# Adrenal Hemorrhage — GCMD Library living collection

Everything in the library about adrenal hemorrhage — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 125 cited statements

## Episodes
### In-Depth Reviews
- [Neuroblastoma](https://library.globalcastmd.com/watch/neuroblastoma-2534) — video · [machine version](https://library.globalcastmd.com/watch/neuroblastoma-2534.md)
- [Neuroblastoma](https://library.globalcastmd.com/watch/neuroblastoma-1620) — podcast · 56:19 · [machine version](https://library.globalcastmd.com/watch/neuroblastoma-1620.md)
- [Neuroblastoma](https://library.globalcastmd.com/watch/neuroblastoma-13431) — podcast · 56:16 · [machine version](https://library.globalcastmd.com/watch/neuroblastoma-13431.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=0) Introduction and Prenatal Diagnosis Approach (Ep 2)
- [4:00](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=240) Postnatal Workup and Observation Strategy (Ep 2)
- [9:07](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=547) Surveillance Protocol and Long-term Follow-up (Ep 2)
- [11:03](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=663) Surgical Approach and Stage MS Disease (Ep 2)
- [14:44](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=884) Workup of Older Child with Abdominal Mass (Ep 2)
- [21:50](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1310) Tissue Biopsy Techniques and Adequacy (Ep 2)
- [30:17](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1817) Risk Stratification and Staging (Ep 2)
- [36:54](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2214) Central Line Selection and Timing (Ep 2)
- [41:49](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2509) Timing of Surgical Resection (Ep 2)
- [47:40](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2860) Surgical Philosophy and Extent of Resection (Ep 2)
- [53:13](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3193) Immunotherapy Advances (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=0) Prenatal Diagnosis and Observation (Ep 1)
- [10:39](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=639) Surveillance Protocol and Indications for Surgery (Ep 1)
- [15:08](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=908) Stage MS Disease with Liver Involvement (Ep 1)
- [21:05](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1265) Workup of Large Abdominal Mass in Older Child (Ep 1)
- [27:10](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1630) Tissue Acquisition Strategies (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=0) Prenatal and Neonatal Neuroblastoma: Diagnosis and Observation (Ep 3)
- [7:28](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=448) Observation Protocols and Stage MS Disease Management (Ep 3)
- [18:08](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1088) Workup of Large Abdominal Mass in Older Children (Ep 3)
- [23:48](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1428) Biopsy Techniques: Open vs Percutaneous Approaches (Ep 3)
- [30:25](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1825) Risk Stratification and the Role of MYCN Amplification (Ep 3)
- [37:24](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2244) Timing and Extent of Surgical Resection in High-Risk Disease (Ep 3)
- [47:40](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2860) Surgical Philosophy: Balancing Aggressive Resection with Safety (Ep 3)
- [53:14](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=3194) Immunotherapy Breakthrough: Anti-GD2 Monoclonal Antibody (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Adrenal hemorrhage is the most common differential diagnosis for prenatal suprarenal mass, more common with history of fetal stress — Daniel von Allmen (clinical) [Ep 1 · 2:11](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=131)
- Other differential diagnoses for suprarenal mass include neuroblastoma, pulmonary sequestration below the diaphragm, and misdiagnosed renal anomaly — Daniel von Allmen (clinical) [Ep 1 · 2:11](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=131)
- Familial neuroblastoma occurs in about 1% of patients — Tony Sandler (epidemiological) [Ep 1 · 4:39](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=279)
- For prenatal suprarenal mass, first postnatal study should be ultrasound of the abdomen — Todd Ponsky (guideline) [Ep 1 · 5:07](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=307)
- CT scan or MRI not needed for 3 cm lesion unless urine catecholamines are elevated — Tony Sandler (guideline) [Ep 1 · 5:34](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=334)
- MIBG scan is the next step if catecholamines are elevated — Daniel von Allmen (guideline) [Ep 1 · 6:02](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=362)
