Contraindications and image-defined risk factors in laparoscopic resection of abdominal neuroblastoma

Gadolinium-based contrast media does not improve the staging of neuroblastoma image-defined risk factors at diagnosis

BACKGROUND

Neuroblastoma risk stratification relies on prognostic risk factors and image-defined risk factors (IDRFs). Evaluating neuroblastoma typically involves magnetic resonance imaging (MRI) with gadolinium-based contrast media (GBCM, "contrast"). However, there are concerns regarding adverse effects and cost of GBCM. We aimed to assess the impact of intravenous GBCM on interobserver agreement for neuroblastoma staging on baseline MRI.

PROCEDURE

We reviewed baseline MRI scans of 50 children with abdominopelvic neuroblastomas confirmed by histopathology. Duplicate sets of images were created, with post-contrast T1-weighted sequences removed from one set. Four pediatric radiologists independently analyzed the scans in a randomized manner. They recorded primary tumor size, presence of IDRFs, and metastatic lesions. Agreement among the reviewers was measured using kappa and Fleiss kappa statistics.

RESULTS

Mean age of included children was 3.3 years (range: 0.01-14.9 years), and 20 [40%] were females. Mean tumor size was 5.7 cm in greatest axial diameter. Pre-contrast versus post-contrast MRI showed excellent agreement for tumor measurement. Overlapping confidence intervals (CIs) were seen in nearly all categories of interobserver agreement on the presence or absence of individual IDRFs, with agreement ranging from poor to substantial, regardless of the presence of contrast. The overall interobserver agreement on the presence of at least one IDRF was substantial with contrast (kappa = .63; 95% CI: .52-.75) and moderate without contrast (kappa = .5; 95% CI: .39-.61); although the overlapping CIs suggest a lack of meaningful difference. Similarly, interobserver agreement on the presence or absence of individual sites of metastatic disease ranged from poor to substantial. The interobserver agreement on the overall determination of presence of metastatic disease was fair with contrast (kappa = .49; 95% CI: .38-.61) and moderate without contrast (kappa = .71; 95% CI: .59-.826).

CONCLUSIONS

Contrast does not improve tumor size measurement or radiologist agreement on the presence or absence of IDRFs or metastatic disease in children with newly diagnosed neuroblastoma.

Beyond image defined risk factors (IDRFs): a delphi survey highlighting definition of the surgical complexity index (SCI) in neuroblastoma

PURPOSE

Preoperative evaluation of Image Defined Risk Factors (IDRFs) in neuroblastoma (NB) is crucial for determining suitability for upfront resection or tumor biopsy. IDRFs do not all carry the same weighting in predicting tumor complexity and surgical risk. In this study we aimed to assess and categorize a surgical complexity (Surgical Complexity Index, SCI) in NB resection.

METHODS

A panel of 15 surgeons was involved in an electronic Delphi consensus survey to identify and score a set of shared items predictive and/or indicative of surgical complexity, including the number of preoperative IDRFs. A shared agreement included the achievement of at least 75% consensus focused on a single or two close risk categories.

RESULTS

After 3 Delphi rounds, agreement was established on 25/27 items (92.6%). A severity score was established for each item ranging from 0 to 3 with an overall SCI range varying from a minimum score of zero to a maximum score of 29 points for any given patient.

CONCLUSIONS

A consensus on a SCI to stratify the risks related to neuroblastoma tumor resection was established by the panel experts. This index will now be deployed to critically assign a better severity score to IDRFs involved in NB surgery.

