The Critical Role of Surgery in Curing Neuroblastoma
Neuroblastoma is a challenging childhood cancer that arises from developing nerve cells. Curing it requires a multi-stage attack plan known as multimodal therapy, which combines chemotherapy, radiation, and immunotherapy to fight the cancer systemically. Within this plan, surgery plays a critical, hands-on role: to physically remove the primary tumor.
For most high-risk cases, surgery is strategically timed after several rounds of chemotherapy. This initial treatment shrinks the tumor, pulling it away from vital organs and blood vessels, making the operation safer and more effective. The goal is to remove over 90% of the cancer mass to prevent it from returning. Given the high stakes, surgeons are constantly pioneering new techniques to resect these complex tumors more completely and with fewer risks. Here are some of the most significant innovations in neuroblastoma surgery today.
Emerging Surgical Approaches and Techniques
Surgeons are refining their methods to achieve more complete tumor removal with fewer complications. This has led to the adoption of minimally invasive procedures for specific cases and highly specialized open approaches for the most complex tumors.
Minimally Invasive Surgery for Localized Tumors
For smaller tumors that are not tangled with major blood vessels, surgeons can use minimally invasive techniques. Using a camera and instruments inserted through small incisions, this approach avoids a large opening, leading to less pain, shorter hospital stays, and better cosmetic results. The magnified view also allows for extremely precise dissection around delicate nerves and vessels.
The "Chest-to-Abdomen" Approach (TPL)
When a neuroblastoma is so massive that it spans both the chest and the abdomen, surgeons may use a single, extensive incision to open both cavities. This thoracophrenolaparotomic (TPL) approach provides a panoramic view of the entire tumor, allowing for the safe removal of huge tumors that would otherwise be considered inoperable.
A Specialized Technique for Pelvic Tumors (PSAM)
For tumors deep in the pelvis, surgeons use a specialized technique called Posterior Sagittal Anorectal Mobilization (PSAM). By making an incision near the tailbone, they can gently move the rectum aside. This creates a direct and safe path to the tumor, allowing for precise removal without damaging nearby nerves that control bladder and bowel function.
Enhancing Surgical Precision Through Tumor Visualization
One of the greatest challenges in neuroblastoma surgery is seeing exactly where the tumor ends and healthy tissue begins. Researchers are developing groundbreaking technology that uses light to illuminate cancer cells in real-time, acting like a biological GPS for the surgeon.
Making Tumors Glow for Precise Removal
Before surgery, a special fluorescent dye is injected that is designed to attach only to neuroblastoma cells. During the operation, a special camera makes these cells glow, providing a real-time map that clearly separates the tumor from healthy tissue. This helps the surgeon remove the cancer with confidence while preserving vital organs.
Finding and Removing Hidden Cancer Remnants
After the main tumor is removed, the surgeon can use the same camera to scan the area for any leftover cancer. Tiny fragments that are invisible to the naked eye will appear as glowing spots, allowing the surgeon to find and remove these hidden deposits, improving the thoroughness of the operation and reducing the risk of recurrence.
A "Search-and-Destroy" Function
This technology may one day have a dual function. After all visible cancer is gone, the dye still attached to any remaining microscopic cells could be activated by a specific wavelength of light. This activation would release a burst of energy, destroying the cancer cell it is attached to without harming healthy tissue, providing a final microscopic "clean-up."
Integrating Surgery with Advanced Systemic Therapies
The treatment of neuroblastoma is evolving into a more dynamic model where surgery is strategically combined with the latest systemic therapies. This integrated approach creates a powerful synergy where each treatment enhances the effectiveness of the others.
Pairing Surgery with Targeted ALK Inhibitors
For neuroblastomas driven by an ALK gene mutation, new drugs like lorlatinib can precisely attack the cancer’s growth engine. Much like standard chemotherapy, these inhibitors can be used before surgery to dramatically shrink the tumor. The subsequent surgical removal of the primary tumor then reduces the overall disease burden, potentially preventing the cancer from developing resistance to the drug.
Priming the Immune System Before Surgery
Researchers are exploring the use of immunotherapy before the main surgery. The goal is to use anti-GD2 antibodies to "prime" the child's immune system, tagging cancer cells for destruction ahead of the operation. This may make the immune system more effective at hunting down any microscopic cells dislodged during the procedure.
Combining MIBG Therapy and Surgery
Metaiodobenzylguanidine (MIBG) therapy delivers targeted radiation directly to neuroblastoma cells throughout the body. For children with widespread disease, MIBG can be used to shrink tumors systemically. Following this "softening up" of the cancer, surgery can be performed to remove the primary tumor, which is now often smaller and less entangled with vital structures.
