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

Robot-assisted laparoscopic adrenalectomy: Extended application in children

BACKGROUND

Minimally invasive surgery for paediatric adrenal tumours has evolved, but robot-assisted laparoscopic adrenalectomy (RALA) in children remains poorly studied. The current prospective study aims to demonstrate the safety and efficacy of RALA in treating children with adrenal tumours.

METHODS

A prospective institutional analysis of children presenting with neuroblastic and endocrine tumours treated with RALA was undertaken over a six year-period. For each child, clinical parameters were collected relating to diagnosis, surgery and outcomes.

RESULTS

A total 50 RALA were performed; 23 for unilateral neuroblastic tumours (87 % neuroblastomas) and 27 for endocrine tumours. Eight neuroblastic tumours (35 %) had image-defined risk factors (all due to tumour invading the renal pedicle). Median length of stay was two days. Resection margins were macroscopically clear in all cases. After median follow-up of 2.9 years (1.6-3.9), two children are under treatment for metastatic relapse (high-risk disease) and three died due to refractory disease. Sixteen children had endocrine tumours: pheochromocytoma (n = 13), or bilateral nodular adrenocortical hyperplasia with Cushing's syndrome (n = 14). One child required non-emergent conversion, and one complication occurred (grade IIIb) after median follow-up of 3.3 years (1.0-5.7).

CONCLUSIONS

The current study is the largest reported experience in the literature and confirms the safety and effectiveness of RALA in carefully selected children with adrenal tumours. Through an iterative process and in the setting of a dedicated paediatric robotic surgical team indications have been clarified and extended. The current study confirms RALA has particularly utility in patients with severe disease (IDRF + metastatic neuroblastomas) or genetic predisposition syndromes.

Robotic-assisted Pediatric Thoracic and Abdominal Tumor Resection: An Initial Multi-center Review

INTRODUCTION

Robotic-assisted minimally invasive surgery (RA-MIS) for tumor resection is an emerging technology in the pediatric population with significant promise but unproven safety and feasibility.

METHODS

A multi-center retrospective review of patients ≤18 years undergoing RA-MIS tumor resection from December 2015-March 2023 was performed. Patient demographics, perioperative variables, and complication rates were analyzed.

RESULTS

Thirty-nine procedures were performed on 38 patients (17 thoracic, 22 abdominal); 37% female and 68% non-Hispanic White. Median age at surgery was 8.3 years (IQR 5.7, 15.7); the youngest was 1.7 years-old. Thoracic operations included resections of neuroblastic tumors (n = 16) and a single paraganglioma. The most common abdominal operations included resections of neuroblastic tumors (n = 5), pheochromocytomas (n = 3), and angiomyolipomas (n = 3). Six patients underwent retroperitoneal lymph node dissection (RPLND) for paratesticular tumors. Median operating time for the cohort was 2:52 h (IQR 2:04, 4:31). Two thoracic cases required open conversion due to poor visualization and lack of working domain. All patients underwent complete tumor resection; one had tumor spillage from a positive margin (Wilms tumor). Median LOS was 1.5 days (IQR 1.1, 3.0). Postoperatively, one patient developed a chyle leak requiring interventional radiology drainage, but none required a return to the operating room.

CONCLUSIONS

Robotic-assisted surgery is safe and feasible for tumor resection in carefully selected pediatric patients, achieving complete resection with minimal morbidity and short LOS. Resection should be performed by those with robotic expertise for optimal outcomes.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Original Clinical Research.

Minimally invasive and robotic-assisted approaches applied to pediatric surgical oncology

The management of pediatric tumors is complex, with surgery, chemotherapy, and radiotherapy being cornerstones in their treatment. Tumor removal is increasingly performed by a minimally invasive approach, which allows for quicker postoperative recovery and less postoperative pain. The goal of this report is to give an overview of minimally invasive surgical approaches for common pediatric tumors, with a focus on technical considerations and postoperative outcomes.