- Radiologists are quite good at identifying adrenal hemorrhage on ultrasound — Daniel von Allmen (opinion) [Ep 1 · 6:02](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=362)
- In perinatal phase, most common metastatic sites are liver, bone, skin, and lymph nodes — Daniel von Allmen (clinical) [Ep 1 · 8:14](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=494)
- Nocktern study data supports observation of prenatal neuroblastoma with careful ultrasound surveillance — Daniel von Allmen (guideline) [Ep 1 · 8:44](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=524)
- Of 84 observed patients in Nocktern study, 16 (approximately 20%) underwent resection for growth or family preference — Tony Sandler (epidemiological) [Ep 1 · 10:39](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=639)
- Nocktern study showed approximately 98% event-free survival and 100% overall survival in observed prenatal neuroblastoma — Erika Newman (epidemiological) [Ep 1 · 11:07](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=667)
- First-year surveillance protocol: ultrasound and catecholamines at birth, 3 weeks, 6 weeks, 12 weeks, then spaced out to one year — Erika Newman (guideline) [Ep 1 · 11:37](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=697)
- After one year, surveillance becomes every six months, then yearly — Erika Newman (guideline) [Ep 1 · 11:37](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=697)
- Case report: child with observed prenatal adrenal mass that resolved presented at age 3 with widely metastatic high-risk neuroblastoma — Daniel von Allmen (clinical) [Ep 1 · 12:27](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=747)
- 5 centimeters is used as size cutoff for surgical intervention in observed prenatal masses — Tony Sandler (guideline) [Ep 1 · 14:36](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=876)
- Volume increase of more than 50% is criterion for considering surgery — Todd Ponsky (guideline) [Ep 1 · 15:08](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=908)
- 50% increase in VMA or HVA prompts consideration of surgery — Todd Ponsky (guideline) [Ep 1 · 15:08](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=908)
- Laparoscopic approach is reasonable for masses less than 6 centimeters — Erika Newman (guideline) [Ep 1 · 16:07](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=967)
- Lymph node status in neuroblastoma is not as important for therapy changes as in Wilms tumor — Daniel von Allmen (clinical) [Ep 1 · 16:36](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=996)
- Biology of neuroblastoma is more important than lymph node status for treatment decisions — Erika Newman (clinical) [Ep 1 · 17:00](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1020)
- Stage MS (formerly 4S) with skin lesions and liver mets still tends to have good biology — Erika Newman (clinical) [Ep 1 · 17:30](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1050)
- Primary concern in stage MS with liver involvement is mass effect causing respiratory compromise — Daniel von Allmen (clinical) [Ep 1 · 17:58](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1078)
- Stage MS without distress can be treated with aggressive observation — Erika Newman (guideline) [Ep 1 · 17:58](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1078)
- Once respiratory compromise begins, treatment options include chemotherapy, radiation, or emergent decompressive laparotomy — Erika Newman (guideline) [Ep 1 · 17:58](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1078)
- Classic findings of stage MS (high catecholamines, blue blebs on skin, liver metastasis, adrenal mass) may not require biopsy — Daniel von Allmen (opinion) [Ep 1 · 19:06](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1146)
- Liver biopsy in newborns is difficult because bleeding is hard to control — Erika Newman (clinical) [Ep 1 · 19:52](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1192)
- If NMYC is amplified in stage MS, staging changes from MS to M — Todd Ponsky (clinical) [Ep 1 · 20:40](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1240)
- VIP secretion can cause severe diarrhea in neuroblastoma — Erika Newman (clinical) [Ep 1 · 21:05](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1265)
- Initial workup for abdominal mass includes ultrasound to determine solid vs cystic, then CT with PO and IV contrast if solid — Erika Newman (guideline) [Ep 1 · 21:05](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1265)
- Ultrasound is important for Wilms tumor to assess venous extension — Tony Sandler (clinical) [Ep 1 · 22:56](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1376)
- Large mass encasing aorta and celiac axis with microcalcifications represents L2 INRG classification — Tony Sandler (clinical) [Ep 1 · 23:50](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1430)
