Neuroblastoma is a cancer arising in the adrenal gland or less often from the extra-adrenal sympathetic chain, including in the retroperitoneum, chest, and neck. Diagnosis is confirmed by biopsy. Treatment may include surgical resection, chemotherapy, radiation therapy, high-dose chemotherapy with stem cell transplantation, cis-retinoic acid, and immunotherapy.
Neuroblastoma is the most common cancer among infants and is the most common solid tumor, other than brain tumors, in children. It accounts for 7 to 8% of all childhood cancers (1). Almost 90% of neuroblastomas occur in children < 5 years of age.
Neuroblastomas are immature, undifferentiated, malignant tumors. Ganglioneuroblastomas are intermediate tumors, and ganglioneuromas are fully differentiated, benign variants of neuroblastoma; collectively, these are referred to as neural crest tumors.
Most neuroblastomas produce catecholamines, which can be detected as elevated levels of urinary catecholamine breakdown products. Neuroblastomas do not typically cause severe hypertension because these tumors do not usually secrete epinephrine.
Neuroblastomas may begin in the abdomen (approximately 65%), thorax (15 to 20%), neck, pelvis, or other sites. Neuroblastoma occurs very rarely as a primary central nervous system cancer.
Approximately 40 to 50% of children have localized or regional disease at diagnosis; 50 to 60% have metastases at diagnosis. Neuroblastoma may metastasize to bone marrow, bone, liver, lymph nodes, or, less commonly, skin or brain. Bone marrow metastases may cause anemia and/or thrombocytopenia. Anemia also occasionally occurs when bleeding into these highly vascular tumors causes a rapid drop in hemoglobin.
Most neuroblastomas occur spontaneously, but 1 to 2% appear to be inherited. Some markers (eg, MYCN oncogene amplification, DNA index, segmental chromosomal aberrations, histopathology) correlate with progression and prognosis. MYCN amplification occurs in approximately 20% of neuroblastoma cases and is associated with advanced disease and unfavorable biology.
Pearls & Pitfalls
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General reference
1. Campbell K, Siegel DA, Umaretiya PJ, et al. A comprehensive analysis of neuroblastoma incidence, survival, and racial and ethnic disparities from 2001 to 2019. Pediatr Blood Cancer. 2024;71(1):e30732. doi:10.1002/pbc.30732
Symptoms and Signs of Neuroblastoma
Symptoms and signs of neuroblastoma depend on the site of the primary cancer and pattern of disease spread. The most common symptoms are abdominal pain, discomfort, irritability, decreased appetite, and a sense of fullness due to an abdominal mass.
Certain symptoms may result from metastases. These include bone pain due to widespread bone metastases, periorbital ecchymosis and proptosis due to retrobulbar metastasis, and abdominal distention and respiratory problems due to liver metastases, especially in infants. Children with bone marrow involvement can have anemia (may have pallor) and thrombocytopenia (petechiae).
Children occasionally present with focal neurologic deficits or paralysis due to direct extension of the cancer into the spinal canal. Tumors in the neck or upper chest may cause Horner syndrome (ptosis, miosis, anhidrosis). They may also present with paraneoplastic syndromes, such as cerebellar ataxia, opsoclonus-myoclonus, watery diarrhea, or hypertension.
Rare diseases that are associated with neural crest tumors (eg, neuroblastoma, ganglioneuroblastoma, ganglioneuroma) include ROHHADNET (rapid-onset obesity with hypothalamic dysfunction, hypoventilation, autonomic dysregulation, and neuroendocrine tumors) and congenital central hypoventilation syndrome.
Diagnosis of Neuroblastoma
CT/MRI
Biopsy
Sometimes bone marrow aspirate or marrow core biopsy plus measurement of urinary catecholamine intermediates
Routine prenatal ultrasound occasionally detects neuroblastoma. Patients presenting with abdominal symptoms or a mass require CT or MRI. Diagnosis of neuroblastoma is then confirmed by biopsy of any identified mass.
Alternatively, diagnosis can be established without biopsy or surgery of the primary tumor by finding characteristic cancer cells in a bone marrow aspirate or core biopsy plus elevated urinary catecholamine intermediates. These methods of diagnosis are not commonly done but can be useful in situations where biopsy and/or surgery is considered high risk because of patient or tumor characteristics.
Urinary vanillylmandelic acid (VMA), homovanillic acid (HVA), or both are elevated in ≥ 90% of patients. A 24-hour urine collection can be used, but a spot urine test is usually sufficient. If the primary site of the neuroblastoma is adrenal, it must be differentiated from Wilms tumor and other renal masses. It may also need to be differentiated from rhabdomyosarcoma, hepatoblastoma, lymphoma, and tumors of genital origin.
