The Role of MIS in Pediatric Malignancy Steven S Rothenberg MD
Advantages § Accurate diagnosis § Decreased morbidity § Quicker recovery § Adjuvant therapy can begin earlier
Disadvantages § Incomplete and or limited visualization or assessment § Inability to palpate surfaces § Tumor Spillage / Upstaging tumor § Incomplete resection § Port site recurrences
Thoracoscopy § Tumor biopsy for diagnosis § Lung biopsy: metastatic lesion/ pulmonary infiltrate § Staging § Tumor resection
Lung Biopsy § Nodules § Infiltrates (Infectious/ Leukemic) § Primary tumors § Lesions < 5mm or deep in the parenchyma - CT guided localization (blood patch)
Mediastinal Masses Posterior Mediastinal : Neurogenic: Neuroblastoma/ Ganglioneuroma Anterior mediastinal Lymphoma/ Teratoma/ Thymoma
Contra - indications § Giant tumor § Tracheal compression with respiratory compromise § Inadequate resection using MIS § Multiple nodules bilaterally (osteosarcoma)
Thoracoscopy in Childhood Cancer Smith, Rothenberg, Brooks, et al.J Pediatr Hematol Oncol. 2002;24:429 - 435 § 63 procedures § 52 patients: 33 males, 19 females § Age: 2 months - 21 years (mean 12.1 years) § Weight: 4.2 - 100 kg (mean 48.5) § Diagnosis made 62/63 - 98.4% (one missed nodule) § Complete tumor resection 6/10 § Conversion to open 8/63 - 12.7% § Average hospital stay (thoracoscopy) - 1.8 days § Average hospital stay (conversion to open) - 3.7 days
Procedures § Thoracoscopic resection of lung nodule - 29 § Biopsy of infiltrate - 15 § Biopsy/resection mediastinal mass - 10 § Diagnostic thoracoscopy - 8 § Lobectomy - 1
Solid Tumors With Metastatic Lung Nodules § 19 patients/ 24 resections - 1 missed nodule § 13/19 alive (3mo - 7 years F/U) § 9 patients OGS - 10 resections § 5/9 alive disease free: 3/4 deaths had high risk features (2 - metastatic disease at presentation, 1 - secondary OGS after retinoblastoma)
Pulmonary Infiltrates § 15 biopsies/14 pts § 80% intubated § 40% pancytopenic § 2 in PICU § 9/15 non - infectious Abx - d/c’d § 6/15 infectious Abx therapy altered
Mediastinal Tumors § Diagnosis - 100% § 6 complete resections ganglioneuroma/ neuroblastoma § 4 partial Hodgkin’s/small cell ca/ recurrent OGS
Mediastinal Teratoma
Ganglioneuroma
Thoracoscopic Resection of Neurogenic Tumors in Children Lacreuse, Valla, de Lagausie, et al. J Pediatr Surg 2007, 42: 1725 - 1728 § 21 patients § 7 months to 14 years § Neuroblastoma (8), Ganglioneuroblastoma (8), Ganglioneuroma (5) § 1 conversion (giant tumor) § Hospital stay: 4 - 12 days § No tumor recurrence (avg. 18 mo F/U)
Resection of Neurogenic Tumors in Children: Is Thoracoscopy Superior to Thoracotomy. Petty, Bensard, et al. J Am Coll Surg. 2006:5; 699 - 703 § 17 patients: mean age 4.7 years § 10 Thoracoscopic/ 7 open (comparable size) § Operative time/ blood loss: No difference § Hospital stay 1.9 vs 4.2 days § No regional recurrence § 8/10 disease free at 25 months f/u § Thoracoscopy preferable
Laparoscopy § Biopsy and Staging: Lymphoma, Neuroblastoma (Pediatric Malignancies are often sensitive to chemotherapy and require only initial tissue biopsy for diagnosis ) § Resection: Adrenal, Ovarian, Renal, Neuroblastoma, Liver, Pancreas § Palliative § Evaluation of response to therapy § Diagnosis of metastasis/ tumor recurrence
Contraindications § Giant Tumors § Changing tumor stage (Wilm’s: biopsy with tumor spillage results in upstaging of tumor)
Abdominal lymphoma
Sacrococcygeal Teratoma
Burkitt’s Lymphoma
Retroperitoneal Neurogenic Tumors
Pancreatic Adenoma
Minimally Invasive Surgery in Pediatric Solid Tumors Chan, Tam, Yeung. J Lapro Surg Tech; 17: 817 - 820 § 38 pts: 35 intra - abdominal § 22 ovarian, 4SCT, 3 adrenal, 3 retroperitoneal, 1 - kidney, liver, testicular § 28 resected with MIS § No recurrence (3.1 years follow - up)
Minimally Invasive Surgery in Pediatric Cancer Patients Spurbeck, Davidoff, Lobe, et al. Ann Surg Onc: 2004;11:340 - 343 § 101 patients: mean age 12.6 yrs (113 procedures/64 laparoscopic) § 27 diagnostic (biopsy of new mass 10/ second look 15) diagnosis in 92% Evaluation of resectability - 2 § 7 primary resections § 30 procedures for complications of malignancy or it’s treatment
Adrenal Masses in Children: The Role of MIS Romano, Avolio, Valla, et al. Surg Laparosc Endosc Tech: 2007:17; 504 - 507 § 26 pts / 29 adrenal masses § 12 laparoscopically/ 17 open § Retroperitoneal approach (5 biopsy/7 resection) – Neuroblastoma, MEN, Pheo. § Recommend for lesions <5cm
Role of Diagnostic and Ablative MIS for Pediatric Malignancies Warmann, Fuchs, Ure, et al. § 301procedures/ 276 children (5yr period) § 90 attempted with MIS / 69 completed. (65 abdominal: Neuroblastoma 14/ Lymphoma 13/Ovarian 3/Hepatoblastoma 5/ Other 27) § 41 biopsy and staging (6 converted) § 24 attempted resections (10 converted) § Diagnostic accuracy 98% § Conversion rate 15% § No port site recurrences
Conclusions § Thoracoscopy is an excellent means to evaluate and treat oncology related disease in the chest § Thoracoscopic lung biopsy is safe and efficacious in even the sickest patients, allowing for more aggressive use to obtain tissue diagnosis
Conclusions § The majority of mediastinal tumors can be adequately diagnosed and staged using MIS and many can be completely excised § Because of the lower morbidity associated with thoracoscopy adjuvant therapy can be started earlier § Port site recurrence is not a factor if the specimen is handled properly
Conclusions § Laparoscopy is extremely effective for biopsy and staging of abdominal solid tumors § Resection of certain tumors (neurogenic/ adrenal/ ovarian/ pancreatic) is safe and effective with less morbidity then open procedures § Tumors > 5cm must be evaluated on a case by case bases, and upstaging a tumor must be avoided § Laparoscopic resection of isolated large liver and renal tumors may be beneficial but further study is indicated.