Neuroblastoma (paediatric): lines of therapy

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9 standard-of-care settings across 3 lines and 3 biomarker subgroups. Rows come from the cancer page's standard of care; the grid places each on its line and subgroup.

Line	FRα	HR-positive	Risk group
Early / localised	·	·	7
Third line and beyond	1	·	·
Special situations	·	1	·

Early / localised

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
Risk group	High-risk	Induction chemo → surgery → tandem transplant → RT → anti-GD2 + isotretinoin; lorlatinib if ALK-mutant.	LorlatinibMonoclonal antibodies	NCI PDQ: Neuroblastoma Treatment (COG risk groups)	99
Risk group	Very-low / low risk (L1, MS)	Observation with serial imaging for asymptomatic L1/MS (many regress); surgery alone for resectable L1; short chemotherapy only for symptoms or progression.	INRG staging and risk groupsUltrasound	NCCN · COG/SIOPEN low-risk protocols (observation …	40
Risk group	Intermediate risk	2-8 cycles of moderate chemotherapy (carboplatin, etoposide, cyclophosphamide, doxorubicin) guided by response and biology; surgery; isotretinoin in some protocols.	DoxorubicinCytotoxic chemotherapyINRG staging and risk groups		93
Risk group	High risk: induction	5-6 cycles (COG: topotecan-cyclophosphamide × 2 then cisplatin-etoposide, cyclophosphamide-doxorubicin-vincristine; SIOPEN: rapid COJEC); stem-cell harvest; ANBL1531 adds 131I-MIBG (randomised) or lorlatinib (ALK); ANBL17P1 adds dinutuximab to induction.	COG ANBL1531131I-MIBG (iobenguane I-131) therapyLorlatinibDinutuximab (ch14.18) / dinutuximab betaDoxorubicin	NCCN · COG ANBL1531 backbone	82
Risk group	High risk: local control	Surgical resection of primary after induction (gross total where safe); external-beam radiotherapy 21.6 Gy to primary site (boost to residual) and MIBG-avid metastatic sites; proton therapy where available.	IMRT / IGRT (modern external beam)Proton therapy		91
Risk group	High risk: consolidation	Tandem autologous transplant (thiotepa-cyclophosphamide, then CEM) in North America (ANBL0532); single busulfan-melphalan transplant in Europe (HR-NBL1).	Tandem autologous transplantAutologous stem cell transplant (high-dose therapy)COG ANBL0532SIOPEN HR-NBL1	NCCN · COG standard (tandem); SIOPEN standard (BuM…	73
Risk group	High risk: post-consolidation	Anti-GD2 antibody (dinutuximab + GM-CSF + isotretinoin; dinutuximab beta in Europe, no IL-2) × 5-6 cycles; then eflornithine maintenance 2 years (US, 2023).	Dinutuximab (ch14.18) / dinutuximab betaCOG ANBL0032Eflornithine (DFMO)NMTRC003/003B (DFMO maintenance)Caution: IL-2 added to anti-GD2 therapy	NCCN · Dinutuximab: FDA-approved standard; eflorni…	86

Third line and beyond

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
FRα	Relapsed / refractory	Irinotecan-temozolomide + dinutuximab or naxitamab (ANBL1221); naxitamab + GM-CSF for marrow/bone disease; 131I-MIBG for MIBG-avid disease; lorlatinib for ALK; GD2 CAR-T (Italy, trials); DFMO-based maintenance; palliative radiotherapy.	Dinutuximab (ch14.18) / dinutuximab betaNaxitamabNaxitamab Study 201131I-MIBG (iobenguane I-131) therapyLorlatinibGD2-CART01 (Bambino Gesù phase 1/2)Anti-GD2 antibody + irinotecan-temozolomide (chemoimmunotherapy)		82

Special situations

Subgroup	Setting	Approach	Products and trials	Guideline	Evidence
HR-positive	Survivorship	Audiology (platinum, DFMO), endocrine and fertility follow-up, cardiac surveillance (anthracycline), second-malignancy screening, neurocognitive support; lifelong late-effects clinic.	Cardio-oncology		79

Sequence and caution pairings

CautionApproved

Caution: IL-2 added to anti-GD2 therapy

Interleukin-2 was part of the original immunotherapy package but a large European trial showed it adds toxicity and no benefit, so it has been dropped.

Lines and subgroups are parsed from the setting text of each standard-of-care row and can misclassify an unusual phrasing; the row’s own setting is always shown. Guideline chips reflect the NCCN category and ESMO-MCBS grade recorded on the cancer page, checked on its stated date. Not medical advice.