- Complete staging workup includes bone marrow biopsy, MIBG scan, chest CT to rule out metastasis, and head CT if clinical symptoms present — Tony Sandler (guideline) [Ep 1 · 23:50](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1430)
- 10% of neuroblastomas are not MIBG avid — Daniel von Allmen (epidemiological) [Ep 1 · 25:06](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1506)
- PET scan may detect metastases in MIBG-negative neuroblastomas — Daniel von Allmen (clinical) [Ep 1 · 25:06](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1506)
- PET scan is not part of routine initial diagnostic workup but may be used for MIBG-negative soft tissue areas to distinguish recurrence from scar — Erika Newman (guideline) [Ep 1 · 26:03](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1563)
- Open retroperitoneal biopsy provides adequate tissue size for pathology and biology studies — Tony Sandler (opinion) [Ep 1 · 27:10](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1630)
- Transperitoneal laparoscopic biopsy may not allow adequate bleeding control for large tumors — Tony Sandler (opinion) [Ep 1 · 27:10](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1630)
- Multiple percutaneous biopsies may not provide adequate tissue for biology studies — Tony Sandler (opinion) [Ep 1 · 27:10](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1630)
- NMYC amplification can be obtained from bone marrow, but additional biology studies require tumor tissue — Tony Sandler (clinical) [Ep 1 · 27:10](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1630)
- Biology studies beyond NMYC include ALK mutation and ploidy status — Tony Sandler (clinical) [Ep 1 · 28:28](https://library.globalcastmd.com/watch/neuroblastoma-2534?t=1708)
- Adrenal hemorrhage is the most common cause of prenatal suprarenal mass, especially with history of fetal stress — Daniel von Allmen (clinical) [Ep 2 · 2:00](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=120)
- Familial neuroblastoma occurs in approximately 1% of patients — Tony Sandler (epidemiological) [Ep 2 · 3:27](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=207)
- The GetNucturne study showed that prenatal/neonatal neuroblastomas can be safely observed with careful ultrasound surveillance, with many patients spared surgery — Daniel von Allmen (clinical) [Ep 2 · 7:24](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=444)
- In the GetNucturne observation study of 84 patients, 16 (approximately 20%) underwent resection for growth or family preference, with 98% event-free survival and 100% overall survival — Tony Sandler (clinical) [Ep 2 · 9:09](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=549)
- Surveillance protocol for observed neonatal masses: ultrasound and catecholamines at birth, 3 weeks, 6 weeks, 12 weeks, then spacing out through first year, then every 6 months, then yearly — Erika Newman (guideline) [Ep 2 · 9:58](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=598)
- Criteria for surgery in observed neonatal neuroblastoma: >50% volume increase or >50% increase in VMA or HVA — Erika Newman (guideline) [Ep 2 · 13:20](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=800)
- Five centimeters is the size cutoff where most experts recommend surgical resection of neonatal neuroblastoma — Tony Sandler (opinion) [Ep 2 · 12:43](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=763)
- Lymph node status in neuroblastoma does not change therapy, unlike Wilms tumor — Daniel von Allmen (clinical) [Ep 2 · 14:21](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=861)
- Stage MS (formerly 4S) neuroblastoma with liver and skin metastases in neonates has good biology and can be observed unless respiratory compromise develops from hepatomegaly — Erika Newman (clinical) [Ep 2 · 14:50](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=890)
- Treatment options for MS neuroblastoma with respiratory compromise include chemotherapy, radiation, or emergent decompressive laparotomy — Erika Newman (clinical) [Ep 2 · 15:42](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=942)
- Approximately 10% of neuroblastomas are not MIBG-avid, which is when PET scan may be useful — Daniel von Allmen (clinical) [Ep 2 · 22:12](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1332)
- Open biopsy via retroperitoneal approach allows adequate tissue for NMEC amplification, ALK mutation, ploidy, and 11q status — Tony Sandler (clinical) [Ep 2 · 23:50](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1430)
- Approximately 50% of children's hospitals now use percutaneous biopsy for suspected neuroblastoma — Erika Newman (epidemiological) [Ep 2 · 26:56](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1616)
- Percutaneous biopsy is equivalent to open biopsy for diagnosis and NMEC determination but may fail for 11q loss of heterozygosity assessment — Erika Newman (clinical) [Ep 2 · 28:04](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1684)
