What is the required surgical margin for neuroblastoma?

Surgical Margins for Neuroblastoma

For neuroblastoma, negative surgical margins are not the recommended goal; instead, gross total resection (>90% of tumor) is the standard surgical objective, as achieving negative margins is rarely feasible and often unnecessary for optimal outcomes.

Surgical Approach Based on Risk Classification

High-Risk Neuroblastoma

• Initial surgical approach:

  • Upfront resection is rarely feasible due to the aggressive nature of these tumors 1
  • Recommended approach is surgical resection after several cycles of initial cytoreductive chemotherapy 1
  • Negative margins are rarely feasible and not the recommended surgical goal 1

• Surgical margin goals:

  • The NCCN panel recommends achieving >90% resection (North American experience) or complete macroscopic resection (European experience) 1
  • This degree of resection is broadly considered a "gross total resection" 1
  • When vital organs, major nerves, and/or major blood vessels would be threatened, subtotal resection is recommended 1

• Evidence supporting this approach:

  • Two large analyses have demonstrated improved event-free survival (EFS) and lower local relapse/progression rates in patients who had >90% resection 1
  • Studies have supported a role for >90% resection of the primary tumor in high-risk patients 2
  • Research shows that ≥90% resection is both feasible and safe in most patients with high-risk neuroblastoma 3

Intermediate-Risk Neuroblastoma

• Surgical margin considerations:
  • Preservation of vital structures and end-organ function is of utmost importance 1
  • Less than complete response has been shown to be an acceptable endpoint of therapy for patients with localized intermediate-risk tumors 1
  • Surgical resection should be considered if chemotherapy has resulted in <50% reduction in tumor size 1

Low-Risk Neuroblastoma

• Surgical approach:
  • If upfront surgery will potentially obviate the need for chemotherapy and can be safely performed with minimal morbidity, a resection should be performed 1
  • Patients with low-risk disease are often managed with surgical resection or observation alone 3

Special Considerations

• Timing of resection:

  • The timing of resection depends on the response to initial therapy and subsequent assessment of surgical risk 1
  • Multidisciplinary discussion regarding the optimal timing of resection should occur 1

• Surgical complications:

  • Studies have reported cumulative complication rates of approximately 20% with surgery-associated mortality rates around 1% 4
  • The risk of complications must be balanced against the potential benefits of more extensive resection

• Impact on survival:

  • In patients with localized neuroblastoma age 18 months or older, especially in INRG high-risk patients harboring MYCN amplification, extended surgery of the primary tumor site improved local control rate and survival 4
  • Multivariable analyses have revealed that complete resection (vs. other extent) and MYCN status (non-amplified vs. amplified) are independent prognostic factors for event-free survival, local progression-free survival, and overall survival 4

Conclusion

When approaching surgical resection for neuroblastoma, the goal should be gross total resection (>90% of tumor) rather than negative margins. This approach balances the benefits of tumor removal with the risks of aggressive surgery near vital structures. The extent of resection should be tailored based on risk classification, with more aggressive approaches considered for high-risk disease, particularly in patients with MYCN amplification.