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Purpose: Advanced stage neuroblastoma (NB) is generally associated with a grim prognosis. Surveillance radiographic imaging is usually performed frequently to detect progressive (PD) or recurrent disease (RD) and promptly begin salvage therapy. We studied children with advanced stage NB to determine both how PD or RD was detected and the impact of detection in asymptomatic versus symptomatic children on outcome.Study Design: A retrospective review of children with NB was performed between 1984 and 1996. Children with advanced stage NB and RD or PD were further studied.Results: Thirty-two children with advanced stage NB and PD or RD were identified. The median time to PD or RD after diagnosis was 1 year 2 months. Nine (28%) children progressed on therapy. One child underwent confirmatory biopsy of residual scan abnormalities at the completion of planned therapy. Disease recurred in 22 (67%) children after therapy (median time 6 months). Two children (6%) had RD detected by surveillance studies associated only with elevated urinary catecholamines. Despite recent normal studies. 29 of 32 children (91%) had onset of new symptoms prompting confirmatory radiographic studies.Conclusions: Surveillance radiographic imaging was insensitive in detecting PD or RD in children with advanced stage NB. Careful history, examination, and selective laboratory evaluation were sensitive and cost-effective in detecting PD or RD.