BOB in Ped Surg 2023 - IPSO Winner - Steven Scoville, MD

All right, Britney, what do we got next? Oh, you're muted there. Only two years into using Zoom, so one day I'll figure it out. But anyway, so now we have a combined heat between Apsa, which is the American Pediatric Surgery Association and Ipso, the International Pediatric Surgery Organization. So hopefully this will make this extra spicy for the competition to put these two uh societies together. But explain, explain why they're together. So I'll just explain. So again, we gave every society an opportunity for three abstracts and not everyone sent us in their abstracts. Um, we tried hard, but we didn't get everybody's. So, uh, because of that, we had to combine those that didn't have a full three together. So this is Ipso and Apsa together. Perfect. And so the first one up is from Apsa and this is from Dr. Jason Fraser. He's a professor in surgery and the program director of the pediatric surgery fellowship at Children's Mercy in Kansas City. And this paper is on his work uh titled the natural history and consequence of a patent processus vaginalis and interim analysis from a multi-institutional prospective observational study. And so the aim of this study was to define the frequency and timing of a symptomatic inguinal hernia in a group of infants with a known patent processus vaginalis. And then the other two presenta uh present presenters and presentations are from Ipso. And so first is Dr. Stephen Scoville from Nationwide Children's Hospital at the Ohio State University, uh presenting the comparison of outcomes between surveillance ultrasound and completion lymph node dissection in children and adolescents with sentinel lymph node positive cutaneous melanoma. And so this study was uh conducted using patients from 2010 to 2020 to compare the outcomes of patients with melanoma and a positive sentinel lymph node that underwent ultrasound observation versus those who had a complete lymph node dissection. And third, second for the Ipso, um grouping is Dr. Bernadette Jerremesse from the Princess Maxima Center for pediatric oncology with the work Multiplex organoid based 3D live imaging platform to screen probes for fluorescence guided surgery. And so basically this is a study where they aim to show the feasibility of using probes with specific tumor targets for fluorescence guided surgery. So remember, this is one from Apsa and two from Ipso and let's start the poll to see which one we'll watch. Hey. All right. Britney, do you have the winner in front of you or you want me to tell you? Can you tell us? Yes. It is comparison of outcomes between surveillance ultrasound and completion lymph node dissection in children and adolescence with sentinel lymph node positive cutaneous melanoma. So that actually had a 70% uh win there. So pretty dominant win. So, uh we'll come back in a minute and we'll be able to roll that video. I'd like to thank you for this opportunity to present our work entitled comparison of outcomes between surveillance ultrasound and completion lymph node dissection in children and adolescents with sentinel lymph node positive cutaneous melanoma. We have no disclosures. Pediatric melanoma has approximately 500 new cases diagnosed annually in children less than or equal to 18 years old. Compared to adults, we know that childhood melanoma is associated with delayed diagnosis and therefore, not surprisingly, more frequently has nodal involvement. It also has unique disease mechanisms. Despite these differences though, management of pediatric melanoma is based on adult studies. Melanoma management is largely based on depth of the tumor as well as presence of metastatic disease. Those with disease less than 8 millimeters thick are largely managed with wide local excision, while those with metastatic disease typically involve consideration of surgical excision and or systemic therapy. Those in the middle category of having tumors greater than or equal to 8 millimeters or less than 8 millimeters with high risk features without the presence of metastatic involvement typically undergo wide local excision with sentinel lymph node biopsies. If the sentinel lymph node biopsy is positive, then these patients would typically undergo ultrasound observation versus a completion lymph node dissection, which has a high risk of morbidity. Within the past six years, two adult trials known as the Decog SLT and the MSLT2 trials helped to show that within these low to intermediate risk patients, there's no significant difference in outcomes for patients with positive sentinel lymph node biopsies who are followed with ultrasound observation versus completion lymph node dissections. However, there is no pediatric data to support one versus the other. Therefore, we set out to answer this question. Our study included patients less than or equal to 18 years old, diagnosed with cutaneous melanoma between 2010 and 2020. 14 total institutions participated through the pediatric surgical oncology Research Collaborative, otherwise known as PISO. Of the 252 patients included this study, we found nearly equal distribution of age, tumor location, while race was predominantly white, consistent with prior literature. Breslow depth ranged from 2 mm C2 to 20 millimeters in depth with a median of 2.55 millimeters and extent of disease was nearly split between localized and regionalized disease. In categorizing our patients, we had four patients who underwent wide local excision alone, that went on to undergo ultrasound observation. We then had a total of 227 patients who underwent wide local excision with sentinel lymph node biopsies. 