Limited information is available regarding the efficacy of external beam radiation therapy in the palliation of metastatic disease from neuroblastoma. From 1960 to 2000, 29 children with 53 metastatic sites received palliative radiotherapy. There were 26 soft tissue (group I), 19 bone (group II), 5 brain (group III), and 3 hepatic (group IV) treated sites. Median radiotherapy doses for groups I, II, III, and IV sites were 2000, 2000, 2400, and 450 cGy, respectively. For group I sites, complete response was complete disappearance of mass, partial response was ≥50% resolution of mass, no response was <50% resolution or ≤25% progression of mass, and progressive disease was >25% progression of mass. For group II sites, complete response was complete pain relief without medication, partial response was ≥50% pain relief with or without medication, no response was <50% change in pain with medication, and progressive disease was increase in pain and/or medication. Median survival was 2.5 months after palliative radiotherapy. For group I sites, complete response was seen in 1 (4%) while partial response was documented in 19 (73%). Duration of response was until death in 18 responders (90%); 2 patients relapsed with an increasing soft tissue mass at 5 months and 1 year after palliative radiotherapy. For group II sites, complete response was seen in 8 (42%) while partial response was documented in 7 (37%). Duration of response was until death in 14 responders (93%); 1 patient had relapse of pain 1 year after palliative radiotherapy. For the 5 group III children, the median survival was 2.5 months with a range of 2 days to 13 months. Four children had neurological improvement after cranial radiotherapy; one patient progressed and died secondary to neurological compromise 2 days after radiotherapy. For the 3 group IV sites, 2 had improvement in respiratory status after radiotherapy, whereas 1 progressed despite doxorubicin, cyclophosphamide, and radiation. The only patient who survived had a stage IV-S neuroblastoma with liver metastases and is alive 13 years after hepatic irradiation. Radiotherapy is an effective treatment for palliation of symptomatic metastatic disease in children with neuroblastoma.