Neuroblastoma is a cancer of the sympathetic nervous system that arises most often in the adrenal glands or along the spine, and it accounts for a disproportionate share of childhood cancer deaths. The girl at the center of this report carried one of the worst prognostic markers in the disease: amplification of the MYCN gene, a genetic signature associated with aggressive, treatment-resistant tumors. Her initial treatment followed the standard European induction protocol known as COJEC, a rapid cycle of cisplatin, vincristine, carboplatin, etoposide, and cyclophosphamide, followed by two courses of topotecan, vincristine, and doxorubicin. When doctors re-evaluated her disease, the news was grim. The primary tumor in her abdomen remained large and active, it pressed on critical blood vessels, and scans revealed widespread involvement of her bones and bone marrow, yielding a skeletal disease score of 45 on the SIOPEN scale used across European pediatric oncology centers.

What followed was a relentless escalation of therapy. Second-line chemotherapy with temozolomide and irinotecan, later combined with the anti-GD2 antibody dinutuximab beta, succeeded in clearing the metastatic disease from her bones and marrow. She then underwent consolidation with two rounds of radiometabolic therapy using iodine-131 labeled MIBG—a radioactive form of the same tracer molecule used to image neuroblastoma—each followed by reinfusion of her own stem cells, and finally high-dose chemotherapy with busulfan and melphalan supported by another stem-cell rescue. Yet when the dust settled, one enemy remained entrenched: a residual mass in her retroperitoneum, the space behind the abdominal organs, measuring 13.3 by 9.8 by 6.9 centimeters. The mass continued to light up on MIBG scans, proof that living neuroblastoma cells persisted within it, and it wrapped around the celiac artery and the right renal artery while compressing the inferior vena cava, the largest vein in the body.

This anatomical situation presented surgeons with an impossible calculus. Any attempt at resection risked catastrophic hemorrhage from vessels that the tumor had encased, and there was no guarantee that a complete removal could be achieved even at that price. A biopsy taken through the skin confirmed that the mass contained viable neuroblastoma tissue showing differentiating features, meaning the cells were still alive and capable of regrowth. It was at this impasse that a multidisciplinary tumor board—bringing together pediatric oncologists, surgeons, interventional radiologists, pathologists, and radiation therapists at Bambino Gesù Children’s Hospital in Rome—turned to a technique that had never before been applied to a child with this disease: percutaneous electrochemotherapy.

The principle behind electrochemotherapy is elegantly physical. Cell membranes, though thin, are formidable barriers that normally prevent many chemotherapy drugs from entering cells efficiently. When short, high-voltage electric pulses are applied across a tissue, they transiently reorganize the lipid bilayer of those membranes, opening nanoscale pores in a process called reversible electroporation. The pores allow drug molecules to flood into the cell interior, and because the pulses are calibrated carefully, the membranes reseal afterward and the cells survive—only to be killed by the chemotherapy they have now absorbed in quantities far beyond what ordinary exposure could achieve. The drugs most commonly paired with electroporation are bleomycin and cisplatin, both of which become dramatically more cytotoxic inside electroporated cells. In adults, the technique has earned validated roles against melanoma, sarcoma, and head and neck tumors, but pediatric experience has been almost nonexistent.

The Roman team tailored the procedure to the unique biology of neuroblastoma. Rather than administering cisplatin intravenously, they injected it directly into the tumor, a strategy designed to maximize drug concentration within the lesion while minimizing systemic side effects—a rational choice given that platinum compounds are among the drugs to which neuroblastoma is classically sensitive. Under general anesthesia, with the child positioned prone, three variable-geometry needle electrodes with an active length of three centimeters were inserted intercostally, between the ribs, using computed tomography and ultrasound guidance. The target was the most metabolically active portion of the mass, precisely the region where MIBG single-photon emission imaging had shown the greatest tracer uptake and where the tumor pressed hardest against the inferior vena cava. Once the electrodes bracketed the target, an 18-gauge coaxial biopsy was taken through the field, and four milligrams of cisplatin at a concentration of two milligrams per milliliter were injected through a Chiba needle. The Cliniporator VITAE device then delivered voltage pulses ranging from 900 to 1,700 volts, completing the session.