Association of image-defined risk factors with clinical features, tumor biology, and outcomes in neuroblastoma: a single-center retrospective study

Image-defined risk factors (IDRF) in neuroblastoma have been developed to predict tumor resectability and surgical complications; however, the potential prognostic value of IDRF in neuroblastoma has been variably reported. Previous studies did not report the IDRF status separately from the International Neuroblastoma Risk Group (INRG) stage. Moreover, the association between IDRF and clinical and pathological factors has not been discussed further. In this retrospective study, we investigated the clinical and biological features of neuroblastoma at different INRG stages based on IDRF. Event-free survival (EFS) and overall survival (OS) related to the INRG stage were analyzed using log-rank tests, and the prognostic value of the IDRF number and type was also evaluated. Among 72 patients, 182 IDRF at diagnosis were found in 79.2%. The distribution of the INRG stages was 10 L1 (13.9.0%), 25 L2 (34.7%), and 37 M/MS (51.4%). Patients with stage M/Ms had a larger tumor volume, a higher percentage of age ≥ 18 months, elevated lactate dehydrogenase (LDH) level, elevated ferritin level, and a higher percentage of COG high-risk compared with stage L1 and L2 patients. EFS and OS were similar for stage L1 and L2 tumors but were significantly poorer for metastatic disease. However, EFS (P = 0.06) and OS (P = 0.07) were similar for IDRF-negative and positive neuroblastomas. Patients with stage M/Ms with IDRF-positive had poorer EFS (P = 0.001) and OS (P < 0.001) compared with patients in stage L2. An IDRF ≥ 4, vascular IDRF, and infiltrative IDRF of the tumor were significant indicators of poor prognosis.   Conclusion: Our study indicates that increasing the INRG stages based on IDRF is associated with various unfavorable clinical features of neuroblastoma. The principal determinant of survival in neuroblastoma is the presence of metastatic disease more than IDRF alone at diagnosis. Both the number and type of IDRF have important clinical significance in the protocol planning of neuroblastoma, rather than just considering the absence or presence of IDRF. What is Known: • The International Neuroblastoma Risk Group Staging System (INRGSS) now employs image-defined risk factors (IDRFs) to stratify and stage disease. • The presence of IDRF at diagnosis are associated with higher rates of operative complications and incomplete surgical resection. What is New: • The principal determinant of survival from neuroblastoma is the presence of metastatic disease at diagnosis, more than IDRF alone. • IDRF number and type should also be considered during the diagnosis and treatment planning of neuroblastoma, rather than just considering the absence or presence of IDRF.

Feasibility and safety of laparoscopic tumor resection in children with abdominal neuroblastomas

PURPOSE

This study aimed to evaluate the feasibility and safety of laparoscopic resection of abdominal neuroblastoma by comparing operative and long-term oncologic outcomes between open and laparoscopic surgeries.

METHODS

This single-center retrospective study included patients who underwent laparoscopic tumor resection, between January 2000 and June 2021, with a maximum tumor diameter of ≤ 60 mm and without image-defined risk factors (IDRFs) at surgery. Data from 35 abdominal neuroblastoma resections were reviewed and compared between the laparotomy and laparoscopic groups.

RESULTS

Nineteen patients underwent laparotomy and 16 had laparoscopic tumor resection. All laparoscopic surgeries achieved complete resection without conversion to open surgery. Median blood loss was significantly lower in the laparoscopic group (0.6 mL/kg) than in the laparotomy group (8.4 mL/kg) (P < 0.0001). There were two locoregional recurrences in the laparoscopic group and two metastatic recurrences in the laparotomy group. Five-year overall survival was 93.8% in both groups.

CONCLUSION

Laparoscopic resection of abdominal neuroblastomas in children is a feasible and safe procedure for tumors ≤ 60 mm in diameter with no IDRFs at surgery, with long-term outcomes equivalent to laparotomy.

The Use of Cavitron Ultrasonic Surgical Aspirator for High-Risk Neuroblastoma with Image-Defined Risk Factors in Children

Aim of the study: The cavitron ultrasonic surgical aspirator (CUSA) has gained popularity in adult surgical oncology, but its application in children is limited to liver surgery and neurosurgical procedures. The complete resection of neuroblastoma with image-defined risk factors (IDRFs) is still considered one of the most difficult procedures to achieve in pediatric surgical oncology, with a high morbidity rate and potential risk of intraoperative mortality. The aim of our study is to describe the application of ultrasonic dissection in neuroblastoma with IDRFs. Methods: A retrospective study was performed, analyzing patients operated on from 2000 to 2018. Patient characteristics, resection completeness, and postoperative surgical and oncology outcomes were analyzed. Main results: Twenty-six patients with high-risk neuroblastoma and IDRFs were operated on in the study period with a CUSA. A complete macroscopic resection was performed in 50% of patients, while the other half was operated on with minimal residual (<5 mL). Six post-operative complications occurred without the need for surgery (Clavien−Dindo < 3). The overall survival was 50%, with a median follow-up of 69.6 months (5.6−140.4). Conclusions: The application of the CUSA in neuroblastoma with IDRFs can be considered an effective and safe alternative technique to achieve a radical resection.