- Optimized percutaneous biopsy technique requires 10-12 cores, higher gauge needle, and pathologist present for frozen section to confirm viable tumor — Erika Newman (clinical) [Ep 2 · 28:55](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1735)
- Open biopsy patients have higher risk of blood transfusion, higher narcotic use, and more frequent hospital admission compared to percutaneous biopsy — Erika Newman (clinical) [Ep 2 · 29:45](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1785)
- NMEC amplification automatically means high-risk neuroblastoma regardless of other factors — Tony Sandler (clinical) [Ep 2 · 31:38](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=1898)
- Loss of heterozygosity at 11q is the most common segmental chromosomal alteration in neuroblastoma and can elevate risk category — Erika Newman (clinical) [Ep 2 · 33:49](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2029)
- Age cutoff for neuroblastoma risk stratification is 18 months (previously was 12 months) — Tony Sandler (guideline) [Ep 2 · 35:25](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2125)
- High-risk neuroblastoma patients require double-lumen external catheter (not port) for bone marrow transplant — Erika Newman (clinical) [Ep 2 · 37:20](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2240)
- Stem cell harvesting for high-risk neuroblastoma typically occurs after cycle 2 of chemotherapy — Tony Sandler (clinical) [Ep 2 · 45:31](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2731)
- Tumor shrinkage in neuroblastoma plateaus after cycle 2-3 of chemotherapy per LaQuaglia and Von Allman studies — Daniel von Allmen (clinical) [Ep 2 · 43:17](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2597)
- After 5-6 cycles of chemotherapy, neuroblastomas become more fibrotic and harder to resect — Erika Newman (clinical) [Ep 2 · 42:40](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2560)
- COG high-risk study showed >90% resection improved event-free survival but not overall survival (approximately 245 patients) — Daniel von Allmen (clinical) [Ep 2 · 44:04](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2644)
- European neuroblastoma group study (approximately 1000 cases) showed >90% resection improved both event-free survival and overall survival — Daniel von Allmen (clinical) [Ep 2 · 45:28](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2728)
- Approximately 70% of high-risk neuroblastoma patients can achieve >90% resection — Daniel von Allmen (epidemiological) [Ep 2 · 46:10](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2770)
- Recent German/European publication stated unequivocally that extent of resection does not make a difference in neuroblastoma outcomes — Tony Sandler (clinical) [Ep 2 · 46:50](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2810)
- High-risk neuroblastoma patients die of metastatic disease, not local disease recurrence — Tony Sandler (clinical) [Ep 2 · 47:40](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=2860)
- Neuroblastoma theoretically does not invade vessel adventitia, though invasion has been observed — Daniel von Allmen (clinical) [Ep 2 · 50:54](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3054)
- There is zero correlation between surgeon operative note description of resection extent and post-operative imaging findings — Daniel von Allmen (clinical) [Ep 2 · 51:30](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3090)
- Nephrectomy should be avoided in neuroblastoma resection because kidney removal requires chemotherapy dose reduction — Tony Sandler (clinical) [Ep 2 · 53:13](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3193)
- Anti-GD2 monoclonal antibody improved high-risk neuroblastoma two-year survival from 46% to 60% — Tony Sandler (clinical) [Ep 2 · 53:44](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3224)
- Checkpoint inhibitors have not been successful in neuroblastoma because it is not an immunogenic tumor — Tony Sandler (clinical) [Ep 2 · 54:40](https://library.globalcastmd.com/watch/neuroblastoma-1620?t=3280)
- The most common differential diagnoses for a prenatal suprarenal mass are adrenal hemorrhage (especially with fetal stress history), neuroblastoma if solid or cystic, pulmonary sequestration below the diaphragm, and renal anomaly misdiagnosed as suprarenal mass. — Daniel von Allmen (clinical) [Ep 3 · 2:00](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=120)
- For prenatal suprarenal mass at 26 weeks gestation, no additional studies are obtained before delivery; after birth, ultrasound and urine catecholamines are the initial workup. — Erika Newman (clinical) [Ep 3 · 2:38](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=158)