The technical choreography matters because electroporation is unforgiving of sloppy planning. The electric field must cover the entire tumor volume homogeneously; any region that falls between electrodes may receive sub-lethal exposure and survive as a seed of recurrence. This is why careful pre-treatment planning and meticulous electrode placement are considered the linchpins of the technique, particularly for large or irregularly shaped lesions like the one in this case. Encouragingly, the procedure itself was uneventful. No immediate or delayed complications occurred, post-procedure monitoring revealed nothing concerning, and the child was discharged in stable condition. The team notes that the approach is also repeatable, an important attribute for a disease where residual lesions sometimes require more than one local intervention.

The follow-up imaging tells the story in two snapshots. One month after the procedure, magnetic resonance imaging revealed a necrotic, liquefied area of 20 by 20 millimeters within the treated field—direct evidence that the electroporated cells had died on schedule, consistent with the six-to-eight-week window in which electrochemotherapy’s radiological effects typically become apparent. The child then completed her maintenance phase of treatment with cis-retinoic acid and dinutuximab beta without any complications. Twelve months after the procedure, computed tomography and MIBG imaging delivered the decisive verdict: the mass had shrunk to 9.2 by 8.9 by 9.4 centimeters, and, critically, no residual MIBG uptake could be detected anywhere in the treated area. The metabolically active component that had survived everything modern pediatric oncology could throw at it had been silenced.

Why does the disappearance of MIBG avidity matter so much? MIBG is a norepinephrine analog that is taken up specifically by neuroblastoma cells, so persistent tracer uptake is a molecular signature of living tumor. In neuroblastoma, residual primary disease that remains MIBG-avid after multimodal treatment is a well-established negative prognostic factor, strongly correlated with relapse and poor survival. The ability to selectively target and neutralize these metabolically active foci—without opening the abdomen, without thermal energy that could damage vessels and adjacent organs, and without adding systemic toxicity—addresses one of the most frustrating gaps in current therapy. Thermal ablation techniques such as radiofrequency ablation and cryoablation have been used in selected pediatric tumors, but they are hazardous near major vessels, which act as heat sinks and limit ablation margins, and near structures like the celiac artery that cannot tolerate thermal injury. Electrochemotherapy’s non-thermal mechanism sidesteps that constraint, and the authors note that its effects are applicable across tumor histologies, including tumors resistant to other modalities.

The caveats are as important as the promise. This is a single case, reported by the team of Giulia Cassanelli, Maria Antonietta De Ioris, and Gian Luigi Natali, and pediatric oncology is littered with promising one-patient results that failed to generalize. The authors themselves are careful, framing electrochemotherapy as a feasible local option for selected patients and calling for further evaluation within a multidisciplinary framework rather than declaring a new standard of care. Yet the signals here are hard to dismiss: a first-in-child application performed safely in one of the most anatomically hostile locations imaginable, durable local control of the exact tumor component that predicts relapse, and a treatment that can be repeated if needed. If larger studies confirm these findings, children with refractory neuroblastoma whose tumors are deemed inoperable may one day have an option that today they lack entirely—a minimally invasive, precisely targeted way to finish what chemotherapy, antibodies, and radiation started.

Subject of Research: Electrochemotherapy for residual MIBG-avid disease in refractory pediatric neuroblastoma

Article Title: Electrochemotherapy as a potential local treatment for residual MIBG-avid disease in refractory pediatric neuroblastoma: a case report

Article References: Cassanelli, G., De Ioris, M. A., & Natali, G. L. (2026). Electrochemotherapy as a potential local treatment for residual MIBG-avid disease in refractory pediatric neuroblastoma: a case report. CVIR Oncology, 2(1), Article 3. https://doi.org/10.1007/s44343-026-00032-8

Image Credits: AI Generated

DOI: 10.1007/s44343-026-00032-8

Keywords: neuroblastoma, electrochemotherapy, electroporation, cisplatin, pediatric oncology, interventional radiology, MIBG imaging, tumor ablation, MYCN amplification, residual disease, case report, local therapy

