Neuroblastoma medical therapy: Difference between revisions
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{{familytree | | X01 | | X02 | | X03 | | | |X01=<div style="width: 20em; padding:0em;">'''Low risk patients'''</div>| X02=<div style="width: 20em; padding:0em;">'''Intermediate risk patients'''</div>| X03=<div style="width: 20em; padding:0em;">'''High risk patients'''</div>}} | {{familytree | | X01 | | X02 | | X03 | | | |X01=<div style="width: 20em; padding:0em;">'''Low risk patients'''</div>| X02=<div style="width: 20em; padding:0em;">'''Intermediate risk patients'''</div>| X03=<div style="width: 20em; padding:0em;">'''High risk patients'''</div>}} | ||
{{familytree|boxstyle= border-top: 0px;| | A01 | | A02 | | A03 | | | |A01=<div style="width: 20em; padding:0em;text-align:left"> | {{familytree|boxstyle= border-top: 0px;| | A01 | | A02 | | A03 | | | |A01=<div style="width: 20em; padding:0em;text-align:left"> | ||
*'''Surgery followed by chemotherapy''' | *'''[[Surgery]] followed by [[chemotherapy]]''' | ||
*'''Chemotherapy with or without surgery''' | *'''[[Chemotherapy]] with or without [[surgery]]''' | ||
*'''Observation without [[biopsy]]''' | *'''[[Observation]] without [[biopsy]]''' | ||
</div>|A02=<div style="width: 20em; padding:0em;text-align:left"> | </div>|A02=<div style="width: 20em; padding:0em;text-align:left"> | ||
*'''[[Chemotherapy]] with or without surgery''' | *'''[[Chemotherapy]] with or without [[surgery]]''' | ||
*'''Surgery and observation''' | *'''[[Surgery]] and [[observation]]''' | ||
*'''[[Radiation therapy]]''' | *'''[[Radiation therapy]]''' | ||
</div>|A03=<div style="width: 20em; padding:0em;text-align:left"> | </div>|A03=<div style="width: 20em; padding:0em;text-align:left"> | ||
*'''A combination of chemotherapy, surgery, stem cell transplantation, radiation therapy, differentiation therapy, [[immunotherapy]], and [[isotretinoin]]''' | *'''A combination of [[chemotherapy]], [[surgery]], [[stem cell transplantation]], [[radiation therapy]], differentiation therapy, [[immunotherapy]], and [[isotretinoin]]''' | ||
</div>}} | </div>}} | ||
{{Family tree/end}} | {{Family tree/end}} | ||
| Line 99: | Line 99: | ||
}}</ref>=== | }}</ref>=== | ||
'''Observation''' | '''Observation''' | ||
* Low risk neuroblastoma patients younger than 6 months of age may be safely observed '''without''' obtaining a definitive histologic diagnosis or performing any surgical intervention. | * Low risk neuroblastoma [[Patient|patients]] younger than 6 months of [[age]] may be safely observed '''without''' obtaining a definitive [[histologic]] [[diagnosis]] or performing any [[Surgery|surgical intervention]]. | ||
* Observation among such patients avoids potential surgical complications, as the majority of neuroblastomas occurring among this age group demonstrate spontaneous regression. | * [[Observation]] among such [[Patient|patients]] avoids potential [[Complications|surgical complications]], as the majority of neuroblastomas occurring among this [[age]] group demonstrate spontaneous [[regression]]. | ||
'''Radiotherapy''' | '''Radiotherapy''' | ||
* Radiotherapy is generally not recommended for the management of low risk neuroblastoma patients. | * [[Radiation therapy|Radiotherapy]] is generally not recommended for the management of low risk neuroblastoma [[Patient|patients]]. | ||
'''Chemotherapy''' | '''Chemotherapy''' | ||
* Indications for chemotherapy for the management of low risk neuroblastoma patients include: | * Indications for [[chemotherapy]] for the management of low risk neuroblastoma [[Patient|patients]] include: | ||
:* Stage 1 or stage 2 tumors associated with ''MYCN'' amplification | :* Stage 1 or stage 2 [[Tumor|tumors]] associated with ''MYCN'' [[amplification]] | ||
