Anesthesia in Children with Neuroblastoma, Perioperative and Operative Management

Abstract

Neuroblastoma (NB) is the most common extracranial, solid, pediatric malignancy and, despite the constant progress of treatment and development of innovative therapies, remains a complex, challenging disease causing major morbidity and mortality in children. There is significant variability in the management of neuroblastoma, partially due to the heterogeneity of the clinical and biological behavior, and partially secondary to the different approaches between treating institutions. Anesthesia takes an integral part in the multidisciplinary care of patients with NB, from diagnosis to surgery and pain control. This paper aims to review and discuss the critical steps of the perioperative and operative management of children undergoing surgery for neuroblastoma. Anesthesia and analgesia largely depend on tumor location, surgical approach, and extension of the surgical dissection. Attention should be paid to the physio-pathological changes on cardiovascular, gastrointestinal, and immune systems induced by the tumor or by chemotherapy. At the time of surgery meticulous patient preparation needs to be carried out to optimize intraoperative monitoring and minimize the risk of complications. The cross-sectional role of anesthesia in cancer care requires effective communication between all members of the multidisciplinary team.

Perioperative hypertension and anesthetic management in patients undergoing resection of neuroblastoma

“…Neuroblastoma is the most common extracranial pediatric solid tumor, accounting for 5–8% of all childhood cancers and 15% of mortalities in pediatric malignancy 1,2 . It most often presents as a retroperitoneal mass arising from the adrenal gland, but it can also be found at any site along the sympathetic chain in the form of a cervical, thoracic, or pelvic mass 3 . Prognosis can range from spontaneous regression without treatment in some infants to aggressive disease that is refractory to multi‐modal therapy.…”

“…Hypertension in patients with neuroblastoma ranges in incidence from 10 to 19% of cases 3 . The underlying etiology is thought to be multifactorial due to both upregulation of the renin–angiotensin–aldosterone system via renal artery or renal parenchymal compression as well as excess catecholamine production from the tumor.…”

“…The underlying etiology is thought to be multifactorial due to both upregulation of the renin–angiotensin–aldosterone system via renal artery or renal parenchymal compression as well as excess catecholamine production from the tumor. Side effects from chemotherapy medications as well as the need for concurrent hyperhydration can also contribute to hypertension 3 …”

“…1,2 It most often presents as a retroperitoneal mass arising from the adrenal gland, but it can also be found at any site along the sympathetic chain in the form of a cervical, thoracic, or pelvic mass. 3 Prognosis can range from spontaneous regression without treatment in some infants to aggressive disease that is refractory to multi-modal therapy. Current management is based on a patient's risk stratification, incorporating factors such as the patient's age, radiological grade, biological factors, and presence of metastases.…”

“…Side effects from chemotherapy medications as well as the need for concurrent hyperhydration can also contribute to hypertension. 3 Case reports of severe intraoperative hypertension for neuroblastoma patients do exist; however, data on the incidence of intraoperative hypertension are lacking. [8][9][10][11] The few studies describing intraoperative hypertension report the incidence to be rare less than 3.5%.…”