Neuroblastoma Surgery

Neuroblastoma (nur-oh-blass-TOE-muh) surgery is a standard treatment for neuroblastoma.

Neuroblastoma is a pediatric cancer that develops in immature nerve tissues, called neuroblasts. “Neuro” means nerves, while “blastoma” means a cancer that starts in immature cells. Neuroblastomas form in the nervous systems of babies and young children.

Neuroblastomas are solid tumors or clusters of malformed cells found mainly on the top of the kidneys in the adrenal glands. They may also be found in the pelvis, spine, chest, and neck. They can spread to the skin, bone marrow, liver, and lungs.

Treatment methods for neuroblastoma include chemotherapy, immunotherapy, and radiation in addition to neuroblastoma surgery. Depending on the stage of cancer, these methods may be used on their own or together to shrink your child’s tumor and kill cancer cells.

Risk categories for neuroblastoma

There are three risk categories:

Low-risk neuroblastoma

Sometimes, tumors that show up on imaging in young infants and children go away on their own without any intervention or treatment. If they need surgery, children with low-risk neuroblastoma have a good chance of complete removal.

Intermediate-risk neuroblastoma

Children in this category typically need surgery to remove the tumor, followed by chemotherapy.

• Chemotherapy after surgery is called adjuvant (ADD-joo-vunt) therapy.
• In some cases, chemotherapy comes before surgery to shrink the tumor. Chemo before surgery is called neoadjuvant (knee-oh-ADD-joo-vunt) therapy. If the response to chemotherapy is very good, surgery may not be required.
• The duration, timing, and type of chemotherapy are determined by your child’s care team.

High-risk neuroblastoma

In this risk category, doctors will want to treat the cancer right away with a combination of surgery, chemotherapy, radiation, and immunotherapy. Some children may need daily medication for several months after treatment.

For children who need surgery, their care team will create a treatment plan outlining the best course of action to shrink and remove tumors.

• After a biopsy, chemotherapy is usually given for several months to shrink the cancer.
• Surgery is then typically required to remove all or at least nearly all of the tumor.
• A combination of chemotherapy, immunotherapy, and radiation therapy is typically given after surgery.

Complications of neuroblastoma surgery

As with any surgery, there are complications to neuroblastoma surgery, including the risk of:

• Damage to organs, blood vessels, or nerves near the surgery site.
• Excessive bleeding.
• Infection.
• Issues with bladder or bowel function.

Is neuroblastoma surgery right for my child?

Sometimes, doctors advise leaving lower-risk neuroblastomas alone and using watchful waiting. That's because these tumors have the potential to go away on their own.

Intermediate or high-risk neuroblastomas should not be left untreated. These tumors may grow, spread, and become life-threatening. If your child has been diagnosed with neuroblastoma, surgical removal of the tumor may be the right course of action.

It’s important to talk to your pediatrician and surgeon to develop a care plan for your child that considers your child’s overall health, the location and number of tumors, and the overall neuroblastoma risk group.

Before surgery

Before surgery, your child may undergo imaging tests to determine the size, scale, and location of the neuroblastoma. You can expect your child’s care team to explain their chosen method of removing the tumor before the procedure begins.

In some cases, a biopsy or tissue sample is required to diagnose neuroblastoma before surgical removal. These tumor samples can be taken through a tiny incision with a laparoscope, a thin tube with a small video camera attached to one end. The surgeon removes a small sample of tumor tissue for testing in a laboratory to diagnose the stage and risk category of the neuroblastoma.

A diagnosis of neuroblastoma is helpful before surgery because it can determine the stage and state of the cancer. In some cases, your child may need neoadjuvant chemotherapy before surgery begins. Neoadjuvant chemotherapy aims to shrink tumors, so they are easier to remove in surgery.

During surgery

Once your child is ready for surgery, an anesthesiologist will give the general anesthesia. Your child will remain asleep for the duration of the surgery.

Next, your child’s surgeon will make an incision based on the location of the tumors. This is typically somewhere on the abdomen. However, if tumors are present in other areas, such as the spine or chest, they make the appropriate incision for the tumor's location.

Once the surgeon has located the tumor(s), they will use a variety of tools to dislodge the tumor(s) and remove them. They will be careful to avoid any vital organs or important structures, such as blood vessels or nerves. They will also examine other surrounding organs to see if cancer has spread.

When the surgeon has finished removing the tumor and any affected lymph nodes or tissues, they will close the incision(s) with stitches, staples, adhesive glue, or another sealing method.

After surgery

After surgery, you can expect your child to take some time to become fully awake after anesthesia. They may be given pain medication while recovering in the hospital. You can expect your child’s care team to discuss the surgery results and recovery plan with you.

