Sandbox:managemenet

Overview

Children oncology group (COG) risk stratification system determines the protocol of management used for neuroblastoma patients. Low risk neuroblastoma patients are usually managed with either observation or surgical resection of the tumor. Intermidiate risk neuroblastoma patients are usually managed with neoadjuvant chemotherapy in advance of a definitive surgical resection. Whereas high risk neuroblastoma patients are usually managed with a combination of surgery, chemotherapy, radiation therapy, hematopoietic stem cell transplantation, and immunotherapy.

Medical Therapy

Risk Stratification

• Children oncology group (COG) risk stratification system determines the protocol of management used for neuroblastoma patients.
• Low risk neuroblastoma patients are usually managed by either observation or surgical resection of the tumor.
• Intermediate risk neuroblastoma patients are usually managed by neoadjuvant chemotherapy in advance of a definitive surgical resection.
• High risk neuroblastoma patients are usually managed by a combination of surgery, chemotherapy, radiation therapy, hematopoietic stem cell transplantation, and immunotherapy.
• The algorithm below summarizes the management approach for neuroblastoma patients:

Children's oncology group risk stratification

Low risk patients

Intermediate risk patients

High risk patients

Surgery followed by chemotherapy Chemotherapy with or without surgery Observation without biopsy

Chemotherapy with or without surgery Surgery and observation Radiation therapy

A combination of chemotherapy, surgery, stem cell transplantation, radiation therapy, immunotherapy, and isotretinoin

Management of Low Risk Neuroblastoma Patients

Observation

• Low risk neuroblastoma patients younger than 6 months of age may be safely observed without obtaining a definitive histologic diagnosis or performing any surgical intervention.
• Observation among such patients avoids potential surgical complications, as the majority of neuroblastomas occurring in this age group demonstrate spontaneous regression.

Radiotherapy

• Radiotherapy is generally not recommended among low risk neuroblastoma patients.

Chemotherapy

• Indications for chemotherapy among low risk neuroblastoma patients include:

• Stage 1 or stage 2 tumors associated with MYCN amplification
• Age older than 18 months presenting with a stage 2B tumor and an unfavorable histology
• Symptomatic patients due to spinal cord compression, respiratory compromise, and hepatic infiltration

• Chemotherapeutic agents recommended for the management of neuroblastoma include:

• Carboplatin
• Cyclophosphamide
• Doxorubicin
• Etoposide

Management of Intermediate Risk Neuroblastoma Patients

Observation

• Observation is generally not recommended among intermediate risk neuroblastoma patients.

Radiation therapy

• Indications for radiotherapy among intermediate risk neuroblastoma patients include:

• Symptomatic life-threatening neuroblastoma refractory to chemotherapy and/or surgery
• Progressive rapidly growing neuroblastoma

Chemotherapy

• Chemotherapeutic agents are generally effective in the treatment of intermediate risk neuroblastoma patients.
• Intermediate risk neuroblastoma patients with favorable histology are successfully managed by 4 cycles of chemotherapy in addition to surgery.
• Intermediate risk neuroblastoma patients with unfavorable histology are successfully managed by 8 cycles of chemotherapy in addition to surgery.
• Neoadjuvant chemotherapy may be used to facilitate the partial resection of previously unresectable neuroblastomas among intermediate risk patients.
• Chemotherapeutic agents recommended for the management of neuroblastoma include:

• Carboplatin
• Cyclophosphamide
• Doxorubicin
• Etoposide