Staging of neuroblastoma
The following should be done to evaluate for metastases:
Bone marrow aspirates and marrow core biopsies from multiple sites (typically, both posterior iliac crests)
Bone scan or iodine-131 metaiodobenzylguanidine (MIBG) scan (MIBG uptake occurs in > 90% of neuroblastomas)
Abdominal, pelvic, and chest CT or MRI
Cranial imaging with CT or MRI is indicated if symptoms or signs suggest brain metastases.
Results of these tests determine stage (extent of spread) of disease. The International Neuroblastoma Staging System (INSS) requires the results of surgery to determine stage. The International Neuroblastoma Risk Group Staging System (INRGSS) uses imaging-defined risk factors rather than surgery to stage neuroblastoma.
Neuroblastoma also has a unique stage called stage 4S (per INSS) or MS (per INGRSS) that often regresses spontaneously without treatment. This stage includes children < 12 months (4S) or 18 months (MS) of age who have a localized primary tumor that has dissemination limited to skin, liver, and/or bone marrow. Marrow involvement should be minimal and limited to < 10% of the total nucleated cells and cannot involve the cortex of the bone.
At diagnosis, attempts should be made to obtain adequate tumor tissue to analyze for DNA index (the ratio of the amount of DNA in a tumor cell to the amount in a normal cell; the DNA index is thus a quantitative measure of chromosome content) and amplification of the MYCN oncogene.
Risk categorization of neuroblastoma
After staging, the staging information, along with other known prognostic factors, including patient age, histology, MYCN amplification, molecular information from the tumor, and DNA index, is used to categorize patients to guide treatment intensity and determine the prognosis for and likelihood of a recurrence of disease after treatment.
Risk categorization is complex, and two major risk group stratification systems exist, the Children's Oncology Group (COG) risk group and the International Neuroblastoma Risk Group (INRG) classification. In both systems, the staging and prognostic factors are used to stratify patients into low-risk, intermediate-risk, and high-risk categories that help determine prognosis and guide treatment. In addition, chromosome 11q aberrations are considered in the INRG classification.
Treatment of Neuroblastoma
Surgical resection
Usually chemotherapy
Sometimes high-dose chemotherapy followed by stem cell transplantation
Sometimes radiation therapy
Cis-retinoic acid for maintenance therapy in high-risk disease
Immunotherapy
Treatment of neuroblastoma is based on the risk category (see also the National Cancer Institute's Neuroblastoma Treatment—Health Professional Version).
Surgical resection is important for low-risk and intermediate-risk disease. For patients with intermediate-risk disease, it is often delayed until neoadjuvant chemotherapy is given to improve the chance of adequate surgical resection.
Radiation therapy is sometimes needed for children with intermediate-risk disease or for children with inoperable tumors and is a standard part of treatment for local control of high-risk disease.
Immunotherapy using monoclonal antibodies against neuroblastoma antigens (GD2) combined with cytokines is used as maintenance therapy in high-risk disease.
In a study of relapsed/refractory neuroblastoma, a combination of immunotherapy with chemotherapy led to impressive clinical responses (1).
Treatment reference
1. Mody R, Naranjo A, Van Ryn C, et al: Randomised Phase II Trial of Irinotecan/Temozolomide (I/T) with Temsirolimus or Dinutuximab (DIN) in Children with Refractory or Relapsed Neuroblastoma (COG ANBL1221): A Report from The Children’s Oncology Group (COG). Lancet Oncol 18(7):946–957, 2017. doi: 10.1016/S1470-2045(17)30355-8
Prognosis for Neuroblastoma
Prognosis for neuroblastoma depends on age at diagnosis, stage, and biologic factors (eg, histopathology, tumor cell ploidy in younger patients, MYCN amplification). Younger children with localized disease have the best outcome.
Survival rates for low-risk and intermediate-risk disease are approximately 90 to 95%. Historically, the survival rate for high-risk disease was approximately 15%. This rate has improved to > 50% with use of more intensified therapy. And a randomized study showed intensive therapy combined with immunotherapy resulted in a 2-year event-free survival rate of 66% (1).
Prognosis reference
1. Park JR, Kreissman SG, London WB, et al: A phase III randomized clinical trial (RCT) of tandem myeloablative autologous stem cell transplant (ASCT) using peripheral blood stem cell (PBSC) as consolidation therapy for high-risk neuroblastoma (HR-NB): A Children's Oncology Group (COG) study. J Clin Oncol 34(Suppl 18):LBA3-LBA, 2016. doi: 10.1200/JCO.2016.34.15_suppl.LBA3
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
International Neuroblastoma Staging System (INSS): A surgical staging system that requires the results of surgery to determine stage
International Neuroblastoma Risk Group Staging System (INRGSS): A preoperative staging system that uses imaging-defined risk factors rather than surgery to stage neuroblastoma
Children's Oncology Group (COG) and the International Neuroblastoma Risk Group (INRG) classification: COG and INRG risk group stratification systems use staging and prognostic factors to stratify patients into low-, intermediate-, and high-risk categories that help determine prognosis and guide treatment
National Cancer Institute: Neuroblastoma Treatment—Health Professional Version
