Symptoms

Signs and symptoms of neuroblastoma vary depending on what part of the body is affected.

Neuroblastoma in the abdomen — the most common form — may cause signs and symptoms such as:

• Abdominal pain
• A mass under the skin that isn't tender when touched
• Changes in bowel habits, such as diarrhea
• Swelling in the legs

Neuroblastoma in the chest may cause signs and symptoms such as:

• Wheezing
• Chest pain
• Changes to the eyes, including drooping eyelids and unequal pupil size

Other signs and symptoms that may indicate neuroblastoma include:

• Lumps of tissue under the skin
• Eyeballs that seem to protrude from the sockets (proptosis)
• Dark circles, similar to bruises, around the eyes
• Back pain
• Fever
• Unexplained weight loss
• Bone pain

When to see a doctor 
Contact your child's doctor if your child has any signs or symptoms that worry you. Mention any changes in your child's behavior or habits.

Causes

In general, cancer begins with a genetic mutation that allows normal, healthy cells to continue growing without responding to the signals to stop, which normal cells do. Cancer cells grow and multiply out of control. The accumulating abnormal cells form a mass (tumor). Cancer cells may invade nearby tissues and can break off from an initial tumor to spread elsewhere in the body (metastasize).

Neuroblastoma begins in neuroblasts — immature nerve cells that a fetus makes as part of its development process. As the fetus matures, neuroblasts eventually turn into nerve cells and fibers and the cells that make up the adrenal glands. The majority of neuroblasts mature by birth, though studies have found a small number of immature neuroblasts in newborns. In most cases, these neuroblasts will mature or disappear. Others, however, form a tumor — a neuroblastoma.

It isn't clear what causes the initial genetic mutation that leads to neuroblastoma. However, because neuroblastoma usually affects very young children, researchers believe the mutation occurs during pregnancy or soon after birth.

Risk factors

The only factor known to increase the risk of neuroblastoma is a family history of the cancer. Yet, familial neuroblastoma is thought to comprise a very small number of neuroblastoma cases. In most cases of neuroblastoma, a cause is never identified.

Complications

Complications of neuroblastoma may include:

• Spread of the cancer (metastasis). Neuroblastoma may spread (metastasize) to other parts of the body, such as the lymph nodes, bone marrow, liver, skin and bones.
• Spinal cord compression. Tumors may grow and press on the spinal cord, causing spinal cord compression. Spinal cord compression may cause pain and paralysis.
• Signs and symptoms caused by tumor secretions.Neuroblastomas may secrete certain chemicals that irritate other normal tissues, causing signs and symptoms called paraneoplastic syndromes. One paraneoplastic syndrome that occurs rarely in people with neuroblastoma causes rapid eye movements and difficulty with coordination. Another rare syndrome causes abdominal swelling and diarrhea.

Preparing for your appointment

Make an appointment with your family doctor or pediatrician if your child has any signs or symptoms that worry you. You may be referred to a doctor who specializes in digestive problems (gastroenterologist) or respiratory problems (pulmonologist).

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your child's appointment. Here's some information to help you get ready, and what to expect from your child's doctor.

What you can do

• Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your child's diet.
• Write down any symptoms your child is experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, as well as any vitamins or supplements, that your child is taking.
• Take a family member or friend along. Sometimes it can be difficult to absorb all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your child's doctor.

Your time with your child's doctor is limited, so preparing a list of questions will help you make the most of your time. List your questions from most important to least important in case time runs out. For neuroblastoma, some basic questions to ask your child's doctor include:

• What is likely causing my child's symptoms or condition?
• What are other possible causes for my child's symptoms or condition?
• What kinds of tests does my child need?
• Is my child's condition likely temporary or chronic?
• What is the best course of action?
• What are the alternatives to the primary approach that you're suggesting?
• My child has these other health conditions. How can they best be managed together?
• Are there any restrictions that my child needs to follow?
• Should my child see a specialist? What will that cost, and will my insurance cover it?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can take with me? What websites do you recommend?
• What will determine whether I should plan for a follow-up visit?

In addition to the questions that you've prepared to ask your child's doctor, don't hesitate to ask questions any time you don't understand something.

What to expect from your child's doctor 
Your child's doctor is likely to ask you a number of questions. Being ready to answer them may allow more time to cover points you want to address. Your child's doctor may ask:

• When did your child begin experiencing symptoms?
• Have your child's symptoms been continuous?
• How severe are your child's symptoms?
• What, if anything, seems to improve your child's symptoms?
• What, if anything, appears to worsen your child's symptoms?

