Pediatric Neuroblastoma Follow-up

Updated: May 14, 2021
  • Author: Norman J Lacayo, MD; Chief Editor: Max J Coppes, MD, PhD, MBA  more...
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Follow-up

Further Outpatient Care

The following are aspects of further outpatient care in patients with neuroblastoma:

  • Patients are periodically monitored in the clinic after each course of therapy to monitor for complications and to assess response to therapy with diagnostic imaging. Myelosuppression and pancytopenia are common complications, and a CBC count with platelet count is obtained as often as twice per week. Some drugs (eg, cisplatin, carboplatin, ifosfamide) affect renal function; thus, close monitoring of electrolytes is required, with oral electrolyte supplementation when necessary. Blood product support is provided when the hemoglobin drops to less than 8 g/dL, the platelet count drops to less than 10,000, or any signs of bleeding are present.

  • After completion of therapy, successfully treated patients require follow-up care and close surveillance for any signs or symptoms of recurrent disease. Follow-up care includes monitoring of urinary catecholamines, physical examination, and diagnostic imaging. Because most recurrences occur during the first 2 years following treatment, most protocols recommend close follow-up care during this interval.

  • Patients who remain free of recurrent disease for 5 years are considered cured, although rare late relapses have been reported. Long-term follow-up care to assess impact of therapy on growth, development, and organ toxicity is essential.

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Further Inpatient Care

The following are aspects of further inpatient care in patients with neuroblastoma:

  • Children with neuroblastoma are admitted to the hospital to expedite the diagnostic workup when unstable or significantly symptomatic.

  • In an asymptomatic child, workup can be performed in the outpatient setting.

  • A central line is commonly placed when biopsy or resection is scheduled in intermediate- or high-risk patients.

  • A pediatric oncologist and surgeons with expertise in managing childhood malignancies perform the initial evaluation.

  • Other subspecialists, such as neurosurgeons or radiation oncologists, may participate in patient care, especially in cases of cord compression.

  • Once the diagnosis is established and the staging workup is completed, the patient and family are instructed on the diagnosis and therapeutic options.

  • Once the treatment plan is developed, chemotherapy is administered, usually in the inpatient setting.

  • Following completion of the treatment cycle, patients are discharged home with detailed instructions for home care and with outpatient follow-up.

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Inpatient & Outpatient Medications

The following medications may be used:

  • Infection prophylaxis: Chemotherapy agents cause myelosuppression and immunosuppression. All patients should receive prophylaxis against Pneumocystis jiroveci with trimethoprim/sulfamethoxazole (trimethoprim 2.5 mg/kg/dose twice daily), administered on 3 consecutive days per week. Prophylaxis is started before chemotherapy and continued for at least 3 months after completing therapy.

  • Colony-stimulating factors: Granulocyte colony stimulating factor (G-CSF) support has become common in pediatric oncology as intensity of chemotherapy has increased. Treat with 5-10 mcg/kg/d subcutaneously to start 24-36 hours after the last dose of chemotherapy. G-CSF is continued until the absolute neutrophil count is 2,000-10,000. See the Absolute Neutrophil Count calculator.

    A mouse model study by Agarwal et al suggested that G-CSF promotes the growth of neuroblastoma cancer stem cells that may be responsible for cancer relapse. [28, 29]

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Transfer

Management by a primary care provider is as follows:

  • With oncology team supervision, routine care can be carried out by the primary care provider for patient convenience.

  • Monitoring of blood counts or chemistries and administration of blood products are common.

  • Some primary care providers with experience in the treatment of febrile neutropenia may be able to manage this complication of chemotherapy. Patients may quickly destabilize upon initiation of antibiotic therapy; thus, access to critical care services is required.

  • Maintain close contact with subspecialists and transfer the patient to the pediatric oncology center for any complications that may require specialized care.

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Deterrence/Prevention

The cause of neuroblastoma is unknown. No specific environmental exposure or risk factors have been identified.

Currently, no specific recommendations on how to prevent this disease are known.

Screening for neuroblastoma in an attempt to diagnose high-risk patients earlier in the course of their disease has uncovered many patients with low-risk disease but has not had an impact on outcome in high-risk disease.

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