- If urine catecholamines are elevated in a neonate with suprarenal mass, MIBG scan is the next step to characterize the primary lesion and identify other areas of disease. — Tony Sandler (clinical) [Ep 3 · 4:45](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=285)
- In neonates and the perinatal phase, the most common sites of neuroblastoma metastasis are liver, bone, skin, and lymph nodes. — Erika Newman (clinical) [Ep 3 · 7:08](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=428)
- Jed Nocturne's study demonstrated that neonatal neuroblastoma with positive MIBG and urine catecholamines can be safely observed with serial ultrasound; many patients are spared surgery. — Daniel von Allmen (clinical) [Ep 3 · 7:28](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=448)
- In Nocturne's study of 84 observed neonatal neuroblastoma patients, 16 (approximately 20%) underwent resection for growth or family preference, with 98% event-free survival and 100% overall survival. — Tony Sandler (epidemiological) [Ep 3 · 9:08](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=548)
- Surveillance protocol for observed neonatal neuroblastoma includes intensive first-year monitoring: ultrasound and urine catecholamines at birth, 3 weeks, 6 weeks, 12 weeks, then every 6 months after 1 year if stable. — Erika Newman (guideline) [Ep 3 · 9:54](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=594)
- A cautionary case: a child with observed neonatal adrenal mass that resolved presented at age 3 with widely metastatic high-risk neuroblastoma. — Daniel von Allmen (clinical) [Ep 3 · 10:40](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=640)
- Criteria for surgical intervention in observed neonatal neuroblastoma include tumor size reaching 5 cm, greater than 50% volume increase, or 50% increase in urine catecholamines (VMA or HVA). — Erika Newman (guideline) [Ep 3 · 12:35](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=755)
- Laparoscopic resection is appropriate for neonatal neuroblastoma less than 6 cm; one case of presumed neuroblastoma removed laparoscopically at 3.5 cm proved to be pulmonary sequestration. — Erika Newman (clinical) [Ep 3 · 13:57](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=837)
- Lymph node sampling is not necessary in neuroblastoma surgery because cross-sectional imaging provides adequate information and lymph node status does not change therapy, unlike Wilms tumor. — Tony Sandler (clinical) [Ep 3 · 14:22](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=862)
- Stage MS neuroblastoma (formerly 4S) with skin lesions and liver metastases in neonates generally has good biology and can be managed with observation unless hepatic mass effect causes respiratory compromise. — Erika Newman (clinical) [Ep 3 · 14:50](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=890)
- The primary concern with liver-predominant stage MS neuroblastoma is mass effect causing respiratory compromise and increasing ventilatory requirements as the tumor enlarges. — Daniel von Allmen (clinical) [Ep 3 · 15:19](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=919)
- Treatment options for stage MS neuroblastoma with respiratory compromise include chemotherapy, radiation if caught early, or emergent decompressive laparotomy for acute decompensation. — Daniel von Allmen (clinical) [Ep 3 · 15:55](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=955)
- Biopsy is not always required for stage MS neuroblastoma with classic findings (high catecholamines, blue skin lesions, liver metastases, adrenal mass), but tissue should be obtained if MYCN amplification is found, as it changes staging from MS to M. — Tony Sandler (clinical) [Ep 3 · 16:27](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=987)
- VIP-secreting neuroblastoma can cause severe diarrhea, though this is a rare presentation. — Erika Newman (clinical) [Ep 3 · 18:44](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1124)
- Initial workup for a 3-year-old with large abdominal mass includes ultrasound to assess solid vs cystic nature, CT with PO and IV contrast, CBC, comprehensive metabolic panel, amylase, lipase, LDH, and urine catecholamines. — Erika Newman (guideline) [Ep 3 · 18:33](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1113)
- A 10 cm mass with aortic and celiac axis encasement and microcalcifications represents L2 classification in the International Neuroblastoma Risk Group system. — Tony Sandler (clinical) [Ep 3 · 20:31](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1231)
- Complete staging workup for suspected neuroblastoma includes CT chest to rule out metastases, MIBG scan, bone marrow biopsy, and head CT if clinically indicated, with final staging requiring tissue biopsy for pathology and biology. — Tony Sandler (guideline) [Ep 3 · 20:57](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1257)