What you can do in the meantime 
Try to keep your child comfortable by avoiding things that seem to worsen signs and symptoms. Not feeling well and an approaching trip to the doctor may make your child feel anxious. To reduce your child's anxiety, try to:

• Stick to your normal daily routine as much as possible.
• Use simple words to explain what will happen at the doctor's office.
• Give your child choices when possible. For instance, let him or her pick out the clothes to wear that day. Or ask your child whether he or she would like apple juice or orange juice.

Tests and diagnosis

Tests and procedures used to diagnose neuroblastoma include:

• Physical exam. Your child's doctor conducts a physical exam to check out any signs and symptoms. The doctor will ask you questions about your child's habits and behaviors.
• Urine and blood tests in children. These may indicate the cause of any signs and symptoms your child is experiencing. Urine tests may be used to check for high levels of certain chemicals that result from the neuroblastoma cells producing excess catecholamines.
• Imaging tests. Imaging tests may reveal a mass that can indicate a tumor. Imaging tests may include X-ray, ultrasound, computerized tomography (CT) scan and magnetic resonance imaging (MRI), among others.
• Removing a sample of tissue for testing. If a mass is found, your child's doctor may want to remove a sample of the tissue for laboratory testing (biopsy). Specialized tests on the tissue sample can reveal what types of cells are involved in the tumor and specific genetic characteristics of the cancer cells. This information helps your child's doctor devise an individualized treatment plan.
• Removing a sample of bone marrow for testing. Your child may also undergo bone marrow biopsy and bone marrow aspiration procedures to see if neuroblastoma has spread to the bone marrow — the spongy material inside the largest bones where blood cells are formed. In order to remove bone marrow for testing, the surgeon inserts a needle into your child's hipbone or lower back and draws out the marrow.

Staging 
Once neuroblastoma is diagnosed, your child's doctor may order further testing to determine the extent of the cancer and whether it has spread to distant organs — a process called staging. Imaging tests used to stage cancer include X-rays, bone scans, and CT and MRI scans, among others.

Using the information from those procedures, your child's doctor assigns a stage to the neuroblastoma. Stages of neuroblastoma include:

• Stage I. Neuroblastoma at this stage is localized, meaning it's confined to one area, and may be completely removed with surgery. Lymph nodes connected to the tumor may have signs of cancer, but other lymph nodes don't have cancer.
• Stage IIA. Neuroblastoma at this stage is localized, but may not be as easily removed through surgery.
• Stage IIB. Neuroblastoma at this stage is localized and may or may not be easily removed through surgery. Both the lymph nodes connected to the tumor and the lymph nodes nearby contain cancer cells.
• Stage III. Neuroblastoma at this stage is considered advanced, and it isn't possible to remove the tumor through surgery. The tumor may be a larger size at this stage. Lymph nodes may or may not contain cancer cells.
• Stage IV. Neuroblastoma at this stage is considered advanced and has spread (metastasized) to other parts of the body.
• Stage IVS. This stage is a special category of neuroblastoma that doesn't behave like other forms of neuroblastoma, though it isn't clear why. Stage IVS neuroblastoma applies only to children younger than 1 year old. Stage IVS indicates that neuroblastoma has spread to another part of the body — most commonly the skin, liver or limited bone marrow involvement. Despite the extent of neuroblastoma, babies with this stage have a good chance of recovery. Neuroblastoma at this stage sometimes goes away on its own and often doesn't require any treatment.

Treatment and drugs

Your child's doctor selects a treatment plan based on several factors that affect your child's prognosis. Factors include your child's age, the stage of the cancer, the type of cells involved in the cancer, and whether there are any abnormalities in the chromosomes and genes. Using this information, your child's doctor categorizes the cancer as low risk, intermediate risk or high risk. What treatment or combination of treatments your child receives for neuroblastoma depends on the risk category.

Surgery 
Surgeons use scalpels and other surgical tools to remove cancer cells. In children with low-risk neuroblastoma, surgery to remove the tumor may be the only treatment needed. Whether the tumor can be completely removed depends on its location and its size. Tumors that are attached to nearby vital organs — such as the lungs or the spinal cord — may be too risky to remove. In intermediate-risk and high-risk neuroblastoma, surgeons may try to remove as much of the tumor as possible. Other treatments, such as chemotherapy and radiation, may then be used to kill remaining cancer cells.

