2025 Pediatric Surgery Update Course - Updates in Oncology

Okay, we are going to do updates in oncology, so we have a couple of talks from Dr. Gonzalez and Dr. Aldrinck focused on a couple key aspects to think about an oncology and how we continue to move forward with the care of kids with cancer. So it's a second thought. Well, thank you very much. I'm Gloria Oncolo from Cleveland Clinic. So we're going to talk about first since guided surgery. And here is our clinical scenario. This is a male 17-year-old soul. Israel had a dysmpleptic small round cell tumor. So he was treated with chemotherapy, good response in images, and needs surgery. And these are the first images. This is pre-treatment. You see a really big burden of disease all over the peritoneum, and usually the spelvic masses and, of course, all around the liver and peritoneum. And this is after chemotherapy. So here we respond really well. It joins chemotherapy. So right now we only have a really small piece in the pelvis and one close to the liver. In an epitome, a really good response, just one spot that is avid in the epitome. But what we do with these patients, we know these patients are really sometimes really bad. So first question. Could you use any localization technique in these patients? What do you do with the pool? Yeah, what do you guys do in the room? Do people use localization techniques for a case like this? Any, ICG, nothing, new localization. Do you do allaproscopic resection, Technician 99? Other that you can tell me, is there anything? And we're seeing this and ICG is one of the main things, and many people do nothing. I mean, they said there's nothing that we can do. So what I'm going to talk to you about, it is two topics. Non-targeted fluorescence and targeted. And we know that ICG a lot. There are many publications of adoncology and ICG. ICG is a fluorescence element that we can see during the surgery. So if we're looking at like an laparoscopic normal laparoscopic, we're not going to see anything. Just pinky stuff, yellow stuff, that's it. Normal colors. But if we put the nearest, we're going to see something's in green. So in oncology, we have been using this a lot. And there are many publications about many of the diseases that respond really well to ICG. But many of those are liver tumors. Because ICG is excreted through the liver, so the liver tumor cells doesn't excrete the ICG really well. And what is targeted fluorescence? Do we know anything about this? Well, this is what we're using. Targeted fluorescence. And I'm going to talk about pafolasis in this slide looks, but there are many elements in targeted fluorescence guidance surgery right now. Most of them comes from adults, of course. And they have been using this targeted ICG. This means it's a monocoder antibody. And you mix or buy these fluorescence elements to that antibody. And we use it in the patients. So for example, cytolox, we're going to say something different. The tumor cells are really, they're replicating. So they have really high or rapidly dividing cancer cells to consume folate all the time. They're avid for folate. So if you mix folate with fluorescence, we're going to see it green during the surgery. This is FDA approved molecule that is used in cancer cells in adults. But what happened in pediatrics? Right now we're starting. Do you want to see anything? Okay, and this is another thing that we are using in this is Iris. Have you used this for anything? Iris? Yes. Carlos, tell us about it. What would you use it for for identification? For the parabolic medicine system? We've used it for the application. It's in the medicine system. It makes things very, very easy to identify by MIS. So this is a fluorescence guide that you can place in any tube. Kind of. So this is your, can you show the picture? This is a urethral one, but you can use it to use like a ERCP, colorectal surgery. Yes. Esophageal diseases and everything, but we are using it in here for urethral. And this is cytoloxin action. Okay, so this is a targeted ICG. It's binding a molecule, a specific molecule with ICG. So here we have a patient that we are doing this, exactly this patient, this is a plastic small round cell tumor with cytoloxidants and the iris place in the urethral. So we can see two or three different images here, the normal one and all the tumors are high lighting. And of course, I would love to do it robotically. In this one, I'm doing it lapper scoping. And I struggle, it's true. So. Okay, it's not with the decision. Yes, yes, yes, yes. I was really kind of pleased. I have to do robotic next year. I will do it. But this way we did it lapper scoping. You can see all the cells that they are high lighting, but this is off level. This is FDA approved in adults. Okay. So this is the normal view, just pink. So if we have only one spot, for example, that two centimeters nodule in the pelvis and you use silox, for example, or in neuroestomat that you, we are using this, Dano, help me. Dano, Dano, Dano, Nituksimab. Dino, Tituksimab. Thank you very much. There is a antibody, like a monoclonal antibody that we're using in neuroestomat right now. Next week, for instance, I, we're going to see the neuroestomat during the surgery. So it's great. This is the future for us. Doria? Yes. So Tim Loudz from Louric Chicago, I think, well, he's one of the others there. I think he won the best post-representation in Cybe last year for calculating the concentration of these specific receptors for cytolax. They were actually higher in the pediatric tumor, so he chose to test them in the adult population. So I know this is still not FDA approved, but I'm guessing it's coming, isn't it? Yes. So it is coming in here. Again, can you show it? There are two ongoing studies to see, to try to see the safety in pediatric patients. And we have been using it like off-label in Cleveland Clinic in patients with the plastic small run-salt tumor specifically, but these are two studies. Louric in Louric Loudz is doing this one in Louric Children's Hospital