- MIBG scan is the primary imaging modality for neuroblastoma staging; PET scan may be useful in the 10% of neuroblastomas that are MIBG-negative to identify metastases. — Daniel von Allmen (clinical) [Ep 3 · 21:51](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1311)
- Traditional open retroperitoneal biopsy approach uses a lateral incision at the predicted site of eventual exploration, allowing retroperitoneal access with compression to control bleeding; hemostasis is achieved with pledgeted sutures packed with Surgicel. — Tony Sandler (clinical) [Ep 3 · 23:40](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1420)
- Approximately 50% of children's hospitals now use percutaneous biopsy for neuroblastoma; approximately 80% of patients at Michigan receive percutaneous biopsy upfront. — Erika Newman (epidemiological) [Ep 3 · 26:56](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1616)
- Percutaneous biopsy is equivalent to open biopsy for making the diagnosis, determining high vs low risk, and assessing MYCN amplification, but historically fails to provide adequate tissue for 11Q loss of heterozygosity determination. — Erika Newman (clinical) [Ep 3 · 27:44](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1664)
- Optimization strategies for percutaneous neuroblastoma biopsy include pathologist presence for frozen section to confirm viable tumor (not necrotic tissue), obtaining 10-12 cores, using higher gauge needles, and retroperitoneal approach. — Erika Newman (clinical) [Ep 3 · 28:29](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1709)
- Patients undergoing open biopsy have higher risk of blood transfusion, higher postoperative narcotic use, and more frequent hospital admission compared to percutaneous biopsy. — Erika Newman (clinical) [Ep 3 · 29:35](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1775)
- Interventional radiologists can embolize the biopsy track on withdrawal to limit bleeding risk in percutaneous neuroblastoma biopsy. — Daniel von Allmen (clinical) [Ep 3 · 30:25](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1825)
- Neuroblastoma risk stratification is based on patient age, histologic category, tumor differentiation, MYCN status, ploidy, and 11Q aberration, yielding pre-treatment risk groups of very low, low, intermediate, or high. — Tony Sandler (guideline) [Ep 3 · 31:26](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1886)
- MYCN amplification automatically confers high-risk status regardless of other factors; MYCN is an oncogene classically described for neuroblastoma. — Tony Sandler (clinical) [Ep 3 · 32:36](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1956)
- Most MYCN non-amplified neuroblastomas are low or intermediate risk, except poorly differentiated tumors in older patients with metastatic disease and diploid status, which may be high risk. — Tony Sandler (clinical) [Ep 3 · 33:07](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=1987)
- 11Q loss of heterozygosity is the most common segmental chromosomal alteration in neuroblastoma and is the only other factor that elevates MYCN non-amplified patients to high risk or from low to intermediate risk. — Erika Newman (clinical) [Ep 3 · 33:51](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2031)
- The age threshold for neuroblastoma risk stratification is 18 months (previously 12 months); patients less than 18 months have better outcomes. — Tony Sandler (guideline) [Ep 3 · 35:26](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2126)
- MYCN non-amplified metastatic neuroblastoma is low risk if the tumor is hyperdiploid; if diploid and patient is less than 18 months old, it is intermediate risk; if greater than 18 months old, it is high risk. — Tony Sandler (clinical) [Ep 3 · 36:00](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2160)
- High-risk neuroblastoma patients require double-lumen central venous access (Broviac or port) for chemotherapy and eventual bone marrow transplant. — Daniel von Allmen (clinical) [Ep 3 · 37:24](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2244)
- Central line placement is typically performed at the same operative session as biopsy and bone marrow aspiration; for high-risk cases, a double-lumen line is placed first, then toweled off before tumor biopsy. — Daniel von Allmen (clinical) [Ep 3 · 38:04](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2284)
- Optimal timing for primary tumor resection in high-risk neuroblastoma is after cycle 3-4 of induction chemotherapy; institutions have moved this up from the COG protocol recommendation of after cycle 5. — Daniel von Allmen (clinical) [Ep 3 · 41:17](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2477)
- Neuroblastoma tumor shrinkage plateaus after 2-3 cycles of chemotherapy with minimal additional volume reduction after cycle 4, based on studies by Laquaglia and institutional data. — Daniel von Allmen (clinical) [Ep 3 · 42:24](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2544)
