Surgical Procedures: Surgery and Staging for Neuroblastoma

What is staging and how is it performed?

Neuroblastoma is a cancer of the nerve cells. Neuroblastoma starts in the neuroblasts or early, immature nerve cells within 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, as well as many other bodily functions. Most neuroblastomas start within the adrenal glands.

Neuroblastomas often affect infants and children under 5 years old and is rare in older children. At times, neuroblastomas can be diagnosed on a fetal ultrasound during pregnancy. When neuroblastomas spread or metastasize, 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 if there is suspicion that the disease is present, your child’s healthcare provider will often order testing to figure out the stage of cancer, which may include:

Physical Exam: This is a general physical exam and talking about medical history and symptoms. The exam 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 such as urine tests look for high levels of the substances 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 such as 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 to be looked at under a microscope.
• Lumbar puncture (spinal tap): Cerebral spinal fluid (CSF) is removed using a needle that has been placed into the spinal column. The fluid is sent to a lab to be checked for cancer cells.
• Lymph node biopsy:
  • Excisional biopsy in which the entire lymph node is removed.
  • Incisional biopsy in which a portion of the lymph node is removed.
  • Core biopsy in which a wide needle is used to aspirate some of the lymph node tissue.
  • Fine-needle aspiration (FNA) biopsy in which a thin needle is used to remove tissue or fluid from within the lymph node.

Neuroblastoma spreads to other parts of the body through the tissue, lymph, and blood systems. Cancer stage determines how extensive the cancer is, how far it has spread, and what treatment course will be recommended. Neuroblastoma is described as stages I through stage IV disease. Additionally, neuroblastomas are further classified by risk group and can be described as low-risk, intermediate-risk, and high-risk.

Sometimes surgery is 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 receiving 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 include 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 provided with instructions on how to care for your child’s surgical incisions and will be given any other instructions prior to leaving the hospital, including medications and activity restrictions.

How can I care for myself?

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 your child is feeling better and the medical team gives the go ahead to resume normal activity.

Be sure your child takes all medications as directed to prevent pain, infection or other conditions and call their medical team with any concerning symptoms.

If constipation is present, speak with your child’s healthcare team about recommendations they have to offer relief.

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

• A simple exercise to do on your own: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

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