to know if these cytolax helps for metastatic patients. And in the Mayo Clinic, they're trying to see all the solid tumors. Because we know pediatric solid tumors are really high in folates receptors. So we are going to have, I think, this is a really breakthrough story. And we are using it right now. And we know the limitations of ICG. Because many people, and you see that answer ICG of one of the options, but the subcomas don't highlight with ICG, and that's a problem. So this is new. I wanted to show it to you. How widespread is available in cytolax for people to use? This is not FDA approval. It will not be easy to go and ask for it. But it will be. Because right now, it has been used for Ovarian tumors in adults, in Goa Man, of course, and lung tumors too. So it is available. What we need now is the FDA. Dr. Yafan. It's not cheap, basically. You need to buy a lot of the vials to use it. That's the other problem. The use of label you can get it. The thing is expensive so far. And there's basically more to come in the next two years, target not ICG fluorescence that are building up the different labs within USA and the world to use in our near-eastern infrared spectrum to focus on that thing. So it's a coming thing that is basically building up the next two years. And actually right now in your lastoma, they are trying the molecule that we saw before. And they're trying to build another thing that is a little more precise than years. It's a different one and allows us to see deeper in that issue. Just right now, the problem is we just see superficial, like a one centimeter superficial with the knee or the other one will be deepest. So this is new and thank you very much. Thank you, Dr. Pizzo. We're going to turn it over. Dr. Alberg is going to talk a little bit about the newest COG renal tumor trial. A lot of us have patients who have renal tumors and have really understanding the way in which this trial impacts the care that we provide and how we need to think about things differently than we've done for the last 10 years. So she's going to walk us through some of that. And what I'm going to talk about as, and I'm a member of the COG renal tumor committee. So I am using the branded slides for COG, just because this is being broadcast. But what I'm going to talk about is essentially like 10% or less of the entire clinical trial. So for those of you who have this study open at your institution, it is really complicated, favorable histology, wellness tumor of all stages. And so I'm just going to walk through one of the important kind of surgical points and kind of see what people would do. So here's your clinical scenario. You have a three-year-old male who presents with an abdominal mass that was appreciated by a caregiver. No pass medical history of any concern, no concerning family history. So specifically, no predisposition or anything that you would worry about. Okay, so these are your labs and your vital signs. Here is your imaging right renal mass. They did a Doppler. Okay, and then this is your scan. So what would people do next? And I realize this is an international audience. So this is certainly going to be a little bit of a strategy. Yeah, recognizing that there is a strategy that would be totally different. So just here are some, yeah, this doesn't mean every answer is wrong. But the correct answer, the answer I'm going to say is correct is in accordance with the clinical trial. So place a central venous line for a neoadjevant chemotherapy, proceed with a right nephrectomy, with central line placement, proceed with a right nephrectomy with nodal sampling or all three. What would you get at the end of the day? What would people do in here? No tumor thrombus. No tumor thrombus. Anyone? Three. That's a great question. No, no, no. We're going to get frectyomy, no sampling answer. The frectyomy, no sampling and central line placement. I think, until we do we do umbrella. But I think one of the favorable things of COGs that there is a little window of opportunity of not giving chemo posteriorly and that happens only if you're under the age of two and other conditions. I think this guy would go with the central line or am I already wrong? Are you wrong? I think you were green at that point. You've read the prior studies and that's exactly right. It was an age cut off of two or under age two. It was a size criteria of under 550 grams. However, currently what we would recommend is right nephrectomy with nodal sampling only and then await for pathology. So just a step back for a second, for those of you who have enrolled on renal tumor studies in the past. So there was this overarching biology study called O3B2 that allowed for banking and central review that is closed and that has been replaced by the renal peck. So this is sort of your enrollment study. Any patient that has a renal mass regardless of whether you have pathology or not, you can start entering this patient in this study or approaching them for study. And there's rapid central review for risk assessment. One of the key points for the renal peck or the biology study is again as soon as the mass is identified, you don't have to wait for surgery or pathology to start entering them. The other key point for 2231 is you absolutely have to get lymph nodes. Does anybody know a magic number? How many lymph nodes would you get and from where? How many? I don't know. Okay. Anyone else? And from where? My, my, my, in your hand. So it's seven or ten. That's around that. I think it's ten for COG and seven for SIOP. And from where it, I think it's important and I don't think it's been established in the previous trials because it's really easy to get some misinterior lymph nodes and just get your count up. But I think it's getting more and more relevant where you take them from. And I've seen some diagrams from JPS in which they'd say so intercalorating nodes are important above the helium below the helium. And in some cases, even going through the other side. But I'm guessing you're going to. That exact