Surgical Procedures: Surgery and Staging for Neuroblastoma

What is staging and how is it done?

Neuroblastoma is a cancer of the nerve cells. Neuroblastoma starts in the neuroblasts or early, immature nerve cells in the sympathetic nervous system. They can be found in the neck, abdomen, pelvis, adrenal glands, chest, and/or spinal cord. The sympathetic nervous system is part of the autonomic nervous system, which controls heart rate, breathing, blood pressure, digestion, and many other bodily functions. Most neuroblastomas start in the adrenal glands.

Neuroblastoma is often seen in infants and children under 5 years old. It is rare in older children. Sometimes neuroblastomas can be diagnosed on a fetal ultrasound during pregnancy. When neuroblastomas metastasize (spread), they often do so in the lymph nodes, bones, bone marrow, liver, and, in infants, to the skin.

Once a diagnosis of neuroblastoma has been made or your provider thinks the disease is present, they will often order testing to figure out the stage of the cancer, which may include:

Physical Exam: This is a general physical exam where you will talk to your child's provider about their medical history and symptoms. It will also include a neurological exam that tests for brain, spinal cord, and nerve function by looking at mental status, coordination, walking ability, and how the muscles, senses, and reflexes work.

Laboratory Studies: Laboratory studies like urine tests look for high levels of vanillylmandelic acid (VMA) and homovanillic acid (HVA). Blood chemistry studies and hormone testing to check for high levels of dopamine and norepinephrine may also be done.

Imaging: Tests like a chest X-Ray, CAT scan (CT scan), magnetic resonance imaging (MRI), bone scan and/or ultrasound may be used to look at the extent of the cancer. An mIBG (meta-iodobenzylguanidine) scan may be used, in which radioactive mIBG is used to find a neuroendocrine tumor.

Procedures:

• Bone marrow aspiration and biopsy: A hollow needle is used to access the hip or breast bone to remove some bone marrow, blood, and a bone fragment (piece of bone) to be looked at under a microscope.
• Lumbar puncture (spinal tap): Cerebrospinal fluid (CSF) is removed using a needle that has been placed into the spinal column. The fluid is sent to a lab to check for cancer cells.
• Lymph node biopsy:
  • Excisional biopsy is when the whole lymph node is removed.
  • Incisional biopsy is when a portion of the lymph node is removed.
  • Core biopsy is when a wide needle is used to remove some of the lymph node tissue.
  • Fine-needle aspiration (FNA) biopsy is when a thin needle is used to remove tissue or fluid from the lymph node.

Neuroblastoma spreads to other parts of the body through the tissue, lymph, and blood systems. Staging is a way to find out how extensive the cancer is, how far it has spread, and what treatment course will be recommended. Neuroblastoma is described as stages I (one) through IV (four) disease. Neuroblastomas are further classified by risk group and can be  low-risk, intermediate-risk, or high-risk.

Surgey can be used to treat neuroblastoma. The goal is to remove as much of the tumor as possible, and often the nearby lymph nodes. Surgery may be done before or after chemotherapy and/or radiation therapy. Your child’s provider will talk to you about your child’s specific surgery and the possible side effects.

What are the risks associated with neuroblastoma surgery?

Possible risks and side effects include:

• Reaction to anesthesia (Anesthesia is the medication given to help sleep through the surgery, not remember it, and manage pain.) Reactions can be things like wheezing, rash, swelling, and low blood pressure.
• Bleeding.
• Infection.
• Blood vessel, organ, or nerve damage.
• Post-operative pain.

What is recovery like?

Recovery from neuroblastoma cancer surgery will depend on the extent of the procedure done. You will be given instructions on how to care for your child’s surgical incisions and will be given any other instructions before leaving the hospital, including medications and activity restrictions.

Will my child be able to care for themselves?

Depending on the extent of your child’s surgery, he or she may need a family member or friend to help with daily tasks until they are feeling better. Your child's providers will tell you when they can go back to normal activity.

Be sure your child takes all medications as directed to prevent pain, infection or other conditions. Call their provider with any concerning symptoms.

If your child is constipated, talk with their provider about recommendations that might help. 

Deep breathing and relaxation can help with pain, keep lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to encourage your child to do deep breathing and relaxation exercises several times a day in the first week, or whenever you notice they are tense.

• A simple exercise to help them do: While sitting, have them close their eyes and take 5-10 slow deep breaths. Tell them to relax your muscles and slowly roll their head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.