Children's Oncology Group's 2023 blueprint for research: Surgery

Surgery plays a crucial role in the treatment of children with solid malignancies. A well-conducted operation is often essential for cure. Collaboration with the primary care team is important for determining if and when surgery should be performed, and if performed, an operation must be done in accordance with well-established standards. The long-term consequences of surgery also need to be considered. Indications and objectives for a procedure vary. Providing education and developing and analyzing new research protocols that include aims relevant to surgery are key objectives of the Surgery Discipline of the Children's Oncology Group. The critical evaluation of emerging technologies to ensure safe, effective procedures is another key objective. Through research, education, and advancing technologies, the role of the pediatric surgeon in the multidisciplinary care of children with solid malignancies will continue to evolve.

[Surgery for abdominal neuroblastoma in children]

This review is devoted to surgical approach for neurogenic tumors in children. The authors discuss epidemiological data, history of surgical approaches, preoperative imaging and risk factors. A special attention is paid to the influence of surgical interventions for various neuroblastomas on overall and event-free survival in pediatric population, as well as the most common surgical complications and modern approaches to their treatment.

Thoracoscopy for Pediatric Thoracic Neurogenic Tumors-A European Multi-Center Study

OBJECTIVES

To assess the efficacy of thoracoscopy and the outcome for children with thoracic neurogenic tumors.

METHODS

We performed a retrospective review of 15 European centers between 2000 and 2020 with patients who underwent thoracoscopy for a neurogenic mediastinal tumor. We assessed preoperative data, complications, and outcomes. Results were expressed with the median and range values.

RESULTS

We identified 119 patients with a median age of 4 years old (3 months-17 years). The diameter was 5.7 cm (1.1-15). INRG stage was L1 n = 46, L2 n = 56, MS n = 5, M n = 12. Of 69 patients with image-defined risk factors (IDRF), 29 had only (T9-T12) locations. Twenty-three out of 34 patients with preoperative chemotherapy had an 18 mm (7-24) decrease in diameter. Seven out of 31 patients lost their IDRF after chemotherapy. Fourteen had a conversion to thoracotomy. The length of the hospital stay was 4 days (0-46). The main complications included chylothorax (n = 7) and pneumothorax (n = 5). Long-term complications included Horner's syndrome (n = 5), back pain, and scoliosis (n = 5). Pathology was 53 neuroblastomas, 36 ganglioneuromas, and 30 ganglioneuroblastomas. Fourteen had a postoperative residue. With a median follow-up of 21 months (4-195), 9 patients had a recurrence, and 5 died of disease. Relapses were associated with tumor biology, histology, and the need for chemotherapy (p = 0.034, <0.001, and 0.015, respectively). Residues were associated with preoperative IDRF (excluding T9-T12 only) and the need for preoperative chemotherapy (p = 0.04 and 0.020).

CONCLUSION

Our results show that thoracoscopy is safe, with good outcomes for thoracic neurogenic tumors in selected cases. Surgical outcomes are related to the IDRFs, whereas oncologic outcomes are related to tumor histology and biology.

Retroperitoneoscopic or Transperitoneal Approach for Neurogenic and Adrenal Tumors in Children? A Comparison on the Way to Enhanced Recovery in Pediatric Surgical Oncology

BACKGROUND

Minimally invasive surgery is increasingly utilized for resection of neurogenic tumors in children. The minimally invasive retroperitoneoscopic approach was recently reported in children, but transperitoneal laparoscopy still remains the most common technique. The aim of this study is to compare a novel single-port retroperitoneoscopy (SPR) approach for pediatric neurogenic tumor resection with transperitoneal laparoscopic (TPL).

METHODS

Patients undergoing minimally invasive resection of abdominal neurogenic tumors over 5 years at a single institution (from 2018 to 2022) were retrospectively reviewed. Tumor volume, stage, presence of image-defined risk factors (IDRFs), neoadjuvant chemotherapy, operative time, estimated blood loss (EBL), length of stay (LOS), complications, oral morphine equivalents per kilogram (OME/Kg), and time to chemotherapy were assessed and compared with SPR and TPL approaches.