:* Patients older than 18 months of age presenting with a stage 2B tumor and an unfavorable [[histology]] | :* [[Patient|Patients]] older than 18 months of age presenting with a stage 2B tumor and an unfavorable [[histology]] | ||
:* Symptomatic patients due to [[spinal cord]] compression, [[respiratory]] compromise, or [[hepatic]] infiltration | :* [[Symptomatic]] [[Patient|patients]] due to [[spinal cord]] compression, [[respiratory]] compromise, or [[hepatic]] infiltration | ||
* Chemotherapeutic regimens recommended for the management of low risk neuroblastoma patients may include agents such as: | * [[Chemotherapy regimens|Chemotherapeutic regimens]] recommended for the management of low risk neuroblastoma [[Patient|patients]] may include agents such as: | ||
:* [[Carboplatin]] | :* [[Carboplatin]] | ||
:* [[Cyclophosphamide]] | :* [[Cyclophosphamide]] | ||
| Line 128: | Line 128: | ||
}}</ref>=== | }}</ref>=== | ||
'''Observation''' | '''Observation''' | ||
* Observation is generally not recommended for the management of intermediate risk neuroblastoma patients. | * [[Observation]] is generally not recommended for the management of intermediate risk neuroblastoma [[Patient|patients]]. | ||
'''Radiotherapy''' | '''Radiotherapy''' | ||
* Indications for radiotherapy for the management of intermediate risk neuroblastoma patients include: | * Indications for [[Radiation therapy|radiotherapy]] for the management of intermediate risk neuroblastoma [[Patient|patients]] include: | ||
:* Symptomatic life-threatening neuroblastoma refractory to chemotherapy and/or surgery | :* [[Symptomatic]] life-threatening neuroblastoma refractory to [[chemotherapy]] and/or [[surgery]] | ||
:* Rapidly growing neuroblastoma associated with progressive disease symptoms | :* Rapidly growing neuroblastoma associated with progressive [[disease]] [[Symptom|symptoms]] | ||
'''Chemotherapy''' | '''Chemotherapy''' | ||
* Chemotherapeutic agents are generally effective for the management of intermediate risk neuroblastoma patients. | * [[Chemotherapeutic agents]] are generally effective for the management of intermediate risk neuroblastoma [[Patient|patients]]. | ||
* Intermediate risk neuroblastoma patients with '''favorable histology''' are successfully managed by '''4''' cycles of chemotherapy following surgery. | * Intermediate risk neuroblastoma patients with '''favorable [[histology]]''' are successfully managed by '''4''' cycles of [[chemotherapy]] following [[surgery]]. | ||
* Intermediate risk neuroblastoma patients with '''unfavorable histology''' are successfully managed by '''8''' cycles of chemotherapy following surgery. | * Intermediate risk neuroblastoma patients with '''unfavorable [[histology]]''' are successfully managed by '''8''' cycles of [[chemotherapy]] following [[surgery]]. | ||
* Neoadjuvant chemotherapy may be used to facilitate the partial resection of previously unresectable neuroblastomas among intermediate risk patients. | * [[Neoadjuvant chemotherapy]] may be used to facilitate the partial [[resection]] of previously unresectable neuroblastomas among intermediate risk [[Patient|patients]]. | ||
* Chemotherapeutic regimens recommended for the management of intermediate risk neuroblastoma patients may include agents such as: | * [[Chemotherapy regimens|Chemotherapeutic regimens]] recommended for the management of intermediate risk neuroblastoma [[Patient|patients]] may include agents such as: | ||
:* [[Carboplatin]] | :* [[Carboplatin]] | ||
:* [[Cyclophosphamide]] | :* [[Cyclophosphamide]] | ||
| Line 169: | Line 169: | ||
}}</ref>=== | }}</ref>=== | ||
'''Observation''' | '''Observation''' | ||
* Observation is generally not recommended for the management of high risk neuroblastoma patients. | * [[Observation]] is generally not recommended for the management of high risk neuroblastoma [[Patient|patients]]. | ||
'''Radiotherapy''' | '''Radiotherapy''' | ||
