High dose chemotherapy and autologous hematopoietic stem cell rescue for children with high risk neuroblastoma: Two case report

Bệnh viện Trung ương Huế 
94 Journal of Clinical Medicine - No. 62/2020
HIGH DOSE CHEMOTHERAPY AND AUTOLOGOUS 
HEMATOPOIETIC STEM CELL RESCUE FOR CHILDREN 
WITH HIGH RISK NEUROBLASTOMA: TWO CASE REPORT
Nguyen Thi Kim Hoa1, Tran Kiem Hao1, Chau Van Ha1, Phan Canh Duy2, 
Dong Si Sang3, Phan Thi Thuy Hoa3, Ho Huu Thien4, Nguyen Thi My Linh1, Pham Nhu Hiep4 
DOI: 10.38103/jcmhch.2020.62.16
ABSTRACT 
Introduction: High-risk neuroblastoma is a childhood malignancy with a poor prognosis. Gradual 
improvements in survival have correlated with therapeutic intensity, and the ability to harvest, process and 
store autologous hematopoietic stem cells has allowed for dose intensification beyond marrow tolerance.
Case: We report two cases which were diagnosed high risk neuroblastoma. The first case had big 
heterogeneous at his left adrenal gland with metastasis in bone marrow and his brain. The second case 
with localised tumor at her right kidney and NMYC positive. Both cases were treated with SIOPEN protocol, 
starting with 8 course RAPID COJECT. Patients had partial response and were collected stem cells. Then 
they were primary tumor resection; receiving high dose chemotherapy with autologous- stem cell rescue, 
radiation and retino acid treatment, respectively. 
Conclusion: This is initially report of autologous stem cell transpant for high risk neuroblastoma. Even 
only two patients, the results showed that stem cell transplant was safe and effective. We are continuing 
to implement for more case with high risk neuroblastoma and will have better report with a bigger number.
 1. Pediatric Center, Hue Central Hospital
 2. Oncology Center, Hue Central Hospital
 3. Blood and Transfusion Center, Hue Central Hospital
 4. Department of Abdominal Emergency and Pediatric 
Surgery, Hue Central Hospital
Corresponding author: Nguyen Thi Kim Hoa
Email: kimhoa.fmi@gmail.com 
Received: 8/5/2020; Revised: 17/5/2020 
Accepted: 20/6/2020
I. INTRODUCTION
Neuroblastoma is the most common extracranial 
solid tumor in children[1], accounting for 7% to 8% 
of all childhood cancers. The prevalence is about 1 
case per 7.000 live births. Neuroblastoma is slightly 
more common in boys than in girls, with a male to 
female ratio of 1.1 to 1. The peak incidence occurs 
at 2 years of age, some studies show that 89% are 
younger than 5 years, and 98% of cases are diagnosed 
in the first 10 years of life. The distribution of cases 
by age clearly shows that this is a disease of infancy 
and early childhood, with the highest number of 
cases diagnosed in the first month of life. Before 
the development of comprehensive, multimodality 
therapy, long term survival probabilities for high 
risk neuroblastoma patient were less than 15% [2]. 
High dose chemotherpay with autologous stem 
cell rescue has improved the outcomes for children 
with high risk neuroblastoma [3,4]. Using busulfan 
and melphalan (BuMel) as conditioning regime, 
the International Society of Pediatric Oncology 
Neuroblastoma HR NBL1 protocol reported 3 year 
High dose chemotherapy and autologous...
Hue Central Hospital
Journal of Clinical Medicine - No. 62/2020 95
EFS and OS of 49% and 60%, respectively[2].
Since 2016, Hue Pediatric Center has been starting 
to treat for children with solid tumor, and has been 
receiving many neuroblastoma patients, in which 
there are 60% high risk neuroblastoma. How to 
improve the survival rate for high risk neuroblastoma 
is a challenge for our team. With the great support 
from Board Director of Hue Central Hospital, Hue 
Pediatric Center did autologous transplant sucessfully 
for two high risk neuroblastoma cases, and hopefully 
we has been continuing to do more cases in order 
to build Hue Central Hospital as one of Vietnam’s 
leading medical center.