RESULTS

Eighteen and fifteen patients underwent TPL and SPR, respectively. No significant differences were found between the TPL and SPR approaches in terms of tumor characteristics and IDRFs. Patients who underwent SPR had a significantly faster recovery (p = 0.008) and less postoperative opioid use compared to those in TPL (p = 0.02), thus allowing an enhanced recovery after surgery (ERAS) protocol application. TPL and SPR approaches were performed in presence of IDRFs, respectively in 2 (11%) and 4 patients (27%), with a IDRFs-related conversion in one TPL procedure. Both approaches had one < Grade 3 Clavien Dindo complication, but not requiring further surgery.

DISCUSSION

SPR approach can be considered as a safe and feasible minimally invasive approach for the resection of pediatric primary adrenal and neurogenic tumors. The retroperitoneoscopic approach performed using a single port technique represents a promising new frontier of ERAS application in pediatric surgical oncology.

CONCLUSION

SPR is a viable surgical alternative in selected neurogenic abdominal tumors with limited IDRFs, thus allowing for the application of ERAS protocols in these patients.

LEVEL OF EVIDENCE

Level III.

Critical elements of pediatric neuroblastoma surgery

Neuroblastoma (NB) is the most common solid extracranial malignancy of childhood with an incidence of 1 per 100,000 in the United States compromising approximately 10 % of childhood cancer. Unfortunately, patients with high-risk NG continue to have long-term survival less than 50 %. Both Children's Oncology Group and the International Society of Paediatric Oncology have demonstrated the important role of surgery in the treatment of high-risk NB. Herein, we compose the results of an extensive literature review as well as expert opinion from leaders in pediatric surgical oncology, to present the critical elements of effective surgery for high-risk neuroblastoma.

Influencing factors of parental selections of minimally invasive procedure in children's abdominal surgery: a cross-sectional study in China

The purpose of our study was to explore the influencing factors of parental selections of minimally invasive procedure including laparoscopic or robotic methods in children's abdominal surgery. The questionnaire survey was conducted among the parents of patients who received abdominal laparoscopic or robotic surgery in our hospital from December 2020 to June 2022. The contents included basic information of the patients and parents, parental educational background, monthly income, insurance details and the parental considerations. Univariate and multivariate logistic regression were applied for the influencing factors analysis. Six categories of diseases involving choledochal cyst (198 cases), spleen related diseases (31 cases), hirschsprung disease (40 cases), inguinal hernia (330 cases), adrenal tumor (15 cases) and ureteropelvic junction obstruction (73 cases) were included in this study. After univariable and multivariable logistic regression analysis accomplished, we discovered that college degree or above (OR = 0.545, P < 0.001), monthly income > 5000 RMB (OR = 0.761, P < 0.001) and involving reconstruction during operation (OR = 0.842, P < 0.001) were the influencing factors for parental selections of robotic surgery. In children's abdominal surgery, parents with college degree or above, monthly income > 5000 RMB and considering the need for reconstruction during operation are more inclined to choose the robotic surgery.

Association of Image-Defined Risk Factors with Clinical, Biological Features and Outcome in Neuroblastoma