Diagnostic yield and accuracy of paediatric image-guided fine needle aspiration biopsy of deep organ tumours

Background

Paediatric tumour cytological diagnosis by image-guided fine needle aspiration biopsy (FNAB) with rapid on-site evaluation (ROSE) has not gained wide acceptance despite increasing publications advocating the procedure.

Objective

The primary aim was an audit of the diagnostic yield and accuracy of paediatric image-guided FNAB with ROSE at a single institution. Evaluation of safety was a secondary aim.

Method

Details of consecutive cases of paediatric image-guided FNAB with ROSE for suspected non-benign deep-seated lesions performed from 01 January 2014 to 30 April 2020 were retrieved from the institutional radiology and laboratory databases. Diagnostic yield and accuracy were evaluated using clinico-pathological-radiological correlation and/or subsequent histological specimen diagnosis correlation. Complications and the frequency of key radiological features potentially affecting yield and accuracy were described.

Results

Of 65 cases retrieved, cytology showed malignancy in 52, benign features in five and one indeterminate diagnosis; seven samples were insufficient for cytological assessment. Of the 65 cases, 58 had subsequent formal histological diagnosis. The overall diagnostic yield was 98.5%, with 94.5% sensitivity, 100.0% specificity, 100.0% positive predictive value, 75.0% negative predictive value and 95.3% diagnostic accuracy. All cases (n = 26) demonstrating restricted diffusion on MRI yielded adequate samples and cyto-histopathological correlation.

Conclusion

Paediatric image-guided FNAB with ROSE has a relatively high diagnostic yield, sensitivity, specificity, positive predictive value and accuracy in the diagnosis of deep-seated tumours. The relatively low negative predictive value may reflect insufficient samples obtained from cystic and/or benign lesions. Sampling from areas of restricted MRI diffusion may enhance diagnostic yield.

Comparison of the Efficacy of Minimally Invasive and Open Surgery on Children with Neuroblastoma: A Meta-Analysis

Purpose: Evaluate the clinical efficacy and safety of minimally invasive surgery (MIS) and open surgery in the treatment of neuroblastoma (NB) in children by a meta-analysis. Materials and Methods: This is a meta-analysis. We searched for random or nonrandomized controlled study of MIS group and OPEN surgery group for the treatment of childhood NB included in PubMed, ClinicalTrials, EMBASE, and Cochrane library before January 31, 2020. Data extraction was performed in a standard format for the included studies, including tumor diameter, operation time, intraoperative bleeding, length of hospital stay (LOHS), complications, recurrence, and MYCN. Results: Seven retrospective studies were finally included, with a total of 571 children, including 162 in MIS group and 409 in the OPEN surgery group. Compared with the OPEN surgery group, the MIS group had reduced intraoperative bleeding (mean difference [MD] = -12.72, 95% CI: -24.84 to -0.61, P < .05), and reduced l LOHS (MD = -3.35, 95% CI: -5.55 to -1.15, P < .05) and decreased postoperative recurrence (MD = 0.20, 95% CI: 0.05-0.75, P < .05). The differences between the groups were statistically significant. There was no significant difference between groups in tumor diameter (MD = -18.84, 95% CI: -48.12 to 10.43, P > .05), operation time (MD = -21.7, 95% CI: -97.52 to 54.13, P > .05), and MYCN results (odds ratio = 2.27, 95% CI: 0.56-9.18, P > .05). Conclusions: Preliminary evidence indicates that the treatment of NB with MIS has the advantages of less intraoperative bleeding, shorter LOHS, and less postoperative recurrence compared with open surgery.

