Neuroblastoma Surgery — How It Works, Benefits & Recovery — Procedure Guide, Recovery & Risks | MyMedicPlus

Neuroblastoma is a malignant tumour arising from primitive neural crest cells of the sympathetic nervous system. It is the most common extracranial solid tumour in children, accounting for approximately 8–10% of all childhood cancers and 15% of paediatric cancer deaths. The majority of cases present before age five, with a median age at diagnosis of 19 months; it is extremely rare in adults. The primary tumour most commonly arises in the adrenal medulla (around 40% of cases), with additional sites including the retroperitoneal sympathetic chain, posterior mediastinum, pelvis, and neck. Tumours vary enormously in biological behaviour: some spontaneously regress, particularly in infants under 18 months with stage MS (formerly stage 4S) disease, while high-risk tumours in older children are aggressive, metastatic, and carry a poor prognosis despite intensive multimodal therapy. Surgical resection of the primary tumour is a critical component of the multimodal treatment strategy for most patients, alongside chemotherapy, radiotherapy, immunotherapy with anti-GD2 antibody (dinutuximab), and autologous haematopoietic stem cell transplantation in high-risk disease. The International Neuroblastoma Risk Group (INRG) classification system stratifies patients by age, tumour stage, histology, MYCN amplification status, DNA ploidy, and genomic segmental chromosomal abnormalities to guide treatment intensity and surgical timing. Neuroblastoma surgery is performed exclusively in specialist paediatric oncology centres with the full multidisciplinary team.

Surgical resection is indicated for virtually all neuroblastoma patients, although timing, extent, and approach vary by risk group. For localised INRG L1 tumours — defined as those with no image-defined risk factors (IDRFs) — upfront primary surgery aims to achieve complete gross resection without compromising adjacent vital structures. For INRG L2 tumours, where image-defined risk factors indicate involvement of or adherence to major blood vessels, vertebral foramina, or adjacent organs, surgery follows induction chemotherapy to reduce tumour volume and vascularity and improve resectability. In high-risk stage M (distant metastatic) disease, surgery is performed as delayed primary surgery after 4–6 cycles of induction chemotherapy have achieved maximum shrinkage, typically with the goal of gross total or near-total resection. Image-defined risk factors (IDRFs) — defined on CT and MRI by the International Society of Paediatric Oncology (SIOPE) — include tumour encasing or compressing major vessels (aorta, inferior vena cava, renal vessels, coeliac axis, superior mesenteric artery), extension into vertebral foramina at risk of spinal cord compression, and bilateral adrenal involvement. These IDRFs guide surgical planning and are the primary determinant of operative risk. Contraindications to upfront surgery include the presence of significant IDRFs placing the patient at unacceptable risk of major vascular haemorrhage or spinal cord injury, which are better addressed after chemotherapy-induced tumour regression.

All neuroblastoma surgery is performed under general anaesthesia with the child positioned supine or laterally depending on tumour location. Pre-operative planning includes detailed review of CT and MRI imaging by the surgical and radiology team to map tumour boundaries and relationship to adjacent major vessels. A midline or transverse abdominal laparotomy incision provides the best access for retroperitoneal and adrenal tumours in most cases; thoracoscopic or laparoscopic approaches are used in selected small, well-localised tumours without IDRFs. The surgical goal is maximal safe resection — complete gross resection is ideal, but near-total resection (greater than 90% excised) is acceptable when complete removal risks major vascular injury. The tumour capsule is carefully identified and dissection proceeds in the plane between tumour and adjacent structures. Major blood vessels — the aorta, inferior vena cava, renal artery and vein, superior mesenteric vessels — are meticulously dissected free from tumour encasement using sharp and bipolar dissection. Nephron-sparing approach preserves the ipsilateral kidney whenever oncologically safe; the contralateral adrenal gland is always preserved. Regional lymph node sampling from the para-aortic and para-caval chains provides additional pathological staging information. Intraoperative blood loss can be significant from the highly vascular tumour bed; cell salvage is used where oncologically appropriate. Duration is typically 3–6 hours for a large retroperitoneal primary tumour. Specimens are sent for histology, MYCN status, and cytogenetic analysis. Post-operatively, children go to a paediatric intensive care unit (PICU) for a minimum of 24–48 hours of monitoring.