Background: Neuroblastoma (NB) is the most common pediatric extracranial solid tumor and the most common cancer encountered in children younger than 12 months of age. Localized tumors have a good prognosis, but some cases undergo treatment failure and recurrence. The aim of the study was to analyze the link between the neuroblastoma risk factors and the prognosis for patients diagnosed with NB. Method: All patients admitted to the department of Pediatric Surgery, “Grigore Alexandrescu” Clinical Emergency Hospital for Children, between 1 January 2010 and 1 July 2022 were included in this analysis when diagnosed with neuroblastoma. Results: Thirty-one patients with NB were admitted to the surgical department, 20 boys and 11 girls. We observed an association between large tumors and positive imaging-defined risk factor (IDRF) status; The Fisher test showed an association between the tumor’s diameter when bigger than 8 cm and a positive IDRF status, with p < 0.001. We supposed that positive IDRF status at diagnosis may be linked to other prognostic factors. We discovered that an NSE value over 300 was associated with IDRF status (p < 0.001, phi = 0.692) and death. Conclusions: This study confirms the impact of IDRF status at diagnosis as it can be clearly correlated with other risk factors, such as a high level of NSE, MYCN amplification status, large tumor size, incomplete tumor resection, and an unfavorable outcome.

Successful laparoscopy-assisted en bloc resection of bulky omental malignant lymphoma involving the ascending colon and multiple lymph node metastases: Report of a technically demanding case in a pediatric patient

We herein report a 13-year-old boy with a chief complaint of abdominal pain and a palpable mass. Contrast-enhanced computed tomography (CT) scan showed an abdominal bulky tumor involving the ascending colon causing severe stenosis, with multiple abdominal lymph node metastases detected by positron emission tomography (PET)-CT. Laparoscopic radical resection with right hemicolectomy and lymph node dissection was planned. The bulky tumor was dissected from the retroperitoneum and resected en bloc with the right-side colon and omentum. The preoperatively detected metastatic lymph nodes were resected along with the tumor. A 6-cm longitudinal umbilical incision was made, and the huge tumor was removed, with functional end-to-end anastomosis performed for intestinal reconstruction. The pathological diagnosis was Burkitt-like lymphoma with 11q aberration. The postoperative course was uneventful. Laparoscopy-assisted extirpation is feasible for pediatric solid tumors involving other organs, but indications and procedures should be carefully determined based on preoperative imaging, intraoperative findings and surgeon's skills.

Laparoscopic surgery for stage III neuroblastoma: A case report

Laparoscopic surgery for malignant solid tumors is still in the stage of clinical exploration. Neuroblastoma is a common solid tumor in children. The present study discussed significance and feasibility of complete resection of stage III neuroblastoma by laparoscopic surgery and its safety and effectiveness was compared with traditional surgery. For children suffering from neuroblastoma with large tumor volume and vascular invasion, preoperative chemotherapy can be given and minimally invasive laparoscopic surgery can be one option to be considered when the tumor volume is <6 cm. During the operation, the tumor tissue can be removed by segmental resection and the removal of as much tumor tissue as possible is an important factor in improving the prognosis. Laparoscopic minimally invasive surgery is associated with minimal surgical trauma and quick recovery of patients, and children can receive postoperative chemotherapy as early as possible, which is conducive to good recovery. Basically, the prerequisite and requirements for performing this operation are professional laparoscopic skills and an experienced team.

Minimally invasive hepatopancreatic and biliary surgery in children: a large centre experience and review of the literature

BACKGROUND

Minimally invasive surgery (MIS) for hepatopancreatic and biliary (HPB) diseases has been widely used in adults, while in children, its application is limited due to its complexity. Herein, we report the experience of MIS for paediatric HPB diseases and literature review.

METHODS

All children (≤18 years-old) undergoing major HPB operations by MIS during January 2017-June 2020 in our institution were prospectively enrolled.

RESULTS

Out of 139 children operated on for HPB diseases with MIS, 26 (18.7%) patients (age: 11 (1-17) years-old; weight: 41.9 (10.7-75.5) kg) underwent major HPB surgery, including 11 pancreatic resections and 15 liver resections, all performed by a full-laparoscopic-technique. Four (15.3%) surgeries were electively converted to an open-technique for safer operative management. None required a blood transfusion. The median hospital admission was 6 days. Post-operatively, all patients had early mobilization and good recovery. Two (7.7%) patients experienced post-operative complications requiring radiological intervention. Oncological radical resection (R0) was achieved in all tumours, and after 2 years, all children were free of tumour recurrence.