Safety and Feasibility of Laparoscopic Resection of Neuroblastoma Without Image-Defined Risk Factors Performed by Pediatric Surgical Trainees: A Multicenter Comparison Study

Introduction: Laparoscopic resection has gradually been adopted for neuroblastoma patients; however, some authors reported that, due to its technically demanding procedures, this operation should be performed only by highly experienced surgeons. The aim of this study was to evaluate the safety and feasibility of laparoscopic resection of abdominal neuroblastoma by pediatric surgical trainees. Subjects and Methods: In this multicenter, retrospective study, including 18 children with abdominal neuroblastoma indicated for 19 laparoscopic resections (1 with bilateral neuroblastomas) from 1999 to 2018, the clinical data were retrospectively reviewed and compared between trainee and attending surgeons. Results: None of the cases had image-defined risk factors (IDRFs) at surgery. All patients successfully underwent complete laparoscopic resection without blood transfusion, open conversion, or intraoperative or postoperative complications. Of the 19 cases, 6 were performed by pediatric surgical trainees under the guidance of attending surgeons, and 13 were performed by attending surgeons. With comparable tumor, largest diameter, operative time, and bleeding amount were not significantly different between the two groups. In the trainee surgeon group, one local recurrence occurred at a secondary resection site in the bilateral neuroblastoma patient with Stage L2. Conclusions: Laparoscopic resection of neuroblastoma could be safe and feasible when limited to absent IDRFs at surgery by pediatric surgical trainees under the guidance of experienced attending surgeons, as well as by attending surgeons.

The quest to develop an effective therapy for neuroblastoma

Neuroblastoma (NB) is a common solid extracranial tumor developing in pediatric populations. NB can spontaneously regress or grow and metastasize displaying resistance to therapy. This tumor is derived from primitive cells, mainly those of the neural crest, in the sympathetic nervous system and usually develops in the adrenal medulla and paraspinal ganglia. Our understanding of the molecular characteristics of human NBs continues to advance documenting abnormalities at the genome, epigenome, and transcriptome levels. The high-risk tumors have MYCN oncogene amplification, and the MYCN transcriptional regulator encoded by the MYCN oncogene is highly expressed in the neural crest. Studies on the biology of NB has enabled a more precise risk stratification strategy and a concomitant reduction in the required treatment in an expanding number of cases worldwide. However, newer treatment strategies are mandated to improve outcomes in pediatric patients who are at high-risk and display relapse. To improve outcomes and survival rates in such high-risk patients, it is necessary to use a multicomponent therapeutic approach. Accuracy in clinical staging of the disease and assessment of the associated risks based on biological, clinical, surgical, and pathological criteria are of paramount importance for prognosis and to effectively plan therapeutic approaches. This review discusses the staging of NB and the biological and genetic features of the disease and several current therapies including targeted delivery of chemotherapy, novel radiation therapy, and immunotherapy for NB.

Minimally invasive surgery for abdominal and thoracic neuroblastic tumors: A systematic review by the APSA Cancer committee

BACKGROUND

Minimally invasive surgery has broad applicability to pediatric diseases, including pediatric cancer resection. Neuroblastic tumors of childhood are highly variable in presentation, and so careful selection of appropriate candidates for minimally invasive resection is paramount to achieving safe and durable surgical and oncological outcomes.

METHODS

The American Pediatric Surgical Association Cancer Committee developed questions seeking to better define the role of minimally invasive surgery for neuroblastic tumors. A search using PubMed, Medline, Embase, Web of Science, ProQuest Dissertations, and Clinical Trials was performed for articles published from 1998 to 2018 in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines.

RESULTS

The evidence identified is all retrospective in nature. Minimally invasive surgical resection of neuroblastic tumors is safe for carefully selected smaller (4-6 cm) image defined risk factor (IDRF)-negative abdominal tumors when oncologic principles are followed. Size is a less-well defined criterion for thoracic neuroblastic tumors. Open approaches for both abdominal and thoracic tumors may be preferable in the presence of IDRF's.