diagram. I thought I had it in the next slide, but I think it's a little bit later. So there's not a confirmed, you know, this is the magic number. It's probably somewhere around five to seven. We only require one. Okay. And it's hard enough to get surgeons to get one lymph node. So you have to have a lymph node to get on the study. Probably the ideal from what we've gathered from retrospective studies is between five and seven, as you mentioned. But that will be, that's one of the secondary aims of the study. So. And then location is important. And I'll, when I put the diagram out, I'll come back to your comment on that. Thanks. So there's a new group. And again, this is again, just 10% of this entire protocol called the modified very low risk. It's newly expanded and refined based on data we learned from prior COG studies and SIOP studies. So stage one patients less than four. So the age has been expanded and I'll show you some data in the next slide to show where that came from. Regardless of any tumor size, which has also been shown to not impact event free and overall survival. But without any negative biomarker or prognostic biomarker, which are listed here. So lots of heterosigacity, 1p16q, 1q gain, or LH 11p15. And then the other component is an epithelial predominant, well, and tumor. So those patients can be classified as a modified very low risk group. And the aim of this study is to demonstrate that this group of patients can be treated effectively with nifrectomy only and can avoid chemotherapy. So again, they have to have unilateral renal tumor, so no predisposition syndrome or solitary kidney. Up front total nifrectomy, which I know is not the routine in all SIOP institutions or umbrella institutions. But up front total nifrectomy without spill partial nifrectomies are not eligible. And so if there's a question and it may be an older kid, is this a Wilms tumor, a renal cell, might be worth the discussion of what procedure you choose? And then lymph node sampling with appropriate drainage. Here is that graphic that I mentioned. This is in the COG protocol. But as you mentioned nicely, you want to basically get for right-sided tumors, hiler, paracable and aorticable region that doesn't include parryportal, that doesn't include iliac nodes and it certainly doesn't include mesenteric lymph nodes. We see a lot of those just to count. And then the left side, kind of the opposite. You want to carve a document where you harvest. Yeah. We found ICG helpful. We've been trying to see just for, okay. No, go ahead. No, take, make your comment. Just wondering if it seems to have points in the right direction. I don't know if it's really shown increased yield, just maybe a mix of more efficient and faster. There have been a couple of small studies going off of Gloria's excellent talk. So ICG for renal tumors has been used for two purposes. Number one, to help identify lymph nodes or sentinel lymph node mapping or, you know, nodal harvest. And then number two, to help, if you're planning a partial niphyrectomy, maybe a pre-treated tumor, you can inject ICG and it actually is inverse. And so the kidney will light up and the tumor will not light up and so that can help you show you margins. Is it really helpful for nodal harvesting? So you haven't found it to be helpful for nodal harvesting in here? Easy, ICG. Yeah, I have used ICG for lymph nodes sampling. It's not EC. You have to puncture the kidney, highlam, and usually it's not that EC. So what happened to me? Exactly. Yes, of course, because you changed everything. So it happens to me that the ICG I plays, it kind of diffended around the kidney and not in the kidney. So I saw everything great. And there are many people that have, it happens the same to many people. So yeah, there should be another way. But isn't there a right direction right? I agree. The times that I've eaten, so you have to inject in the kind of perihailer region and then it just oozes out. And so all you see is green. So I haven't found it to be super helpful. And I worry that somebody might inject the tumor and then you've got it still. But with an open effect on me, I don't find it difficult to get five nodes. Why would you need ICG? I think they're pro for ICG. It's more for laparoscopic cases, which are probably, oh, you're talking about laparoscopic cases, which is usually have a low lymph node sampling. But I don't think this is the setting for laparoscopic. Okay. Yeah. I mean, would anyone do laparoscopic? Why not? I mean, it's instantly found really early. Why not? There's no reason you can't. If you can do the same operation without spill and you harvest lymph nodes, then sure. Or robotically. The other one, the sweet robot. The other point to make with regards to this one little section of the trial is central venous access. And so we've all been trained. You have a renal tumor. They're going to need chemotherapy. Well, there's a bigger subset of patients, probably about 50 to 20% more patients who may be able to avoid chemotherapy. And so you have to really be thoughtful about the target or the timing of central venous access. And so for a patient who's under age four that you don't see any obvious rupture that you haven't spilled the tumor that there's no stage four disease, you would probably consider delaying placement of central line. You can use, if you have a suspicious lymph node, you can use intraoperative frozen section to confirm that and then guide your decision to place a line at the time of surgery and avoid a subsequent anesthetic. Or you could combine central line placement if the patient was a candidate for uncle fertility with that procedure. So again, biomarkers will be routinely tested for these patients. They cannot have any negative biomarkers because those have been shown to increase the risk of recurrence. I thought I had a data slide, but maybe not. This is our current renal tumor roster just to give credit, work credits, do. So thank you. Thanks for having any questions. Let us know. Thank you, everybody.