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A routine history and physical examination of the patient are always the most important initial investigations.


Blood work

Routine blood work and urinalysis including:

  • CBC – may have normochromic, normocytic anemia 
  • Liver and kidney function studies
  • Coagulation screen (clotting problems associated with liver metastases)


Urinary catecholamines: vanillylmandelic acid (VMA) and homovanillic acid (HVA)

    • Excreted into the urine in large quantities
    • Levels are elevated in 90% of neuroblastoma patients.
    • The absolute values of VMA and HVA are not significant, but the VMA: HVA ratio in patients with disseminated disease correlates with outcome (the higher the value the better the prognosis - VMA: HVA ratio greater than or equal to 1.5 do better than if this ratio is less than 1.5).  



    • Produced by neuroblastoma cells in vitro
    • Levels increased in about 50% of patients with Stage III or IV disease at diagnosis.
    • In Stage III disease an elevated ferritin level is a poor prognostic feature.




Staging Investigations

To determine local and distant extent of disease:


CT scan of the primary site and liver shows the extent of the primary tumor


MR scan again shows local extent especially for paraspinal disease



MIBG scan  shows uptake in the primary and metastatic disease in most neuroblastomas.

  • Meta-IodoBenzylGuanidine is taken up by adrenergic secretory vesicles and is handled by the cells in the same way as norepinepherine. 
  • It is radiolabelled using I-131. 
  • Initially used to visualize the adrenal medulla and pheochromocytoma.
  • MIBG scans can be used to follow disease


Bone marrow aspirate and biopsy is done in all cases to exclude metastatic disease to this site


Bone scan shows distant skeletal metastases, but is rarely necessary as MIBG scans accurately delineate bone involvment.


PET scan shows increased metabolic activity in the primary and metastatic neuroblastoma. Very rarely neuroblastoma may be MIBG negative and in these circumstances, PET-CT may have a role.


CT scan can be used to identify metastatic disease in the liver, para-aortic lymph nodes and lytic disease in bone.



Neuroblastoma stage information at the National Cancer Institute


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