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metastatic (Koop 1968a), essentially an early attempt to define risk status. During the 1960s workers in both Japan and Europe also described their experience with neuroblastoma resection (Kasai and Watanabe 1968; Menjyo 1968; Schenga 1969; Zittel and Wuttke 1969). With the introduction of adjuvant chemotherapy in 1965 (James et al. 1965), plus major advances in pediatric imaging, surgery, anesthesia, blood banking, and critical care (Harrison et al. 1974; Hollmann and Lampert 1975; Stephen 1977; Tsunooka 1972), and the establishment of the pediatric oncology cooperative groups in the 1970s, multi-institution data became available and the number of surgical reports on neuroblastoma has steadily increased. Retrospective studies from the Children's Cancer Study Group (CCSG) on the role of surgery in disseminated neuroblastoma and localized neuro-blastomas were published in 1983 and 1985, respectively (O'Neill et al. 1985; Sitarz et al. 1983). In 1988 investigators from the Pediatric Oncology Group (POG) published a prospective study (Nitschke et al. 1988) showing that certain localized neuroblastomas could be effectively treated with surgery alone despite regional nodal involvement. Furthermore, the authors noted that overall survival was excellent, even in patients who developed relapses; however, comparisons between cooperative group experiences were hampered by lack of a uniform staging system. This was remedied by the establishment of the International Neuroblastoma Staging System (INSS) in 1988 and its revision in 1993 (Brodeur et al. 1988, 1993).

During the 1980s and early 1990s controversy arose as to the efficacy of primary tumor resection in patients with advanced-stage disease. Table 11.4.1 compares surgical reports supporting surgical resection of the primary tumor in high-risk neuroblas-toma with those that do not. Despite doubts as to the feasibility, safety, and efficacy of surgical resection in high-risk neuroblastoma, the present consensus in the Children's Oncology Group (COG), and European and Japanese cooperative groups is that an aggressive resection of loco-regional disease should be attempted. Surgery has an even more important role in low-and intermediate-risk disease.

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