The impact of chemotherapy and radiation therapy on secondary operations for neuroblastoma.

From January, 1969 through July, 1979, 37 children with neuroblastoma were cared for at the Oklahoma Children's Memorial Hospital. Nineteen patients with extensive disease were studied to examine the interrelationships of chemotherapy, radiation therapy and secondary surgery. Eleven children had secondary surgery in the abdomen or cervical region with one postoperative death. All patients had chemotherapy and ten had radiation therapy between the primary and secondary operation or death. Five children survived. Four of five survivors were less than one year of age at diagnosis and initial treatment. Fourteen of 15 patients, one year of age or older, died. Each case had pathologic examination of tumor before and after therapy. All survivors showed sequential maturation of tumor tissue but only one nonsurvivor had this finding. Unusual metastatic spread was found in patients having combined therapy. Multimodal therapy for advanced neuroblastoma accentuates the need for sensible timing and utilization of secondary operative procedures. The secondary procedures ideally eradicate the primary focus of tumor, and may also serve to excise selective areas of metastatic disease or to biopsy residual disease in aiding continuing therapy. Secondary surgery ought to follow the onset of radiation therapy by four to six weeks, or of chemotherapy by 12 to 24 weeks. This delay allows maximum control of primary and generalized disease, as well as maturation, differentiation, encapsulation and shrinkage of extensive initially unresectable primary tumors.