II. CASE REPORT
2.1. Clinical features and imaging finding
The first case: 5 year old male was admitted 
to Hue Pediatric Center due to fever and pain at 
his right knee. He was done CT scan whole body 
and found out one heterogeneous tumor at his 
retroperitoneum, measuring 8.6x5.1x4.9cm, with 
calcification inside. The tumor encased some 
arteries at retroperitoneum, invased left kidney and 
left adrenal gland. At his occipital area and sinciput 
area, there were lesions measuring from 10-40 mm. 
He was done bilateral bone marrow biopsy and the 
result showed metastasis neuroblastoma. 
The second case: 5 year old female was admitted to 
Hue Pediatric Center due to She came to my hospital 
due to her abdominal distention. She was done CT 
scan whole body and found out one heterogeneous 
tumor at her right kidney measuring 7.9x8.3x8.9 cm 
(Figure 1, Figure 2). This tumor compressed right 
kidney and the right kidney had hydronephrosis. The 
tumor also invased the liver and right adrenal gland. 
She was done bilateral bone marrow biopsy and the 
result was negative. She was done needle biopsy with 
the result: neuroblastoma, NMYC: positive.
Figure 1: CT scan whole body of the first patient showed tumours at his abdomen and his brain (at initial time)
Figure 2: CT scan whole body of the second patient showed tumours at her abdomen (at initial time)
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96 Journal of Clinical Medicine - No. 62/2020
2.2. Pathology results
For the first case, we did needle biopsy the 
primary tumor and the result showed neuroblastoma, 
with synaptophysin, chromogranin: positive, LCA, 
CK AE1/3, Vimemtin, CD 99: negative. The result 
of bilateral bone marrow biopsy were reviewed in St 
Jude Children’s Research Hospital. The result showed 
that the mononuclear cells were subset positive for 
vimentin, chromogranin A, synaptophysin, CD 
99dim while negative for keratin AE1/3, EMA. CD 
43, myogenin, MyoD1, CD42b. These finding were 
consistent with metastatic neuroblastoma.
After remove the residual tumor, we sent the 
sample to St Jude Children’s Research Hospital 
in Memphis to review. The result showed: 
microscopic examination of the slide showed a 
large nerve fascicle attached to a small fragment 
of the tumor with evidence of therapy effect. The 
tumor was composed of Schwannian stroma with 
scattered neuroblastic cells in different stages of 
maturation along with ganglion cells and scattered 
hemosiderin - laden macrophages. Fuorescence in 
situ hybridization for MYNC performed at St. Jude 
was negative for amplification. 
The result of second case:
The histologic sections showed a neuroblastic 
tumor composed of sheets of malignant small round 
cells with minimal interspersed fibrillary neuropil-
like material and large areas of tumor necrosis. 
The tumor cells exhibitted brisk mitosis with 
karyorrhexis in more than 4% of the tumor cells. 
Immunohistochemically, the tumor cells showed 
patchy positive staining for synaptophysin, whereas, 
cytokeratine AE1/AE3, desmin, BCOR, and CD 99 
are negative. The overall features were consistent 
with a poorly differentiated neuroblastoma with an 
unfavorable histopathology.
Fluorescence in situ hybridization testing 
performed at St. Jude showed MYCN amplification.
2.3. Diagnosis and treatment and evaluation
Both cases were diagnosed high risk neuroblas-
toma and were treated with SIOPEN protocol for 
high risk neuroblastoma. They were received 8 
course of RAPID COJECT. 
After 8 course chemotherapy, both patients had partial respones. 
The first patient: the tumor at his adrenal gland shrank significantly, with the dimesion: 3.6x3.1x2.8 cm. 
The lesion at his brain membrane at the right side of sinciput shrank, measuing: 39x10 mm (Figure 3, 
Figure 4). 