* Radiation therapy to consolidate local control after surgical resection is recommended for the management of high risk neuroblastoma patients. | * [[Radiation therapy]] to consolidate local control after [[surgical resection]] is recommended for the management of high risk neuroblastoma [[Patient|patients]]. | ||
'''Chemotherapy''' | '''Chemotherapy''' | ||
* Chemotherapy for high risk neuroblastoma patients is divided into the following three phases: | * [[Chemotherapy]] for high risk neuroblastoma [[Patient|patients]] is divided into the following three phases: | ||
:* '''Induction therapy:''' | :* '''Induction therapy:''' | ||
::* Chemotherapeutic regimens used in the induction therapy may include: | ::* [[Chemotherapy regimens|Chemotherapeutic regimens]] used in the induction therapy may include: | ||
:::* [[Cisplatin]] | :::* [[Cisplatin]] | ||
:::* [[Etoposide]] | :::* [[Etoposide]] | ||
| Line 183: | Line 183: | ||
:::* [[Topotecan]] | :::* [[Topotecan]] | ||
:* '''Consolidation therapy:''' | :* '''Consolidation therapy:''' | ||
::* Consolidation therapy of high risk neuroblastoma patients consists of high dose chemotherapeutic agents administered in tandem with hematopoietic stem cell transplantation. | ::* Consolidation therapy of high risk neuroblastoma [[Patient|patients]] consists of high dose [[chemotherapeutic agents]] administered in tandem with [[hematopoietic stem cell transplantation]]. | ||
::* Chemotherapeutic regimens used in the consolidation therapy may include: | ::* [[Chemotherapy regimens|Chemotherapeutic regimens]] used in the consolidation therapy may include: | ||
:::* [[Carboplatin]] | :::* [[Carboplatin]] | ||
:::* Etoposide | :::* [[Etoposide]] | ||
:::* [[Melphalan]] | :::* [[Melphalan]] | ||
:::* [[Busulfan]] | :::* [[Busulfan]] | ||
:::* Vincristine | :::* [[Vincristine]] | ||
:::* [[Irinotecan]] | :::* [[Irinotecan]] | ||
:* '''Maintenance therapy:''' | :* '''Maintenance therapy:''' | ||
::* A combination of differentiation therapy ([[GM-CSF]] and [[IL-2]]), [[isotretinoin]], and [[immunotherapy]] (chimeric anti-GD2 antibody-ch14.18) are adminstered following [[hematopoietic]] [[stem cell]] [[transplantation]] to improve the survival of high risk neuroblastoma patients. | ::* A combination of differentiation therapy ([[GM-CSF]] and [[IL-2]]), [[isotretinoin]], and [[immunotherapy]] (chimeric anti-GD2 antibody-ch14.18) are adminstered following [[hematopoietic]] [[stem cell]] [[transplantation]] to improve the survival of high risk neuroblastoma [[Patient|patients]]. | ||
==References== | ==References== | ||
Latest revision as of 14:21, 5 March 2019
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Risk calculators and risk factors for Neuroblastoma medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Zahir Ali Shaikh, MD[2]Haytham Allaham, M.D. [3]
Overview
Children oncology group (COG) risk stratification system determines the protocol of management used for neuroblastoma patients. COG risk stratification system divides the patients into 03 groups: low risk, intermediate risk and high risk patients. Low risk neuroblastoma patients are usually managed by either observation or surgical resection of the tumor. Intermediate risk patients are managed by neoadjuvant therapy in advance of a definitive surgical resection. High risk neuroblastoma patients are usually managed by a combination of surgery, chemotherapy, radiation therapy, hematopoietic stem cell transplantation, immunotherapy and isotretrinoin.
Medical Therapy
Risk Stratification[1][2][3][4]
- Children Oncology Group (COG) risk stratification system determines the protocol of management used for neuroblastoma patients.
- Low risk neuroblastoma patients are usually managed by either observation or surgical resection of the tumor.
- Intermediate risk neuroblastoma patients are usually managed by neoadjuvant chemotherapy in advance of a definitive surgical resection.
