Neuroblastoma

High-risk neuroblastoma survival remains 38–40% despite multimodal therapy including chemotherapy, immunotherapy, radiation, and surgery [e434-c1, e651-c1]. Surgical resection extent remains controversial. Large European (n=1,324) and COG (n=230) studies demonstrate improved event-free survival with >95% resection; the European cohort uniquely showed overall survival benefit [e434-c12, e434-c13, e651-c8, e651-c9]. German data (n=278) found no survival difference by resection completeness [e434-c9, e651-c7]. Post-operative MIBG-positive residue predicts worse outcomes (5-year EFS 25–27% vs. 51% without MIBG uptake), whereas radiologically detected but MIBG-negative residue does not impact survival [e10044-c17, e10044-c18, e10044-c19, e10044-c25]. Surgical morbidity approximates 30% with <1% mortality when performed by experienced teams using vessel-based dissection techniques [e434-c2, e651-c2, e434-c15]. Neoadjuvant chemotherapy produces maximal tumor response within two cycles; additional cycles increase fibrosis without volume reduction [e434-c3, e651-c3]. Image-guided core needle biopsy (≥10 cores) provides tissue adequacy equivalent to open biopsy with lower transfusion requirements and complications [e291-c8, e7988-c4, e7988-c5, e7988-c6, e9212-c15]. Observation is appropriate for L1 tumors in infants <6 months (97% 4-year EFS) . Long-term survivors face premature aging with chronic conditions by age 20 (vs. age 50 in siblings), radiation-induced second malignancies (cumulative 3% at 10 years), growth impairment unresponsive to GH, metabolic syndrome from abdominal RT, and premature ovarian failure [e10159-c5, e10159-c30, e10159-c22, e10159-c24, e10159-c32].