The review synthesizes three decades of literature, spanning 1995 through early 2025, on five distinct ablation modalities applied to malignant solid tumors in patients aged 18 years or younger: radiofrequency ablation, cryoablation, microwave ablation, irreversible electroporation, and electrochemotherapy. Each works through a fundamentally different biophysical mechanism. Radiofrequency ablation, the oldest and most widely studied thermal technique, drives alternating electrical current through an electrode tip, generating resistive heat that coagulates tissue at temperatures above roughly 60 degrees Celsius. Cryoablation takes the opposite approach, cycling argon and helium gases through a probe to freeze and thaw tissue, rupturing cell membranes through ice-crystal formation and osmotic stress. Microwave ablation uses electromagnetic fields at around 915 MHz or 2.45 GHz to agitate water molecules, heating tissue faster and over larger volumes than radiofrequency energy while remaining less susceptible to the heat-sink effect created by nearby blood vessels, a phenomenon in which circulating blood carries thermal energy away from the treatment zone and leaves tumor cells at the margin viable.

The two nonthermal techniques in the review sidestep heat altogether. Irreversible electroporation delivers short, high-voltage electrical pulses that destabilize cell membranes, creating permanent nanoscale pores that trigger cell death while largely preserving the protein scaffolding of surrounding tissue, including blood vessels, nerves, and ducts. That tissue-sparing property makes it theoretically attractive near critical structures such as the liver hilum, though animal work has shown that cardiac-gated synchronization is needed to prevent ventricular arrhythmias when ablation occurs near the heart. Electrochemotherapy combines intravenous or intratumoral chemotherapy, typically bleomycin, with electrical pulses that transiently permeabilize cell membranes, dramatically increasing drug uptake inside tumor cells. A 2026 case report highlighted in the review describes electrochemotherapy as a potential local treatment for residual MIBG-avid disease in refractory pediatric neuroblastoma, illustrating how the technique may reach children whose disease resists conventional therapy.

Behind the technical catalog lies an epidemiological backdrop that gives the review its urgency. The authors report that hepatoblastoma, the most common malignant liver tumor of early childhood, has shown the steepest rising incidence among ablation-relevant solid tumors, with an annual percent change of +2.17 percent. Meanwhile, five-year survival for pediatric bone tumors and soft tissue sarcomas remains stuck near 60 percent, a figure that has improved only incrementally over decades. For children with relapsed or refractory disease, options narrow sharply, and this is precisely where ablation has carved out its clinical niche. The review is emphatic on one point: surgical resection and systemic chemotherapy remain the primary treatment for all malignant solid tumors discussed, and ablation is reserved for relapsed, refractory, or surgically limited scenarios, such as pulmonary metastases of osteosarcoma that cannot all be removed surgically, or recurrent liver tumors in a child who has already undergone hepatic resection.

The clinical evidence, however, is fragile. For malignant solid tumors, the review finds the literature limited to small retrospective series with heterogeneous populations and short follow-up, precluding any conclusions about survival benefit. A phase 1 pilot study of radiofrequency ablation for recurrent pediatric solid tumors published in Cancer in 2009 remains one of the few prospective efforts, and a 2014 systematic review in Pediatric Radiology, along with a 2020 meta-analysis of interventional radiology-guided procedures in pediatric solid tumors in the European Journal of Pediatric Surgery, both concluded that the pediatric literature consists largely of case reports and single-institution experiences. A 2022 series in Pediatric Blood & Cancer on percutaneous ablation of malignant and locally aggressive solid tumors in children added valuable multi-modality data but remained retrospective. The contrast with adult interventional oncology is stark: in adults, randomized trials and large registries have established ablation as standard care for selected hepatocellular carcinomas and other lesions, while pediatric practice continues to extrapolate from devices and evidence generated for grown bodies.