CONCLUSION

Small tumors without IDRF's are reasonable candidates for minimally invasive resection. Surgical oncologic guidelines should be closely followed. The quality of data supporting this systematic review is poor and highlights the need for refinement in the study of such surgical techniques to improve knowledge and outcomes for patients with neuroblastic tumors.

TYPE OF STUDY

Systematic Review.

LEVEL OF EVIDENCE

Level III and Level IV.

How well do image-defined risk factors (IDRFs) predict surgical outcomes and survival in patients with neuroblastoma? A systematic review and meta-analysis

INTRODUCTION

Since their introduction to the International Neuroblastoma Risk Group (INRG) staging system in 2009, the role of Image-Defined Risk Factors (IDRFs) in predicting outcomes has been studied in heterogeneous populations with varying results. We conducted a systematic review and meta-analysis in order to determine quantitative measures of precisely how well pre-treatment IDRFs predict surgical outcomes and survival.

METHODS

A systematic review was performed for studies between January 1990 and July 2019 that compared surgical outcomes and/or survival in pediatric neuroblastoma patients with one or more IDRFs to patients without IDRFs. Summary risk ratios (RR) and hazard ratios (HR) were calculated using a random-effects model.

RESULTS

19 retrospective cohort studies were included, representing data from 1132 patients. The risk ratio (RR) of incomplete surgical resection in IDRF-positive patients compared to IDRF-negative patients was 2.45 (95% CI 1.51-3.97). The RR of surgical complications was 2.30 (95% CI 1.46-3.61). The hazard ratio (HR) for 5-year EFS was 2.08 (95% CI 2.93-4.13) while the 5-year HR for OS was 2.44 (95% CI 1.46-4.08).

CONCLUSION

IDRF-positive neuroblastoma patients have a higher risk of incomplete surgical resection, surgical complications, and 5-year mortality and/or relapse. Our results affirm that IDRFs remain a useful prognostic tool for neuroblastoma patients both for short and long-term outcomes.

LEVEL OF EVIDENCE

II.

Pediatric minimally invasive surgery for malignant abdominal tumor: Single center experience

This study examined the safety and usefulness of minimally invasive surgery (MIS) for malignant abdominal tumors in pediatric patients and analyzed the factors affecting the resection margin, operative time, and hospital stay of neuroblastoma (NBL) patients.We retrospectively reviewed data of pediatric patients who underwent MIS for malignant abdominal tumors from January 2011 to June 2017 at the Seoul National University Children's Hospital. Sex; age at operation; diagnosis; tumor location; operation-related data, such as operation time and transfusion; and follow-up data were reviewed. We divided patients into an excision group and a biopsy group. Detailed pathologic data were reviewed to analyze factors affecting the resection margin of NBL. Median value and range were calculated for all continuous variables. Mann-Whitney test and χ test were used as appropriate. P values of <.05 were considered significant.Thirty-four pediatric patients were included; 21 were boys. The median age was 4 (0.2-18) years. The most common diagnosis was NBL (17 patients; 50.0%). Three patients each were diagnosed with lymphoma, solid pseudopapillary tumor of the pancreas, and teratoma. The median tumor size was 3.4 (0.5-10.2) cm. The median operation time was 108 (55-290) minutes, and the median hospital stay was 5 (2-11) days. The number of conversions to open surgery was 4. There were no postoperative complications or mortality. There were 18 patients in the excision group and 16 in the biopsy group. Diagnosis and the number of patients receiving preoperative chemotherapy differed between the 2 groups. R0 resection of NBL was significantly higher in patients with stage 1 disease and those aged >2 years. There were no clinical factors influencing operative time or hospital stay.MIS was feasible and safe in pediatric patients with malignant abdominal tumors. R0 resection of NBL was related to age and stage.