CONCLUSION

MIS for HPB surgery is safe and feasible in children, with less surgical trauma, short hospital-stay and better aesthetic results. An adequate learning curve in specialized centres is essential for good outcomes.

Surgical management in pediatric neuroblastoma diagnosis and treatment: a 20-year, single-center experience

BACKGROUND

The currently utilized International Neuroblastoma Risk Group (INRG) staging system developed in 2009 uses image-defined risk factors as a measure of surgical risk, separating resectable neuroblastoma from those best preceded by chemotherapy. The previous International Neuroblastoma Staging System was based primarily on surgical findings. We hypothesized there would be a change to the role of the surgeon in neuroblastoma treatment in the more recent decade.

METHODS

This is a single center 20-year retrospective analysis of 104 patients with International Classification of Diseases-9 and -10 codes for neuroblastoma. Patient demographics, tumor site, cancer treatment modality, survival, biopsy technique, surgical intervention, and pathology staging were collected. Data was analyzed by analysis of variance (ANOVA) and Student's t test.

RESULTS

There was a decrease in open surgeries for extra-adrenal neuroblastomas in the later decade (77%, 31%, P = 0.01). There was a narrowing of the time interval to surgery in the later cohort, likely as a result of uniformity in surgical timing on treatment protocols relying on INRG staging.

CONCLUSIONS

Our findings mirror changes in practice patterns globally. We found an increase in minimally invasive approaches but did not find a difference in the role of the surgeon under the INRG staging system.

Minimally invasive surgery for neuroblastic tumours: A SIOPEN multicentre study: Proposal for guidelines

INTRODUCTION

Surgery plays a key role in the management of Neuroblastic tumours (NB), where the standard approach is open surgery, while minimally invasive surgery (MIS) may be considered an option in selected cases. The indication(s) and morbidity of MIS remain undetermined due to small number of reported studies. The aim of this study was to critically address the contemporary indications, morbidity and overall survival (OS) and propose guidelines exploring the utility of MIS for NB.

MATERIALS & METHODS

A SIOPEN study where data of patients with NB who underwent MIS between 2005 and 2018, including demographics, tumour features, imaging, complications, follow up and survival, were extracted and then analysed.

RESULTS

A total of 222 patients from 16 centres were identified. The majority were adrenal gland origin (54%) compared to abdominal non-adrenal and pelvic (16%) and thoracic (30%). Complete and near complete macroscopic resection (>95%) was achieved in 95%, with 10% of cases having conversion to open surgery. Complications were reported in 10% within 30 days of surgery. The presence of IDRF (30%) and/or tumour volume >75 ml were risk factors for conversion and complications in multivariate analysis. Overall mortality was 8.5%.

CONCLUSIONS

MIS for NB showed that it is a secure approach allowing more than 95% resection. The presence of IDRFs was not an absolute contraindication for MIS. Conversion to open surgery and overall complication rates were low, however they become significant if tumour volume >75 mL. Based on these data, we propose new MIS guidelines for neuroblastic tumours.

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.

Improving Exposure Using Thoracoscopy for Apical Thoracic Neuroblastoma Encasing the Subclavian Vessels

