title: Surgical challenges associated with intensive treatment protocols for high-risk neuroblastoma.
abstract: BACKGROUND
  High-risk neuroblastoma (NB; age, >1 year; INSS stage 4) is associated with a poor outcome. At our institution, the current dose-intensive high-risk Children's Oncology Group protocol for advanced NB appears to have a higher surgical complication rate as compared with previous protocols.
  
  
  METHODS
  All stage 4 patients (n = 51) entered in high-risk protocols between 1995 and 2005 were analyzed. Patients in the current high-risk protocol, Children's Oncology Group A3973 (n = 22), were compared with those in the 2 previous protocols, CCG 3891 and POG 9341 (n = 29).
  
  
  RESULTS
  Patients were comparable in their mean age and tumor markers, including Shimada histology, MYCN amplification, 1p deletion, tumor origin, and extent of metastasis. However, transfusion requirement (86% vs 45%; P = .0019), postoperative infection rate (32% vs 3%; P = .02), and other postoperative issues including nutritional support (45% vs 3%; P = .0001) were significantly higher with the current protocol. No perioperative mortality was noted in either group, and the extent of resectability and margins were similar. Importantly, with the current protocol, the survival rate was higher (P = .0022) and the recurrence rate was significantly lower (P = .0003).
  
  
  CONCLUSIONS
  Despite higher surgical morbidity associated with the current high-risk protocol (2.59 vs 0.86 complications/person; P < .01), the recurrence rate is lower and interim survival rate is improved for patients with high-risk NB. Therefore, the higher surgical complication rates associated with the current high-risk protocol are acceptable.
authors: Division of General Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada M5G 1X8.
authors: Mae F
authors: MF
authors: Cantos
authors: J Ted
authors: JT
authors: Gerstle
authors: Meredith S
authors: MS
authors: Irwin
authors: Alberto
authors: A
authors: Pappo
authors: Shannon
authors: S
authors: Farley
authors: Timothy
authors: T
authors: Cheang
authors: Peter C W
authors: PC
authors: Kim