Clinical & Research Update: Neuroblastoma with Drs. Katherine Somers, Cara Morin, Juan Gurria, and Meera Kotagal
hosted by Dr. Sophia Schermerhorn
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Diffusion-weighted imaging (DWI) with high B-value makes retroperitoneal adenopathy from neuroblastoma very obvious and easy to identify.
MRI is superior to CT for identifying image-defined risk factors in neuroblastoma, particularly for visualizing lymph nodes separate from the mass, neural foraminal involvement, and bony disease, though it requires sedation and takes up to 60 minutes.
For neuroblastoma patients with L2 tumors (local regional tumor with positive image-defined risk factors), those with MYCN amplification did extremely poorly when treated as intermediate risk compared to their MYCN non-amplified cohorts.
Percutaneous core biopsy can provide adequate tissue for genetic analysis needed to risk-stratify neuroblastoma patients; open biopsy is not required for every patient if adequate cores are obtained in collaboration with pathology.
The addition of tandem stem cell transplants into the standard of care for high-risk neuroblastoma is associated with significant improvement in progression-free and overall survival.
The optimal timing for surgical resection of neuroblastoma is after cycle 4 of chemotherapy, when the biggest tumor response has occurred but before significant fibrosis develops that would make surgery more challenging.
On T2-weighted MRI, neuroblastoma that has responded well to chemotherapy appears extremely dark due to calcification.
The robotic platform provides 7 degrees of freedom in motion compared to 6 with the human hand, allowing better access to tight spaces.
Robotic surgery should not be pursued for neuroblastoma with image-defined risk factors involving major vessels (aorta, SMA, celiac, renal pedicles) post-therapy, just as laparoscopy would not be pursued in these cases.
Robotic surgery for neuroblastoma has been performed safely in patients as small as 5 kg, with port spacing of 3 cm sufficient in smaller babies compared to 5 cm in larger patients.
For thoracic neuroblastomas extending beyond the diaphragm, robotic approach provides excellent visualization and access, avoiding the need for two large incisions.
For intermediate-risk neuroblastoma, a reduction of 50% of the original tumor volume may be acceptable rather than gross total resection if needed to preserve function of important organs and vessels.
The da Vinci robotic system is the commercially available platform used for pediatric neuroblastoma surgery in the United States, though it is not FDA approved for pediatrics.
Osseous metastatic lesions from neuroblastoma can be extraordinarily painful, and starting chemotherapy is one of the best ways to treat the pain.
For neuroblastoma with widespread high CURIE score disease, the primary tumor tends to respond better to chemotherapy than bony metastases.
For open neuroblastoma resection, medial visceral rotation mobilizing the spleen and pancreatic tail is critical for safe visualization of vessels, particularly when working near the SMA and celiac artery.
The key surgical principle for neuroblastoma resection is to start from known anatomy (aorta, bifurcation) and work toward unknown, staying on vessels as a safe plane.
For neuroblastoma surgery, ligature or harmonic devices should be used laterally and away from primary vessels; direct dissection with right angle and cautery is safer near the aorta and major vessels.
Using surgical ties rather than clips in proximity to vessels during neuroblastoma resection prevents imaging artifact on post-operative CTA.
For neuroblastoma resection, dividing the tumor into pieces does not change outcomes and allows safer dissection when working along major vessels like the renal artery or SMA.
Post-operative ileus was the most common complication in neuroblastoma surgery prior to implementation of ERAS protocols.
ERAS protocols for neuroblastoma include turning off IV maintenance fluids on post-operative day 1 even if patients aren't drinking well, monitoring urine output and giving boluses as needed.
With ERAS protocols, neuroblastoma patients can be cleared for chemotherapy by 7 days after surgery, with typical hospital stays of 3 days even for complex open resections.
Allowing pediatric oncology patients to lose weight on therapy, particularly toddlers, is not acceptable and nutritional support is essential for surgical outcomes and overall tolerance of therapy.
Neuroblastoma is a systemic disease at its core; local primary control is essential but systemic therapy cannot be forgotten even for localized tumors.
With new targeted therapies, molecular therapy, cellular therapy, anti-GD2, and anti-MYCN treatments, surgeons should not be required to dissect in the subadventitial plane of the aorta to achieve local control of neuroblastoma.
Neuroblastoma falls into the category of pediatric oncology diagnoses where event-free survival, progression-free survival, and overall survival are not yet acceptable.
The pathway to cure for relapsed or refractory neuroblastoma is dismal, making upfront intensification of therapy essential to avoid relapse.
Indocyanine green (ICG) for neuroblastoma surgery is given intraoperatively rather than days in advance, and is used primarily for vascular identification and delineation of tumor edge; the tumor itself often does not take up ICG but surrounding structures do.
ICG can be given multiple times during a neuroblastoma operation as it gets metabolized quickly, allowing repeated assessment of vascular relationships during dissection.
Robotic surgery for neuroblastoma, with experience, has better outcomes, shorter length of stay, and less chance of conversion to open compared to laparoscopic approach.
Robotic approach to neuroblastoma is safe and efficient with no increase in morbidity or mortality and no decrease in event-free survival, based on review of over 100 procedures.
Cases needed for proficiency in robotic surgery have been cut in half compared to transitioning from open to laparoscopic surgery, and surgical times have also been cut in half while maintaining safety and efficiency.
Enhanced recovery after surgery (ERAS) protocols for neuroblastoma reduced nasogastric tube use from over 90% to 16%, enabled ambulation 3 days earlier, cut opioid consumption in half, reduced complications, and nearly halved length of stay.