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).
Ferritin
- 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:
| Local | CT scan of the primary site and liver shows the extent of the primary tumor
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MR scan again shows local extent especially for paraspinal disease
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Distant |
MIBG scan shows uptake in the primary and metastatic disease in most neuroblastomas.
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Bone marrow aspirate and biopsy is done in all cases to exclude metastatic disease to this site
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Bone scan shows distant skeletal metastases, but is rarely necessary as MIBG scans accurately delineate bone involvment.
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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.
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CT scan can be used to identify metastatic disease in the liver, para-aortic lymph nodes and lytic disease in bone.
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Neuroblastoma stage information at the National Cancer Institute
