Comprehensive Metabolic Panel for Neuroblastoma Patients
For patients with neuroblastoma, a comprehensive metabolic panel should include electrolytes (calcium, phosphate, magnesium), creatinine, alanine aminotransferase, bilirubin, and thyroid studies (TSH with free T4 if TSH is abnormal), along with additional laboratory tests based on risk stratification. 1
Essential Laboratory Tests for Initial Diagnosis
The following laboratory tests are recommended for the initial workup of neuroblastoma:
- Complete blood count (CBC) with differential - essential for all patients 1, 2
- Comprehensive metabolic panel - essential baseline assessment 1, 2
- Urine catecholamine levels - homovanillic acid (HVA) and vanillylmandelic acid (VMA) 1, 2
- Required for diagnosis if bone marrow is the only diagnostic tissue
- Elevated in majority of neuroblastoma patients (50-100% depending on stage) 2
- Lactate dehydrogenase (LDH) - elevated levels associated with worse prognosis 1, 2
- Serum ferritin - elevated levels associated with worse prognosis 1, 2
- Prothrombin time/INR - particularly if liver involvement or bleeding concerns exist 1, 2
Monitoring Laboratory Tests Based on Risk Classification
High-Risk Disease
- CBC with differential - same frequency as imaging 1
- Electrolytes (including calcium, phosphate, magnesium) - every 3 months for year 1, every 6 months for years 2-3, annually for years 4-5 1
- Creatinine - every 3 months for year 1, every 6 months for years 2-3, annually for years 4-5 1
- Alanine aminotransferase - every 3 months for year 1, every 6 months for years 2-3, annually for years 4-5 1
- Bilirubin - every 3 months for year 1, every 6 months for years 2-3, annually for years 4-5 1
- Thyroid studies (TSH) - every 6 months for years 1-2, annually for years 3-5 1
- Include free T4 analysis if TSH is abnormal
- Spot catecholamine levels - consider during surveillance if elevated at diagnosis 1
Intermediate-Risk Disease
- CBC with differential - if bone marrow was involved at diagnosis 1
- Creatinine - every 6 months for year 1, annually for years 2-3, then as clinically indicated 1
- Thyroid studies (TSH) - annually through year 3, then as clinically indicated 1
- Include free T4 analysis if TSH is abnormal
- Spot catecholamine levels - consider during surveillance if elevated at diagnosis 1
Additional Tests Based on Treatment and Clinical Indication
- Hemoglobin A1c - evaluate if clinically indicated, especially for high-risk patients 1
- Reproductive health laboratory tests - follicle-stimulating hormone, luteinizing hormone, anti-Müllerian hormone if clinically indicated 1
- Echocardiogram - every 2-5 years if normal at end of therapy for high-risk patients (cardiotoxicity monitoring) 1
Clinical Pearls and Pitfalls
- Diagnostic utility of VMA varies by disease stage: 50% in Stage I/II, 88% in Stage III, 93% in Stage IV, and 100% in Stage IV-S 2
- Urine catecholamine levels are no longer recommended as part of International Neuroblastoma Response Criteria (INRC) for routine surveillance but can be considered if elevated at diagnosis 1
- Late effects monitoring should be tailored to the individual patient based on their risk classification and treatment exposure 1
- Ototoxicity is common in patients receiving platinum-based chemotherapy, requiring regular audiologic assessment 1
- Thyroid function can be impacted by neuroblastoma treatment, necessitating regular monitoring 1
By following this structured approach to laboratory monitoring, clinicians can effectively assess disease status, treatment response, and potential complications in neuroblastoma patients, ultimately improving morbidity, mortality, and quality of life outcomes.