Italian Association of Nuclear Medicine, Molecular Imaging and Therapy (AIMN) practical guide for radiopharmaceutical imaging in neuroblastoma. The role of nuclear medicine imaging in neuroblastoma management

Neuroblastoma (NBL) is the most common extracranial solid malignancy in children and remains one of the main causes of pediatric cancer deaths. Its marked biological and clinical heterogeneity, reflected by a broad histological spectrum of peripheral neuroblastic tumours and diverse genomic alterations, underpins highly variable outcomes. Current risk stratification according to the International Neuroblastoma Risk Group (INRG) integrates age, stage based on image-defined risk factors, histology, MYCN status, segmental chromosomal aberrations and ploidy to classify patients into very low-, low-, intermediate- and high-risk categories, thereby guiding treatment intensity. In this context, nuclear medicine plays a pivotal role across the disease course. This paper provides practical recommendations for the standardised performance and interpretation of [¹²³I]mIBG SPECT/CT, [¹⁸F]FDG PET/CT, [¹⁸F]F-DOPA PET/CT and [⁶⁸Ga]Ga-DOTA-peptide PET/CT in children with NBL, including procedural prerequisites, pediatric radiopharmaceutical dosing, acquisition protocols and response assessment. [¹²³I]mIBG scintigraphy remains the reference technique for staging, restaging and response evaluation, with semiquantitative skeletal scoring systems (Curie and SIOPEN) incorporated into the revised International Neuroblastoma Response Criteria. [¹⁸F]FDG PET/CT is recommended as a complementary tool, particularly in mIBG-non-avid or discordant disease, and provides additional prognostic information through metabolic parameters. [¹⁸F]F-DOPA PET/CT is emerging as the most sensitive alternative to mIBG for initial staging, response assessment and detection of relapse, while [⁶⁸Ga]Ga-DOTA-peptide imaging offers theranostic implications in somatostatin receptor-expressing tumours. Finally, novel PET tracers such as [¹⁸F]mFBG and [¹²⁴I]mIBG may further refine disease characterisation and dosimetry, supporting increasingly individualised management of pediatric neuroblastoma.