children <15 years worldwide
• Age – <5 years; median is 2 years
• Sex – M<F (1:2.1)
• Occurrence – mostly sporadic; 1-2% are familial

Conditions Associated with Increased Risk of Neuroblastoma 

• Neurofibromatosis
• Congenital central hypoventilation syndrome
• Hirschsprung disease
• Neurocristopathy syndrome

Pathophysiology

• Malignant tumor from undifferentiated or poorly differentiated neuroectodermal cells of the neural crest
  • Some infants born with tumors
• Abdominal tumors in ~65% of cases, 40% of which are adrenal
• About 50% of cases have aggressive, fast-growing tumors
  • May spread to lymph nodes and other organs before symptoms are evident

Clinical Presentation

• Symptoms determined by tumor location and stage
  • Abdominal site most common – symptoms include abdominal pain
• Localized tumors often asymptomatic 
• Metastatic tumors frequently associated with crying and irritability, fever, bone pain, weight loss
  • Initially may be asymptomatic (~50% of patients)
  • Orbital metastases – periorbital ecchymoses (“raccoon eyes”) and proptosis
    • May be confused with trauma
  • Paraspinal disease – paresis and cord compression
  • Cervical, apical thoracic disease 
• Syndromes associated with neuroblastoma
  • Horner syndrome – ptosis, miosis, anhidrosis (associated with thoracic or cervical [neck] primary tumor)
  • Hutchinson syndrome – limping and irritability associated with bone pain and bone marrow metastases
  • Neurocristopathy syndromes – congenital neuroblastoma associated with other neural crest disorders
    • Congenital central hypoventilation syndrome (also called Ondine curse)
    • Hirschsprung disease – congenital megacolon
    • Opsoclonus-myoclonus syndrome (also called dancing eyes-dancing feet syndrome, Kinsbourne syndrome, myoclonic encephalopathy of infants)
      • Involuntary eye fluttering
      • Muscle jerking
      • Ataxia
  • Pepper syndrome – massive metastatic disease in infants <1 year involving skin, liver, bone marrow
  • Kerner-Morrison syndrome – vasoactive intestinal polypeptide secretion causing refractory diarrhea, hypokalemia, hypovolemia, failure to thrive

Indications for Laboratory Testing

• Tests generally appear in the order most useful for common clinical situations
• Click on number for test-specific information in the ARUP Laboratory Test Directory

Click the plus sign to expand the table of additional tests.

Test Name and Number	Comments
Vanillylmandelic Acid (VMA), Urine 0080421 Method: Quantitative High Performance Liquid Chromatography
Homovanillic Acid (HVA), Urine 0080422 Method: Quantitative High Performance Liquid Chromatography
Neuron Specific Enolase 0098198 Method: Quantitative Enzyme-Linked Immunosorbent Assay
Ferritin 0070065 Method: Quantitative Chemiluminescent Immunoassay
Achondroplasia (FGFR3) 2 Mutations 0051266 Method: Polymerase Chain Reaction/Fluorescence Resonance Energy Transfer
Neuronal Nuclear (Hu, Ri, Yo, and Amphiphysin) Antibodies IgG by Immunoblot 2007963 Method: Qualitative Immunoblot
Lactate Dehydrogenase Total, Body Fluid 0020505 Method: Quantitative Enzymatic