- High risk neuroblastoma patients are usually managed by a combination of surgery, chemotherapy, radiation therapy, hematopoietic stem cell transplantation, differentiation therapy, immunotherapy, and isotretinoin.[5]
- The algorithm below summarizes the management approach for neuroblastoma patients:
Children's Oncology Group risk stratification | |||||||||||||||||||||||||||||
Low risk patients | Intermediate risk patients | High risk patients | |||||||||||||||||||||||||||
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Management of Low Risk Neuroblastoma Patients[5][6][7]
Observation
- Low risk neuroblastoma patients younger than 6 months of age may be safely observed without obtaining a definitive histologic diagnosis or performing any surgical intervention.
- Observation among such patients avoids potential surgical complications, as the majority of neuroblastomas occurring among this age group demonstrate spontaneous regression.
Radiotherapy
- Radiotherapy is generally not recommended for the management of low risk neuroblastoma patients.
Chemotherapy
- Indications for chemotherapy for the management of low risk neuroblastoma patients include:
- Stage 1 or stage 2 tumors associated with MYCN amplification
- Patients older than 18 months of age presenting with a stage 2B tumor and an unfavorable histology
- Symptomatic patients due to spinal cord compression, respiratory compromise, or hepatic infiltration
- Chemotherapeutic regimens recommended for the management of low risk neuroblastoma patients may include agents such as:
Management of Intermediate Risk Neuroblastoma Patients[5][8]
Observation
- Observation is generally not recommended for the management of intermediate risk neuroblastoma patients.
Radiotherapy
- Indications for radiotherapy for the management of intermediate risk neuroblastoma patients include:
- Symptomatic life-threatening neuroblastoma refractory to chemotherapy and/or surgery
- Rapidly growing neuroblastoma associated with progressive disease symptoms
Chemotherapy
- Chemotherapeutic agents are generally effective for the management of intermediate risk neuroblastoma patients.
- Intermediate risk neuroblastoma patients with favorable histology are successfully managed by 4 cycles of chemotherapy following surgery.
- Intermediate risk neuroblastoma patients with unfavorable histology are successfully managed by 8 cycles of chemotherapy following surgery.
- Neoadjuvant chemotherapy may be used to facilitate the partial resection of previously unresectable neuroblastomas among intermediate risk patients.
- Chemotherapeutic regimens recommended for the management of intermediate risk neuroblastoma patients may include agents such as:
Management of High Risk Neuroblastoma Patients[5][9][10]
Observation
- Observation is generally not recommended for the management of high risk neuroblastoma patients.
Radiotherapy
- Radiation therapy to consolidate local control after surgical resection is recommended for the management of high risk neuroblastoma patients.
Chemotherapy
- Chemotherapy for high risk neuroblastoma patients is divided into the following three phases:
- Induction therapy:
- Chemotherapeutic regimens used in the induction therapy may include:
- Consolidation therapy:
- Consolidation therapy of high risk neuroblastoma patients consists of high dose chemotherapeutic agents administered in tandem with hematopoietic stem cell transplantation.
- Chemotherapeutic regimens used in the consolidation therapy may include:
- Maintenance therapy:
- A combination of differentiation therapy (GM-CSF and IL-2), isotretinoin, and immunotherapy (chimeric anti-GD2 antibody-ch14.18) are adminstered following hematopoietic stem cell transplantation to improve the survival of high risk neuroblastoma patients.