Figure 3: CT scan whole body of the first patient after treatment
The second patient: the tumor shrank very well, measuring 3.2x4x4.5 cm.
High dose chemotherapy and autologous...
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Journal of Clinical Medicine - No. 62/2020 97
Figure 4: CT scan whole body of the second patient after treatment
With the partial reponses, both patients were collected stem cells. The first patient had 4.11x 106 CD 
34 cells, the second patient had 2.87x106 CD 34 cells. Then, both of them was removed than 80% original 
tumors, and were ready for stem cell transplantation.
2.4. High dose chemotherapy and stem cell transplantation
Both patients were received conditioning regimen with Bul/Mel as the below:
Medicine - 7 - 6 -5 -4 -3 -2 -1 0
Busulfan IV xx xxxx xxxx xxxx xx
Melphalan IV x
Hydration 3l/m2/d x x x x x x x
Stem cell infusion x
Mephalan dose: 140mg/m2/day, Busulfan dose: 
1mg/kg/day.
During transplant, patient were received ursodiol 
300mg/m2/day (from D-8 to D+80 to prevent VOD; 
Acyclovir 250mg/m2 every 8 hours from D-8 đến 
D 100. Levofloxacine 10mg/kg x 2 times per day 
(D-8 to D30; G-CSF since D+5 until Neutrophile > 
0.5x109/l for two consecutive days, and radiation 
blood products.
After transplant, both patients appeared 
neutropenic fever, mucosa ulcer with grade I, II, 
elevated CRP and PCT, and were treated with 
antibiotic and antifungal. The second case lasted 
fever for 6 days due to Chromobacterium violaceum 
infection. The first patient had neutrophile and 
platelet recovery on day 11 and day 25 respectively. 
The second patient had neutrophile and platelet 
recovery on day 42 and day 45 respectively. Both 
patients were discharged on day 32 and day 72 
respectively without any special side effects (kidney, 
interstitial pneumonitis and venoocclusive diseas). 
Then they were received radiation to primary tumor, 
and took 13 cis retino acid. Now, both of them 
are very healthy: the first patient has completed 
remission after 13 months, and the second patient has 
completed remission after 12 months.. 
III. DISCUSSION
The diagnosis of high risk neuroblastoma for 
both patients were clearly and based on their 
responses, they had indication to receive high 
dose chemotherapy and autologous stem cell 
transplantation.[5] However, due to receiving 
many chemotherapy, their marrows were often 
hypocellulary, so the amount of stem cell 
collection were not high, only 4.11x 106 CD 
34 cells for the first case, and 2.87x106 CD 34 
cells for the second case. This is a reason why 
nowadays, they prefer to collect stem cells earlier 
if patients do not have bone marrow metastasis 
or bone marrow clears after chemotherpy. [4,6] 
Regarding conditioning regimen, there are two 
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regimens: Bul/Mel (busulfan and melphalan) and 
CEM (carboplatin, etoposide and melphalan). 
[3,6,7] We chosed myeloablative therapy with 
Bul/Mel followed by 13 cis retino-acid.[8,9] After 
transplant, the first patient recoveried faster than 
the second patient. This could be explained due to 
the amount of CD 34 cell infusion. According to 
Fish and Ali: the number of CD34+ cells infused 
to a patient correlates with the likelihood of 
successful engraftment. [4,10] The treatment was 
well tolerated. Mucositis was the main toxicity, 
with grade I and II. Both of them had developed 
neutropenia fever and without any special 
side effects, such as: renal effects, interstitial 
pneumonitis and venooclusive disease. 
IV. CONCLUSION
Management high risk neuroblastoma is 
very challenge and need combined many drugs. 
Autologous stem cell transplant plays an important 
role in consolidation. This is the first two case 
autologous stem cell transplant for high risk 
neuroblastoma. Both of them tolerated well and had 
no special side effects. Until now, they have one more 
year survival since diagnosis. We continue to follow 
up and implement the new therapy to more patients.
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High dose chemotherapy and autologous...