LYMPH NODES
All grossly visible lymph nodes must be sampled, regardless of whether they appear normal or
not. Lymph nodes removed need to be carefully labeled, and correlated with a detailed operative
report, including distinction for nodes that are contiguous and attached to the primary tumor
versus those which are not. This is essential to differentiate INSS stage 1 with positive attached
nodes versus INSS 2B with positive regional nodes. It is advised to sample the following nodal
areas in the various anatomical locations.
Neck: Sample nodes along the cervical chain both adjacent to the tumor and high and low in the
neck.
Thorax: Sample nodes from upper, mid-, lower paraspinal or mediastinal chains (total 6-9
nodes).
Abdomen: Sample nodes from as high under the diaphragm as possible, from the immediate
paraaortic drainage level of the primary tumor and from the area of bifurcation of the aorta (total
6-9 nodes). Try to obtain nodes from paracaval (right) interaortocaval (mid), and paraaortic (left)
chains and label carefully. Mesenteric portal and celiac nodes may also be sampled.
Pelvis: Sample nodes from paraaortic and paracaval chains, the aortic bifurcation, and from both
iliac chains, from the aortic bifurcation area and the iliac chain (total 6-9 nodes).
Management of Surgical Complications
Intraoperative complications are site-dependent. Major hemorrhage from either venous or arterial
structures is of concern with more infiltrative tumors. The principles of vascular surgery,
including proximal and distal control, pertain. Appropriate intraoperative vascular surgical
consultation should be sought if necessary. Crucial vessels like the carotid, subclavian, hepatic,
superior mesenteric or renal arteries should be repaired and flow restored even if bypass grafting
is required. Nerve injuries may also be incurred and should be primarily repaired using
magnification.
Special Operative Techniques
Nerve stimulation
Nerve stimulation can be useful in detecting motor nerves in the brachial, or lumbo-sacral
plexus. This requires cooperation from the anesthesiologist, as muscle relaxation must be
allowed to wear off. Nerve stimulation, as well as neuro monitoring should always be used when
dissection along the pelvic sidewall or in the neck or thoracic inlet.
Ultrasonic dissector-aspirators
Some authors have described the use of ultrasonic dissectors (CUSA) to debulk the interior of
large tumors allowing an easier capsular dissection. The technique is useful for friable tumors
but not those that are stroma rich. The surgeon should try to perform a generous incisional
biopsy prior to ultrasonic dissection as it is difficult to capture the tumor specimen after it has
been aspirated into the device.
Thoracoscopy
Video-assisted thoracoscopy can be used to remove small posterior mediastinal or thoracic inlet
tumors provided there is no vascular encasement. One-lung ventilation may be helpful, as is low
pressure carbon dioxide into the chest cavity.
Laparoscopy
Laparoscopic resection of small adrenal or pelvic primaries can be done. Extensive
tumors or those with significant vascular encasement, or loco regional nodal spread can
be more completely resected using standard open approaches.
Radiofrequency Ablation, Cryosurgery
These techniques have significant drawbacks when applied to lesions in proximity to major
vascular structures and should be avoided when treating Neuroblastoma.
Central Line Placement
Patients will require central venous access both for treatment and potential stem cell
transplantation or apheresis. It is usually feasible and efficient to place a vascular access device
and obtain a bone marrow aspirate and biopsy during the initial anesthetic. The appropriate
catheter should be placed from initiation of therapy