Neuroblastoma Risk Groups

Risk groups are used to help predict how likely it is that a child can be cured. For example, a child in a low-risk group can often be cured with limited treatment, such as surgery alone. Children in higher risk groups often need more intensive treatment to have the best chance of being cured. The risk groups included here are commonly accepted standard risk groups in the US. Other internationally used risk groups are being tested in clinical trials.

Children’s Oncology Group (COG) risk groups

The Children’s Oncology Group (COG) uses the major prognostic factors discussed in the staging section, combined with the INRGSS stage of the disease, to place children into 3 different risk groups: low, intermediate, and high. COG risk groups in the past used certain prognostics factors along with the INSS stage of the disease, and have transitioned to INRGSS more recently. Some study results that used INSS to determine a child's risk group have not been published yet, and these results will probably come out over the next few years, For that reason, you might hear about both staging systems.  

These risk groups are based on what is now known about neuroblastoma and how it is treated. As new research provides more information, these risk groups may change over time. For example, in recent treatment recommendations the age cut-off for some of these categories has been revised from up to 12 months (365 days) to up to 18 months (547 days). 

Low risk

  • All children who are Stage 1
  • Any child who is Stage 2A or 2B and not yet 1 year old
  • Any child who is Stage 2A or 2B, older than 1 year, whose cancer has no extra copies of the MYCN gene
  • Any child who is Stage 2A or 2B, older than 1 year, whose cancer has extra copies of the MYCN gene AND has favorable histology (appearance under the microscope)
  • Any child who is Stage 4S (not yet 1 year old), whose cancer has favorable histology, is hyperdiploid (excess DNA) and has no extra copies of the MYCN gene

Intermediate risk

  • Any child who is Stage 3, not yet 1 year old, whose cancer has no extra copies of the MYCN gene
  • Any child who is Stage 3, older than 1 year old, whose cancer has no extra copies of the MYCN gene and has favorable histology (appearance under the microscope)
  • Any child who is Stage 4, not yet 1 year old, whose cancer has no extra copies of the MYCN gene
  • Any child who is Stage 4S (not yet 1 year old), whose cancer has no extra copies of the MYCN gene and has normal DNA ploidy (number of chromosomes) and/or has unfavorable histology

High risk

  • Any child who is Stage 2A or 2B, older than 1 year, whose cancer has extra copies of the MYCN gene and unfavorable histology
  • Any child who is Stage 3, not yet 1 year old, whose cancer has extra copies of the MYCN gene
  • Any child who is Stage 3, older than 1 year, whose cancer has extra copies of the MYCN gene
  • Any child who is Stage 3, older than 18 months, whose cancer has unfavorable histology
  • Any child who is Stage 4, whose cancer has extra copies of the MYCN gene regardless of age
  • Any child who is Stage 4 and older than 18 months
  • Any child who is Stage 4 and between 12 and 18 months old whose cancer has extra copies of the MYCN gene, unfavorable histology, and/or normal DNA ploidy (a DNA index of 1)
  • Any child who is Stage 4S (not yet 1 year old), whose cancer has extra copies of the MYCN gene

International Neuroblastoma Risk Group (INRG) classification

A newer risk group classification system, the International Neuroblastoma Risk Group (INRG) classification, is now being used to help researchers in different countries compare results and work together to find the best treatments. This system is based on the newer INRGSS staging system, which includes the image-defined risk factors (IDRFs), as well as many of the prognostic factors listed in the staging section, such as:

  • The child’s age
  • Tumor histology (how the tumor looks under the microscope)
  • The presence or absence of MYCN gene amplification
  • Certain changes in chromosome 11 (known as an 11q aberration)
  • DNA ploidy (the total number of chromosomes in the tumor cells)

The INRG classification uses these factors to put children into 16 different pre-treatment groups (lettered A through R). Each pre-treatment group falls into 1 of 4 overall risk groups:

  • Very low risk
  • Low risk
  • Intermediate risk
  • High risk

This system will most likely be used in addition to the COG Risk Classification system in the United States.

The American Cancer Society medical and editorial content team
Our team is made up of doctors and master's-prepared nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Brodeur GM, Hogarty MD, Bagatell R, Mosse YP, Maris JM. Neuroblastoma. In: Pizzo PA, Poplack DG, eds. Principles and Practice of Pediatric Oncology. 7th ed. Philadelphia Pa: Lippincott Williams & Wilkins; 2016:772–792.

Cohn SL, Pearson AD, London WB, et al. The International Neuroblastoma Risk Group (INRG) Classification System: An INRG task force report. J Clin Oncol. 2009; 27: 289–297.

National Cancer Institute. Physician Data Query (PDQ). Neuroblastoma Treatment. 2017. Accessed at www.cancer.gov/cancertopics/pdq/treatment/neuroblastoma/healthprofessional on October 12, 2017.

Pinto NR, Applebaum MA, Volchenboum SL, et al. Advances in risk classification and treatment strategies for neuroblastoma. J Clin Oncol. 2015: 30;3008-3017.

Last Medical Review: March 19, 2018 Last Revised: March 19, 2018

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