Chemotherapy 
Chemotherapy uses chemicals to destroy cancer cells. Chemotherapy targets rapidly growing cells in the body, including cancer cells. Unfortunately, chemotherapy also damages healthy cells that grow quickly, such as cells in the hair follicles and in the gastrointestinal system, which can cause side effects.

Children with low-risk neuroblastoma that can't be removed surgically may undergo chemotherapy. Sometimes chemotherapy is administered before surgery (neoadjuvant chemotherapy) to shrink the tumor to a size that's more easily removed. In other cases, chemotherapy may be the only treatment.

Children with intermediate-risk neuroblastoma often receive a combination of chemotherapy drugs before surgery to improve the chances that the entire tumor can be removed.

Children with high-risk neuroblastoma usually receive high doses of chemotherapy drugs to shrink the tumor and to kill any cancer cells that have spread elsewhere in the body. Chemotherapy is usually used before surgery and before bone marrow stem cell transplant.

Radiation therapy 
Radiation therapy uses high doses of energy particles to destroy cancer cells. Radiation therapy primarily affects the area where it's aimed. Your child's radiation therapy team tries to protect the healthy cells near the cancer, but some healthy cells may be damaged by the radiation. What side effects your child experiences depends on where the radiation is directed and how much radiation is administered.

Children with low-risk or intermediate-risk neuroblastoma may receive radiation therapy if surgery and chemotherapy haven't been helpful. Children with high-risk neuroblastoma may receive radiation therapy after chemotherapy and surgery, to prevent cancer from recurring.

Stem cell transplant 
Children with high-risk neuroblastoma may receive a transplant using their own blood stem cells (autologous stem cell transplant). The bone marrow produces stem cells, which mature and develop into the red and white cells and platelets that make up the blood. Your child undergoes a procedure that filters and collects stem cells from his or her blood. Then high doses of chemotherapy are used to kill any remaining cancer cells in your child's body. Your child's stem cells are then injected into your child's body, where they can form new, healthy blood cells.

Long-term and late side effects of cancer treatment 
As more and more children are surviving cancer and living into adulthood, doctors are increasingly aware of the long-term side effects of cancer treatment. Doctors recommend childhood cancer survivors be seen regularly by a doctor who understands the long-term and late side effects that can affect children after cancer treatment.

Side effects vary depending on treatment, but may include impaired growth, thyroid problems, second cancers and infertility, which may be caused by chemotherapy drugs. Difficulty thinking and trouble processing thoughts may be long-term side effects of radiation, especially brain radiation or total body irradiation.

Coping and support

When your child is diagnosed with cancer, it's common to feel a range of emotions — from shock and disbelief to guilt and anger. In the midst of this emotional roller coaster, you're expected to make decisions about your child's treatment. And while you're trying to sort it all out, friends and family may be calling for updates and to find out if they can help. It can be overwhelming. If you're feeling lost, you might try to:

• Gather all the information you can. Learn all you can about neuroblastoma. Talk with your child's health care team. Keep a list of questions to ask at the next appointment. Visit your local library and ask for help searching for information. Consult the National Cancer Institute (NCI) and the American Cancer Society (ACS) for more information. Both organizations provide information through their websites and toll-free telephone information lines. Call the NCI at 800-4-CANCER (800-422-6237). Call the ACS at 800-ACS-2345, (800-227-2345). Knowing more about your child's condition may help when choosing treatment options.
• Organize a support network. In the coming weeks and months, your child will undergo tests and procedures that will be time-consuming and may require traveling to a specialized medical center. If you want to be with your child through this time, you may have to take time off from work. Some people will be able to organize this with their employers. For others, time off from work and time without income won't be possible. Find friends and family who can help. Loved ones can accompany your child to doctor visits or sit by his or her bedside in the hospital when you can't be there. If you can take time away from work to be with your child, your friends and family can help out by spending time with your other children or helping around your house.
• Take advantage of resources for kids with cancer. Seek out special resources for families of kids with cancer. Social workers and other members of your health care team can tell you what programs are available. Support groups for parents and siblings put you in touch with people who understand what you're feeling. Your family may be eligible for summer camps, temporary housing and other support.
• Maintain normalcy as much as possible. Small children can't understand what's happening to them as they undergo cancer treatment. To help your child cope, try to maintain a normal routine as much as possible. Try to arrange appointments so that your child can have a set nap time each day. Have routine mealtimes. Allow time for play when your child feels up to it. If your child must spend time in the hospital, bring items from home that help him or her feel more comfortable. Ask your health care team about other ways to comfort your child through his or her treatment. Some hospitals have recreation therapists or child-life workers who can give you more specific ways to help your child to cope.