That extrapolation problem is more than academic. A 2023 study in Cardiovascular and Interventional Radiology asked pointedly whether there is really no kit for kids, quantifying how few high-volume interventional radiology devices carry manufacturer recommendations for pediatric use. Ablation probes are sized, powered, and shaped for adult anatomy; a probe designed to create a five-centimeter ablation zone in an adult liver may overshoot dangerously in the liver of a toddler. Pediatric operators must therefore adapt technique on the fly, adjusting power settings, overlapping smaller ablations, and relying on experience rather than validated device labeling. The same research group published a companion analysis in 2023 on cryoablation for bone and soft tissue lesions in pediatric patients, cataloguing complications and preventive measures, and a 2024 report describing a decade of cryoablation experience in extra-abdominal desmoid tumors in children and young adults, one of the larger single-center pediatric ablation experiences in the literature.

Imaging guidance is the quiet enabler of all these techniques, and its evolution matters as much as the energy sources themselves. Ultrasound offers real-time visualization without ionizing radiation, a decisive advantage in children, but struggles with deep or bone-encased targets. Computed tomography provides precise needle-path planning for lung and bone lesions, as demonstrated in the CT-guided thermal ablation of pulmonary osteosarcoma metastases reported in Annals of Surgical Oncology in 2016. Magnetic resonance guidance represents the frontier: MR thermometry allows operators to watch temperature maps build in real time, and MR-guided focused ultrasound surgery, which ablates through intact skin without any needle at all, has established clinical services for pediatric bone tumors such as osteoid osteoma, as outlined in 2016 guidelines for building such programs. Three-dimensional visualization systems have also been paired with microwave ablation for relapsed hepatoblastoma in a small pilot study, suggesting that fusion imaging and volumetric planning will increasingly define the pediatric standard of care.

What emerges from the review is a field at an inflection point. Clinical adoption is accelerating, device technology is improving, and the biophysical rationale for each modality is well understood, yet the pediatric evidence remains confined to small, retrospective, single-institution series with heterogeneous populations and short follow-up. The authors identify a coordinated multicenter registry with standardized survival endpoints as the most urgent unmet need in the field, a call that echoes the standardization of terminology and reporting criteria established for image-guided tumor ablation in the adult literature more than a decade ago. Without shared endpoints, pooled data, and honest complication reporting, pediatric ablation risks remaining a promising anecdote rather than an evidence-based option. The review also transparently notes that generative AI was used during manuscript preparation to cross-check the literature search and copy-edit, with all content reviewed and verified by the authors, a sign of how the field’s own scholarship is modernizing.

For families facing a relapsed osteosarcoma nodule in the lung, a recurrent hepatoblastoma after resection, or a refractory neuroblastoma mass wrapped around vital structures, image-guided ablation already offers something precious: a percutaneous option that can destroy tumor while preserving tissue, function, and future growth potential. The review’s message to the medical community is that the next decade must be spent proving, not merely practicing, that promise. With hepatoblastoma incidence climbing, survival for sarcomas plateauing near 60 percent, and devices still built for adults, the children who stand to benefit most from needle-based tumor destruction are precisely those whose evidence base is weakest. Turning scattered single-center experiences into a rigorous, multicenter evidence engine, the authors argue, is no longer optional. It is the prerequisite for making image-guided ablation a standard, trusted pillar of pediatric cancer care rather than a last resort practiced in the shadows of the operating room.

Subject of Research: Image-guided percutaneous ablation modalities for malignant solid tumors in children

Article Title: Image-guided ablation for pediatric malignant solid tumors: a review of modalities, evidence, and clinical applications

Article References: Shashi, K., Sabado, J., Chewning, R., Shahin, M., & Shaikh, R. (2026). Image-guided ablation for pediatric malignant solid tumors: a review of modalities, evidence, and clinical applications. Pediatric Radiology. https://doi.org/10.1007/s00247-026-06781-1

Image Credits: AI Generated

DOI: 10.1007/s00247-026-06781-1

Keywords: pediatric oncology, image-guided ablation, radiofrequency ablation, cryoablation, microwave ablation, irreversible electroporation, electrochemotherapy, hepatoblastoma, sarcoma, interventional radiology, Pediatric Radiology, tumor ablation