Surgical resection is a cornerstone of curative intent treatment across all neuroblastoma risk groups, and the extent of resection directly influences event-free and overall survival in most analyses. In low-risk disease (INRG very-low and low risk), surgery alone achieves over 90% five-year overall survival, and observation alone is appropriate for select patients under 6 months with stage MS disease showing spontaneous regression. In intermediate-risk disease, surgery combined with moderate-intensity chemotherapy achieves 3-year overall survival of 85–95%. For high-risk neuroblastoma — which constitutes approximately 40–50% of all cases at presentation — a multimodal approach incorporating induction chemotherapy, maximal surgical resection, autologous stem cell rescue, anti-GD2 immunotherapy (dinutuximab), isotretinoin maintenance, and radiotherapy achieves 5-year overall survival of 50–60% in current trials, representing a substantial improvement from the 30–35% survival seen two decades ago. Complete or near-complete gross resection (less than 1 mL residual tumour) is associated with improved event-free survival compared with macroscopic residual disease in registry analyses. Minimally invasive laparoscopic or thoracoscopic resection, in appropriately selected L1 tumours without IDRFs, achieves equivalent oncological outcomes with faster recovery and reduced wound morbidity compared with open surgery.

Neuroblastoma surgery carries significant operative risk due to the intimate anatomical relationship of the tumour with major retroperitoneal blood vessels. Haemorrhage from injury to the aorta, inferior vena cava, or renal vessels is the most feared intraoperative complication, occurring in 3–8% of cases; multidisciplinary preoperative planning and experienced paediatric oncological surgical teams substantially reduce this risk. Renal injury requiring nephrectomy occurs in under 5% when nephron-preservation is intended; injury to the contralateral kidney or ureter is very rare but serious. Horner syndrome — ptosis, miosis, and anhidrosis — results from injury to the cervical or thoracic sympathetic chain and occurs in up to 15–20% of patients with cervical or superior mediastinal primary tumours; it is usually permanent. Chylous ascites from lymphatic vessel injury presents as milky peritoneal fluid post-operatively and is managed with low-fat or parenteral nutrition for 4–8 weeks in most cases, resolving spontaneously. Incomplete tumour resection requiring re-operation or radiation therapy increases treatment burden. Spinal cord complications from epidural tumour extension are rare with careful preoperative planning but can result in permanent neurological deficits. Long-term musculoskeletal sequelae from para-spinal surgery in growing children include spinal deformity (scoliosis) in a minority. Recurrent disease despite complete resection occurs in approximately 50% of high-risk patients, reflecting the systemic nature of the disease.

Following neuroblastoma surgery, children are managed in the paediatric intensive care unit for 24–72 hours for haemodynamic monitoring, fluid balance, and pain management with intravenous opioids or epidural analgesia. Nasogastric tube and urethral catheter are removed as tolerated, usually by day 2–3. Oral feeding commences when bowel function returns, typically at 2–4 days for laparoscopic approaches and 3–7 days after open procedures. Hospital discharge is usually at 5–10 days depending on the procedure complexity and child's recovery. Post-operative analgesia transitions from intravenous to oral paracetamol and NSAIDs before discharge. Wound care involves keeping the abdominal incision clean and dry for 2 weeks. Physical activity is restricted for 4–6 weeks to allow wound healing; return to school and normal play is guided by the child's recovery. Most children who require adjuvant chemotherapy commence treatment 3–4 weeks after surgery once they have recovered adequately. Risk-stratified post-operative treatment protocols — delivered by the paediatric oncology multidisciplinary team — include further cycles of chemotherapy for intermediate- and high-risk disease, high-dose chemotherapy with autologous stem cell rescue, anti-GD2 immunotherapy with dinutuximab, and local radiotherapy to the tumour bed. Response is assessed with CT, MIBG scintigraphy (123I-MIBG), and bone marrow trephines at defined intervals. Long-term follow-up continues for a minimum of 5–10 years to monitor for recurrence and late treatment effects.