111 of these had negative sentinel lymph nodes with six of those who went on to undergo ultrasound observation. In contrast, 115 patients had positive sentinel lymph node biopsies, about 51%. Of those, 36 went on to have ultrasound observations, whereas 65 underwent completion lymph node dissections. Finally, two patients had wide local excision alone or had unknown sentinel lymph node biopsy results, went on to have completion lymph node dissections. For a total of 46 patients in the ultrasound observation group compared to 67 that had completion lymph node dissections. Comparing outcomes between ultrasound observation versus completion lymph node dissection, we found that patients who underwent completion lymph node dissection were significantly older and more likely to receive advent therapy. Furthermore, there was no significant differences between recurrence or death from disease between these two groups. Additional subgroup analysis found that positive sentinel lymph node biopsies had significantly higher rate of disease recurrence at 18% compared to 3% for the negative sentinel lymph node biopsy group. We also found that only 21% of those who went completion lymph node dissection had additional positive nodal disease. However, we found that rate of recurrence was not significantly different between completion lymph node dissection patients with or without additional nodal burden. In doing an analysis based on recurrence versus no recurrence, we found that recurrence was associated with positive nodal disease, deeper Breslow depth and greater use of advent therapy and a higher rate of death. Therefore, to summarize, pediatric melanoma presents as advanced disease with nearly 50% positive sentinel lymph node biopsy rate. Management of nodal disease had no significant impact on disease outcomes with respect to recurrence or death from disease. Only 21% of patients that underwent completion lymph node dissection had additional nodes discovered and findings of additional nodal disease did not significantly correlate with recurrence. Recurrence did most strongly associate with positive sentinel lymph node biopsies and deeper Breslow depth. I would like to personally thank our many collaborator collaborators across the 14 institutions who helped with our data acquisition, analysis and our manuscript preparation. Thank you. Well, this was outstanding. Uh Dr. Schwell, thanks for joining us. Thanks for having me. Britney, Tony, any comments or questions? Um, I have one question. Um, after this presentation, I like what I get from is is that if you have a positive sentinel lymph node, it's the same to look at with ultrasound that to do a complete life lymph node section? Is that okay? Yeah. So essentially outcomes, at least from what we could tell, we didn't find any statistical difference between those that underwent completion lymph node dissection versus uh sentinel lymph node with um ultrasound observation. So, you know, and we even looked um at the the timeline from when the Decog and MSLT2 trials came out. And you know, before those trials came out, there was a much higher rate of uh completion lymph node dissection even in in kids. And then after those trials, the rate has gone down, but it's still higher than what's done uh typically in adults. And so, uh what we're finding is that for most children we can, um while the disease is thought to be more severe, you can still observe these patients with sentinel lymph nodes and not uh move forward with um completion lymph node dissection. Stephen, this is a an excellent presentation. Thank you very much. Uh in pediatric surgery, we don't see melanoma that frequently and so it's kind of rare. So this is very helpful for our for practice. So, the concept of doing the central lymph node will then give systemic therapy? Is that correct? That's the first question. Yep. Sorry, can you repeat your question one more time, sorry? Yeah, there was some background noise. So the if a sentinel lymph node is positive, that will then indicate systemic disease, is that correct? Uh certainly more severe disease than if there wasn't there, yes. Yeah. That systemic therapy, I mean, you'll give systemic therapy if the sentinel node is positive? So not, um not always. Uh some of those patients, so we didn't specifically look at that question among among these, but we did look to see uh, you know, once they had those who went on to receive therapy. Obviously, if they have sentinel lymph nodes, they're more likely to get advent therapy versus not. Um, a lot of it then depends I think a little bit on the genetic makeup of of the melanoma. Um, and then uh also just the overall risk factors of the tumor itself, the size and things like that. So, so my second question is then, if you do decide to do the ultrasound follow up, what is your response if you see a lymph node getting bigger? Do you go and resect it or do you change therapy? What is the point to the of the ultrasound follow up? Yeah, so, um we didn't specifically address that in this study, but I believe that you would then, um, you know, if you hadn't been on therapy at that point, um, you know, you would move forward with it. The other important thing is that most of these patients, you didn't have clinically positive nodes at the time of your initial dissection. So you're looking so I'm assuming your question is if you were to have a clinically positive node at that point, what would you do? And I think the the answer would more likely just be to move forward with systemic therapy. Uh I don't think people would move forward with the completion lymph node at that time. You would just go with advent therapy. Yeah. Thank you. Thank you. There so we're out of time, but I will tell you if you wouldn't mind Stephen to go into the chat, there's some questions I know Tony answered. I think, um, uh Andrew Fleming's question, but questions about pets and teas and things that you can go answer in the chat. Um, so great job, congratulations, amazing work, uh and uh hopefully we'll be able to see you in the next round. Thank you. Thank you. All right, who's next here? Is it who's turn is it? Um, now we have Oh, break. Yeah. We we are a little bit ahead, so that's a surprising thing. And we are going to take a break because we are in we already did five hits and there are five left. So we are going to take a five minute break so we can all go and do some stuff. We'll see you in five minutes to complete the rest of the heat. Take care.