- After 5-6 cycles of chemotherapy, neuroblastoma tumors become more fibrotic and hard, making surgical resection more technically difficult. — Erika Newman (clinical) [Ep 3 · 42:50](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2570)
- Stem cell harvest in high-risk neuroblastoma is typically performed after the second cycle of chemotherapy. — Tony Sandler (clinical) [Ep 3 · 45:31](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2731)
- Isolated suprarenal neuroblastoma mass with no metastases should be resected upfront without neoadjuvant chemotherapy. — Daniel von Allmen (clinical) [Ep 3 · 43:48](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2628)
- The goal for high-risk neuroblastoma resection is greater than 90% tumor removal, based on COG high-risk study (245 patients) showing statistically significant improvement in event-free survival but not overall survival. — Daniel von Allmen (clinical) [Ep 3 · 44:08](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2648)
- A larger unpublished European Neuroblastoma Group study (approximately 1000 cases) demonstrated that greater than 90% resection improved both event-free survival and overall survival. — Daniel von Allmen (clinical) [Ep 3 · 44:52](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2692)
- Approximately 70% of high-risk neuroblastoma patients achieve greater than 90% tumor resection. — Daniel von Allmen (epidemiological) [Ep 3 · 45:20](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2720)
- High-risk neuroblastoma responds well to chemotherapy due to its highly proliferative rate and responsiveness to chemotherapeutic agents. — Tony Sandler (clinical) [Ep 3 · 45:46](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2746)
- Residual tissue after neuroblastoma chemotherapy is often fibrous scar along vessels and abdominal structures; local disease is not usually the cause of death in high-risk patients—metastatic recurrence is. — Tony Sandler (clinical) [Ep 3 · 46:00](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2760)
- A recent German publication analyzing European data stated that extent of local disease resection does not affect survival in neuroblastoma. — Tony Sandler (clinical) [Ep 3 · 46:26](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2786)
- Aggressive neuroblastoma resection should be pursued only with safe technique, avoiding significant lymphatic leak, unnecessary nephrectomy, or vascular reconstruction; patients die of systemic disease, not local disease. — Tony Sandler (opinion) [Ep 3 · 46:55](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2815)
- Combination of radiation and aggressive surgery provides excellent local control in neuroblastoma, but patients still have metastatic disease; any survival improvement from aggressive resection is incremental and difficult to demonstrate. — Daniel von Allmen (clinical) [Ep 3 · 47:48](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=2868)
- Surgical technique for neuroblastoma resection should start by identifying normal vascular anatomy away from the tumor and tracking vessels to stay on the adventitia; neuroblastoma theoretically does not invade vessels, though invasion has been observed. — Daniel von Allmen (clinical) [Ep 3 · 50:55](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=3055)
- There is zero correlation between surgeon operative note descriptions of extent of resection and postoperative imaging findings in neuroblastoma; surgeons frequently overestimate the amount of tumor removed. — Daniel von Allmen (clinical) [Ep 3 · 51:39](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=3099)
- Neuroblastoma surgery should not cause disability; nephrectomy should be avoided when possible because it requires chemotherapy dose reduction, and operations near brachial plexus or other critical structures require careful consideration of risk vs benefit. — Erika Newman (opinion) [Ep 3 · 52:21](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=3141)
- Anti-GD2 (ganglioside) monoclonal antibody is now accepted therapy for high-risk neuroblastoma and has improved two-year survival from 46% to 60%, representing the first major immunotherapy breakthrough in childhood cancer. — Tony Sandler (clinical) [Ep 3 · 53:33](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=3213)
- Checkpoint inhibitors have not been successful in neuroblastoma because it is not an immunogenic tumor; the future goal is to make neuroblastoma immunogenic to enable effective immunotherapy. — Tony Sandler (clinical) [Ep 3 · 54:21](https://library.globalcastmd.com/watch/neuroblastoma-13431?t=3261)

## Changelog
- Oct 22: 3 items added automatically

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