Minimally Invasive Surgery in Pediatric Surgical Oncology: Practice Evolution at a Contemporary Single-Center Institution and a Guideline Proposal for a Randomized Controlled Study

Background: Despite the lack of randomized or controlled trials for minimally invasive surgery (MIS) in pediatric surgical oncology, the integration of MIS into the surgical practice of pediatric oncology has become increasingly popular. The aim of this study was to evaluate the implementation of MIS in a pediatric tertiary cancer center and compare present use of MIS to that in a previous analysis at our center. Methods: We retrospectively reviewed the medical records of patients with pediatric cancer treated with MIS at a single institution between 2000 and 2014. Results: A total of 252 MIS procedures were performed: 73 laparoscopic (29%) and 179 thoracoscopic (71%). MIS was used for diagnostic purposes in 59% (146 thoracoscopic and 34 laparoscopic) and the therapeutic resection in 24% (39 laparoscopic cases and 33 thoracoscopic cases). Conversion to an open procedure occurred in 18 tumor resections (6%) and in 22 diagnostic biopsies (7%), mostly due to technical challenges in identifying or mobilizing tumors. Complications occurred in seven tumor resections (2%) and included three pneumothoraces, two bleeding complications, one bowel injury, and one wound infection. Complications occurred in 10 diagnostic biopsies (3%), mostly pneumothoraces. No tumor upstaging or trocar site recurrences occurred (follow-up time, 1-15 years). Conclusions: Over the last decade, we demonstrate the evolution of MIS in the management of solid tumors in children. We encourage surgeons and oncologists to join the call to arms to establish prospective trials evaluating MIS in pediatric surgical oncology.

Association between image-defined risk factors and neuroblastoma outcomes

BACKGROUND

The current neuroblastoma (NBL) staging system employs image-defined risk factors (IDRFs) to assess numerous anatomic features, but the impact of IDRFs on surgical and oncologic outcomes is unclear.

METHODS

The Vanderbilt Cancer Registry identified children treated for NBL from 2002 to 2017. Tumor volume (TV) and IDRFs were measured radiographically at diagnosis and before resection. Perioperative and oncologic outcomes were evaluated.

RESULTS

At diagnosis of 106 NBL, 61% were IDRF positive. MYCN-amplified and undifferentiated NBL had more IDRFs than nonamplified and more differentiated tumors (p = 0.001 and p = 0.01). Of 86 NBLs resected, 43% were IDRF positive, which associated with higher stage, risk, and TV (each p < 0.001). The presence of IDRF at resection was also associated with increased blood loss (p < 0.001), longer operating times (p < 0.001), greater incidence of intraoperative complications (p = 0.03), more frequent ICU admissions postoperatively (p < 0.001), and longer hospital stays (p < 0.001). IDRF negative and positive tumors did not have significantly different rates of gross total resection (p = 0.2). Five-year relapse-free and overall survival was similar for IDRF negative and positive NBL (p = 0.9 and p = 0.8).

CONCLUSIONS

IDRFs at diagnosis were associated with larger, less differentiated, advanced stage, and higher risk NBL and at resection with increased operative difficulty and perioperative morbidity. However, the frequency of gross total resection and patient survival after resection were not associated with the presence of IDRFs.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

Level III.

Neuroblastoma: Tumor Biology and Its Implications for Staging and Treatment

Neuroblastoma, the most common extracranial solid tumor of childhood, has widely variable outcomes dependent on the specific biology of the tumor. In this review, current biologic principles that are used to stratify risk and guide treatment algorithms are discussed. The role for surgical resection in neuroblastoma is also reviewed, including the indications and timing of surgery within the greater treatment plan.

Minimally Invasive Approaches to Pediatric Solid Tumors

Over the last decade, driven in part by the favorable adult experience and a crescendoing number of case series and retrospective reports in the pediatric surgical literature, minimally invasive surgical (MIS) approaches are increasingly used as adjunctive or definitive surgical treatments for an ever-expanding list of pediatric tumors. Although most current treatment protocols lack surgical guidelines regarding the use of MIS, this growing body of MIS literature provides a framework for the development of multicenter trial groups, prospective registries, and further centralization of subspecialist services. This article highlights the current available data on MIS approaches to a variety of pediatric malignancies.