• If additional chemotherapy, radiation, or other treatment is needed after surgery, your child’s care team will discuss the next steps.
• You can expect follow-up visits for several months or years, depending on how your child’s cancer responds to the surgery and other therapies.

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.

One business day before your child’s surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age.

The following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.

For infants under 12 months

• Up to six hours before the scheduled arrival time, formula-fed babies may be given formula.
• Up to four hours before the scheduled arrival time, breastfed babies may nurse.

For all children

• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before the scheduled arrival time, give them nothing to eat or drink.

Once your child has been registered for the surgery, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery. They will ask questions about your child’s health and about when your child last ate.

Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

• As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
• If your child is very scared or upset, the doctor may give a special medication to help them relax. This medication is flavored and takes effect in about 10 to 15 minutes.
• If you wish, you may be allowed to go with your child to the room where the surgery will be done and stay while the sleep medication is given.
• Younger children will get their sleep medication through a “space mask” that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.
• Older children may choose between getting their medication through a mask or directly into a vein through an intravenous (IV) line.
• When your child has fallen asleep, you will be taken to the waiting room. If it has not already been done, an IV will be started so that medication can be given to keep your child sleeping throughout the surgery.

While your child is asleep, their heart rate, blood pressure, temperature, and blood oxygen level will be checked continuously. Your child will have a breathing tube placed while they are asleep. Your child might have a sore throat after the surgery.

To keep your child asleep during the surgery, they might be given anesthetic medication by mask, through the IV tube, or both. When the surgery is over, the medications will be stopped, and your child will begin to wake up.

After surgery, your child will be moved to the recovery room to allow the anesthetic to wear off. You will be called so that you can be there as they wake up.

• Children coming out of anesthesia react in different ways. Your child might cry, be fussy or confused, feel sick to their stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off.
• While your child is in recovery, your surgeon will talk to you about the surgery. This is a good time to ask questions about pain medications, diet, and activity.
• When your child is awake enough, they might be given a Popsicle® or “slushy” to drink in the recovery room.
• Once the anesthesiologist sees that your child is recovering and their pain is controlled, they will be moved to their hospital room. This usually takes about an hour, but every child is different, so times may vary.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

• You are encouraged to talk to your child or hold their hand before the surgery, while sleep medication is given, and while in recovery.
• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold before and after the surgery.

• During the surgery, your child will be given a numbing medication directly into the incision to relieve discomfort after the surgery.
• After the surgery, your child will most likely have abdominal pain. Your child may take Tylenol^® or Motrin^®. If your child is still having pain, your child’s doctor may prescribe a stronger medication or a narcotic.
• Before you go home, your doctor will prescribe pain medication for your child.

After your child is discharged and goes home, they should avoid strenuous activity for the next two to four weeks.

In general, your child will not need a follow-up appointment with their surgeon. However, you will be given instructions on what to call into the office for. This could result in an appointment being scheduled.

Bathing

Your child may take a shower one to three days after the surgery. Baths are allowed five to seven days after surgery.

Activity

Following the surgery, activity needs to be somewhat restricted.

• Your surgeon will determine when your child may resume normal activities.
• Your child may return to school when they feel up to it.
• Participation in contact sports and gym class is not permitted until cleared by the surgical team (typically two to four weeks after surgery).
• Swimming is permitted one to two weeks after surgery.
• Walking and stair climbing are encouraged.

If your child has a fever higher than 101.5 F, bleeding, or foul-smelling drainage from the area around the incisions, call your surgeon right away.

Also, call the doctor if your child has:

• Increased or unexplained pain.
• Increased swelling or redness at the incision site.
• Increased tenderness near the incision.
• Nausea, vomiting, diarrhea, or constipation that is not improving.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before the surgery. After the surgery, you may call the Division of Pediatric General and Thoracic Surgery at UPMC Children’s and ask to speak with your child’s surgeon or speak with them during the follow-up visit, if needed.

If your child has any special needs or health issues you feel the doctor needs to know about, please call the Division of Pediatric General and Thoracic Surgery at UPMC Children's Hospital of Pittsburgh before the follow-up visit and ask to speak with a nurse. It is important to notify us in advance about any special needs your child might have.

At UPMC Children’s Hospital of Pittsburgh, every child diagnosed with neuroblastoma receives an individualized treatment plan and family-centered care.

Because neuroblastoma surgery can be incredibly complicated, sometimes with long periods between diagnosis and surgery, you want to choose a provider with vast experience in treating this condition.

• Surgeons at UPMC Children’s have trained at the nation’s leading neuroblastoma treatment centers. They are among the country’s most experienced in neuroblastoma resection surgeries.
• In addition, surgeons at UPMC Children’s are pioneering the use of Intraoperative Molecular Imaging. This helps guide the most complete and safest resection of the tumor as possible.