References
- ↑ Chizuko Okamatsu, Wendy B. London, Arlene Naranjo, Michael D. Hogarty, Julie M. Gastier-Foster, A. Thomas Look, Michael LaQuaglia, John M. Maris, Susan L. Cohn, Katherine K. Matthay, Robert C. Seeger, Tsutomu Saji & Hiroyuki Shimada (2009). "Clinicopathological characteristics of ganglioneuroma and ganglioneuroblastoma: a report from the CCG and COG". Pediatric blood & cancer. 53 (4): 563–569. doi:10.1002/pbc.22106. PMID 19530234. Unknown parameter
|month=ignored (help) - ↑ Susan L. Cohn, Andrew D. J. Pearson, Wendy B. London, Tom Monclair, Peter F. Ambros, Garrett M. Brodeur, Andreas Faldum, Barbara Hero, Tomoko Iehara, David Machin, Veronique Mosseri, Thorsten Simon, Alberto Garaventa, Victoria Castel & Katherine K. Matthay (2009). "The International Neuroblastoma Risk Group (INRG) classification system: an INRG Task Force report". Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 27 (2): 289–297. doi:10.1200/JCO.2008.16.6785. PMID 19047291. Unknown parameter
|month=ignored (help) - ↑ Chrystal U. Louis & Jason M. Shohet (2015). "Neuroblastoma: molecular pathogenesis and therapy". Annual review of medicine. 66: 49–63. doi:10.1146/annurev-med-011514-023121. PMID 25386934.
- ↑ Andrew M. Davidoff (2012). "Neuroblastoma". Seminars in pediatric surgery. 21 (1): 2–14. doi:10.1053/j.sempedsurg.2011.10.009. PMID 22248965. Unknown parameter
|month=ignored (help) - ↑ 5.0 5.1 5.2 5.3 Neuroblastoma treatment–for health professionals. National Cancer Institute (2015) http://www.cancer.gov/types/neuroblastoma/hp/neuroblastoma-treatment-pdq#section/_1 Accessed on October, 8 2015
- ↑ Jed G. Nuchtern, Wendy B. London, Carol E. Barnewolt, Arlene Naranjo, Patrick W. McGrady, James D. Geiger, Lisa Diller, Mary Lou Schmidt, John M. Maris, Susan L. Cohn & Robert C. Shamberger (2012). "A prospective study of expectant observation as primary therapy for neuroblastoma in young infants: a Children's Oncology Group study". Annals of surgery. 256 (4): 573–580. doi:10.1097/SLA.0b013e31826cbbbd. PMID 22964741. Unknown parameter
|month=ignored (help) - ↑ Douglas R. Strother, Wendy B. London, Mary Lou Schmidt, Garrett M. Brodeur, Hiroyuki Shimada, Paul Thorner, Margaret H. Collins, Edward Tagge, Stanton Adkins, C. Patrick Reynolds, Kevin Murray, Robert S. Lavey, Katherine K. Matthay, Robert Castleberry, John M. Maris & Susan L. Cohn (2012). "Outcome after surgery alone or with restricted use of chemotherapy for patients with low-risk neuroblastoma: results of Children's Oncology Group study P9641". Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 30 (15): 1842–1848. doi:10.1200/JCO.2011.37.9990. PMID 22529259. Unknown parameter
|month=ignored (help) - ↑ David L. Baker, Mary L. Schmidt, Susan L. Cohn, John M. Maris, Wendy B. London, Allen Buxton, Daniel Stram, Robert P. Castleberry, Hiroyuki Shimada, Anthony Sandler, Robert C. Shamberger, A. Thomas Look, C. Patrick Reynolds, Robert C. Seeger & Katherine K. Matthay (2010). "Outcome after reduced chemotherapy for intermediate-risk neuroblastoma". The New England journal of medicine. 363 (14): 1313–1323. doi:10.1056/NEJMoa1001527. PMID 20879880. Unknown parameter
|month=ignored (help) - ↑ Valeria Smith & Jennifer Foster (2018). "High-Risk Neuroblastoma Treatment Review". Children (Basel, Switzerland). 5 (9). doi:10.3390/children5090114. PMID 30154341. Unknown parameter
|month=ignored (help) - ↑ K. Beiske, S. A. Burchill, I. Y. Cheung, E. Hiyama, R. C. Seeger, S. L. Cohn, A. D. J. Pearson & K. K. Matthay (2009). "Consensus criteria for sensitive detection of minimal neuroblastoma cells in bone marrow, blood and stem cell preparations by immunocytology and QRT-PCR: recommendations by the International Neuroblastoma Risk Group Task Force". British journal of cancer. 100 (10): 1627–1637. doi:10.1038/sj.bjc.6605029. PMID 19401690. Unknown parameter
|month=ignored (help)