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Because no report presents more recent results with 4N, we analyzed our large 4N experience. All 51 pediatric 4N patients (&lt;18\u2009years old) diagnosed 1985 to 2021 were reviewed. HR\u2010NB included <jats:italic>MYCN<\/jats:italic>\u2010nonamplified 4N diagnosed at age \u226518\u2009months and <jats:italic>MYCN<\/jats:italic>\u2010amplified 4N. Among 34 <jats:italic>MYCN<\/jats:italic>\u2010nonamplified high\u2010risk patients, 20 are relapse\u2010free 1.5+ to 37.5+ (median 12.5+) years post\u2010diagnosis, including 13 without prior MAT and 5 treated with little (1\u2009cycle; n\u2009=\u20092) or no mAb (n\u2009=\u20093), while 14 patients (7 post\u2010MAT, 8 post\u2010mAbs) relapsed (all soft tissue). Of 15 <jats:italic>MYCN<\/jats:italic>\u2010amplified 4N patients, 7 are relapse\u2010free 2.1+ to 26.4+ (median 11.6+) years from the start of chemotherapy (all received mAbs; 3 underwent MAT) and 4 are in second remission 4.2+ to 21.8+ years postrelapse (all soft tissue). Statistical analyses showed no significant association of survival with either MAT or mAbs for <jats:italic>MYCN<\/jats:italic>\u2010nonamplified HR\u2010NB; small numbers prevented these analyses for <jats:italic>MYCN<\/jats:italic>\u2010amplified patients. The two patients with intermediate\u2010risk 4N (14\u2010months\u2010old) are relapse\u2010free 7+ years postresection of primary tumors; distant disease spontaneously regressed. The natural history of 4N is marked by NB confined to soft tissue without early relapse in bones or bone marrow, where mAbs have proven efficacy. These findings plus curability without MAT, as seen elsewhere and at our center, support consideration of treatment reduction for <jats:italic>MYCN<\/jats:italic>\u2010nonamplified 4N.<\/jats:p>","DOI":"10.1002\/ijc.34693","type":"journal-article","created":{"date-parts":[[2023,8,22]],"date-time":"2023-08-22T09:33:53Z","timestamp":1692696833000},"page":"2019-2031","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Stage <scp>4N<\/scp> neuroblastoma before and during the era of <scp>anti\u2010G<sub>D2<\/sub><\/scp> immunotherapy"],"prefix":"10.1002","volume":"153","author":[{"given":"Brian H.","family":"Kushner","sequence":"first","affiliation":[{"name":"Department of Pediatrics Memorial Sloan Kettering Cancer Center  New York New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael P.","family":"LaQuaglia","sequence":"additional","affiliation":[{"name":"Department of Surgery Memorial Sloan 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