Background: Posterolateral thoracotomy provides limited access to the thoracic apex that can result in poor visualization of subclavian vessels, their branches, and the brachial plexus. A thoracoscopic approach may overcome these limitations. Purpose: We report a thoracoscopic approach and associated technical challenges in resecting apical thoracic neuroblastoma encasing the subclavian artery. Methods: A single-institution retrospective chart review was performed (2018-2020) for patients undergoing thoracoscopic resection of apical neuroblastoma encasing the subclavian artery. Patient demographics, imaging, and hospital course were reviewed. Operative video recordings were assessed for exposure quality, technical challenges, and percentage of tumor resection. Patients were placed laterally, with three 5-mm ports triangulated to the apex. Dissection started at the tumor edge and followed along the vessel and branches. Results: Four patients (median age 2.7 years) underwent thoracoscopic apical neuroblastoma resection. Median length of stay was 2.5 days. One low-risk patient underwent resection for tumor growth during observation. One intermediate and 2 high-risk patients received neoadjuvant chemotherapy. Two patients continued having persistent vascular encasement, whereas in 1 patient the mass decreased in size and only abutted the subclavian and vertebral arteries. In 1 patient, tumor involved the brachial plexus, which was freed and preserved thoracoscopically. All cases had substantial tumor-feeding vessels branching from the subclavian artery. There was one conversion to open thoracotomy due to dense tumor adherence to the subclavian artery and vein. More than 95% resection was achieved in all cases. All patients had baseline Horner syndrome. No complications were reported. Conclusion: The thoracoscopic approach for resecting apical neuroblastoma provides optimal exposure and safe access in selected patients.

Minimally Invasive Techniques in Pediatric Surgical Oncology

Minimally invasive approaches to pediatric cancer surgery are increasingly used, not only for the benefits of smaller incisions, but also for better field visualization and precise dissection. Advances in technology and surgeon experience have facilitated this trend. However, the appropriate indications for its use remain to be determined, and oncologic principles should not be compromised. We discuss the current and potential future uses, and new technologies that are being developed and introduced to assist with and enhance the role of minimally invasive surgery in the management of children with cancer.

The Role of Video-Assisted Thoracoscopic Surgery in Pediatric Oncology: Single-Center Experience and Review of the Literature

Aim: Video-assisted thoracoscopic surgery (VATS) has been widely used in the last decades. Nevertheless, the pros and cons of thoracoscopy vs. open surgery in pediatric oncology are still under debate. In literature, VATS has been applied for both diagnostic and ablative surgery to treat neurogenic tumors, thymic neoplasms, lung tumors and metastases, germ cell tumors, lymphoproliferative diseases, and other rare tumors. Recent reviews described excellent outcomes in pediatric oncology as well as in the treatment of adult lung cancer, with a significantly higher rate of mortality and complication in thoracotomy compared to VATS. We reviewed our experience on thoracoscopy in pediatric malignancy and compared it to the literature. Materials and Methods: This was a retrospective cohort-study of pediatric oncological patients who underwent VATS at our institution from 2007 to 2020, and a review of the recent literature on the topic. Results: A total of 43 procedures were performed on 38 oncological patients (18 males, 20 females). Median age was years 7.72 (0.35-18.6). Diagnosis: 10 neurogenic tumors, nine hematological diseases, five metastases, four lypoblastomas, three thymic pathologies, three germ cell tumors, two pleuropneumoblastomas, two myofibroblastic tumors, one myoepithelial carcinoma, one liposarcoma, and three suspected oncological mass. In three cases, a 3D model was elaborated to better plan the surgical approach. Diagnostic biopsies were 22 (51.1%), and ablative surgeries, 21 (48.9%). One neurogenic tumor was resected with the Da Vinci Robot. Median operative time was 120 min (30-420). A drain was left in place in 20 (46.5%) for a median of 4 days. Median length of hospitalization was 5 days (1-18). One case (2.3%) was converted (intraoperative bleeding). There were three post-operative complications (7.0%): one pneumonia, one pleural effusion, and one diaphragmatic paralysis (need for plication). Results were compared to recent literature, and morbidity and conversion rate were comparable to reviewed publications. Conclusion: VATS represents a valuable tool for diagnostic and therapeutic procedures in pediatric oncology. Nonetheless, it is a challenging technique that should be performed by expert surgeons on oncological and mini-invasive surgery. Three-dimensional reconstruction can optimize the pre-operative planning and guarantee a safer and more targeted treatment. Finally, the advent of robotics-assisted surgery represents a new challenge that may further implement the advantages of VATS.