Ovarian Teratoma - Ovarian Torsion - Soft Tissue Sarcoma: Update Course 2015

I want to introduce uh Doctor Andrea Hayes Jordan. Uh, Andrea, are you there? She's here. Andrea, I'm here. Hello. Hey, we can hear you. We don't see you yet, but we hear you. Um, can you, can you see me now? Mark's gonna, Mark's gonna take care of that in a second. Uh, Doctor Hayes Jordan is from, uh, University of Texas, uh, Houston, MD Anderson. And she is going to talk to us on a few rapid fire topics. She's going to talk to us about ovarian teratoma, ovarian torsion, and soft tissue sarcoma. Well, thank you everybody for inviting me. I'm going to share these 3 rapid fire topics and what are meant to be about 5 minutes, um, but please interrupt if necessary, and of course we're focusing on updates on these particular topics. So this first case is a 13 year old female who presented with abdominal pain. The ultrasound shows a huge ovarian mass. Can't really tell whether it's mostly cystic or mostly solid. It seems like a combination. So the surgeon performs a unilateral oophorectomy, uh, and no further therapy is given. Uh, however, the pathology does not reveal a teratoma, which the, uh, surgeon thought it was. It revealed a yolk sac tumor. And then 3 months later, they're concerned about recurrent disease. So we're gonna come back to the case after we go through some updates. So, most ovarian masses are gonna be teratomas, of course, 80% of them, and the management of a teratoma hasn't changed in the last 50 or so years as far as completing the complete gross resection of the tumor. The controversy comes in trying to distinguish an ovarian benign tumor from the list of malignant tumors that I've listed there. And we do know that over the last decades that the survival has improved a bit. The top line you can see shows that in the year 2000, the girls have almost 100% survival, so that we really aren't dealing with a lethal disease, but it really is the management of the disease to allow you to reach that 100%. So the, the staging is pretty simple. The stage one is limited to the ovary as far as an update. The uh ovarian tumors are limited to the ovary. We used to give, uh, chemotherapy for some of those. Now those are only limited to the ovary. Do not receive chemotherapy, but only oophorectomy. Microscopic residual and lymph node involvement patients will receive, uh, chemotherapy. The uh germ cell tumors are, are organized by the stage and the risk category. Again, surgery alone for stage one patients and the intermediate risk patients receive the chemotherapy as well as the surgery, and the high-risk patients, we really don't have any novel treatment for at this time. Of course, you're gonna be checking your serum markers, but what's what I really wanna emphasize is documenting in your operative note, whether you've done, you've looked at things, so basically just looking around, and most people are doing these laparoscopically, so it's very straightforward to look at the omentum and look at the diaphragm and get peritoneal washings if there's no ascites present. The, what they did determine was in the most recent data that because you have about a 2, 25% of the girls that you'll miss if you don't do the peritoneal cytology and you don't do the washings that really that is uh an important part of the surgery. Also, the staging guidelines have been modified to reflect that each portion of the staging procedure, um, and again, stage one tumors, if you can get the, if it's just the, the oophorectomy and you've documented that your lymph nodes and your peritoneal washings are negative, those patients will not receive any therapy. Other than surgery. Um, the, if you, uh, omit those, uh, statements in an operative report, the oncologist will treat them as a stage 2. So just, just mentioning whether you see anything in the omentum and the lymph nodes, uh, will allow the oncologist to only, uh, follow their, uh, markers. So the washings and the ascites are important, inspecting the diaphragm and only biopsying the other, other ovary if you see any disease. That's an important consideration. This is a, uh, as far as updates are concerned, this is a newer entity that's uh been more recently described in more detail. And if, this is a laparoscopic view of a patient with an ovarian teratoma and it looks like, this is a diaphragm, this is the hole where I've taken a biopsy. It looks pretty bad and nasty, but actually this is a benign disease appearance of this gliomatosis peritonei. And I wanted to show this so that people would not uh see this and be concerned, but just to know to biopsy it because these patients um have pretty much 100% survival with this gliommatosis. And this is another view laparoscopically of the same thing. Here's the falciform ligament and the liver and the diaphragm you can see, uh, here, but again, benign disease in the presence of uh, usually a teratoma. And you don't need to place this intravenous catheter, you just need to follow these people. The last thing I wanna mention in this rapid fire is about bilateral ovarian disease. Uh, if you see a child with bilateral ovarian disease, most of the time it's, it's, uh, not benign, but the size of the lesion should determine whether you biopsy it. So if you have more than a 10 cm. Centimeter uh tumor, you want to definitely biopsy it, uh, and if there's any suspicion or doubt, uh, but have a lower threshold for doing a bilateral oophorectomy on the first operation. So that pretty much completes the updates on, um, ovarian teratomas girls. So I'll be happy to go over something or or answer questions. Andrea, thank you very much. Um, that was uh very uh. A very good amount of information about something we don't see that often. So, um, it's a great review. I wanna do, if it's OK, I wanna do a 2 minutes of rapid fire here in the studio about some common issues or questions that I have that come up. Let me just start with this way, rapid fire, just give a quick, give a quick answer. Um, so, uh, Dan Dan. 12 year old comes in, has uh abdominal pain, you get a uh uh an ultrasound. There's a big mass, you get, I don't know if you get a CT and it looks like a teratoma. It's mostly cystic, but there's elements of calcifications. It looks like it's a teratoma. Uh, your operative approach, do you, what do you do for that patient? Laparotomy, laparoscopy, or something else that you do preoperatively that I'm not thinking of? So I think Andrea presented a great overview of the changes. Um, one of the most important things is we've gone back to surgery alone for stage one tumors, and so, uh, I think that you have to have some caution with the laparoscopic approach if you are not sure that you can get the tumor out. Without rupturing it, because if you rupture it, then you've committed the patient to chemotherapy, and that chemotherapy includes platinum, so that's one thing. Uh, the other thing has to do with staging, and that is that 15% of ovarian tumors, especially in the age range you're talking about with that patient you presented, actually have epithelial tumors, and the staging is different for an epithelial tumor. So that's one of the things we struggle with, the difference between the COG staging criteria. For an ovarian tumor and the um adult staging criteria for an epithelial tumor. OK, uh, uh, Tony stepped out. Uh, I'm curious, um, what your thoughts are on the technique of gluing the, the bag to the tumor. If it's mostly cystic and you think it's, it's got the imaging characteristics of a teratoma, I think that's absolutely a great way to minimize. The incision and we, we do that routinely. You do that, Andrea. Do you do that? Uh, yes. The other thing I was gonna mention is if you have time to get, uh, the alphatoprotein and beta 8CG levels and those levels are normal, you can't have 100% comfort, but you can have some comfort about, um, you know, draining the cyst cavity in a, in a pocket that allows you not to have any contamination, however you want to do that is fine. I usually put a purse string in it through an umbilical incision and bring it up that way and then drain it and then close the close the suture that I've put in after I've drained the cyst cavity. So there's many ways to do it, but the key, as Dan said, was just to make sure that there's no spillage. Who here after you drain this mostly cystic teratoma. Does ovarian salvage. Who salvages the ovary? Salvage. Dan salvages. Max salvages. Do you take it out? I have some data on that in the next presentation. OK, fine. All right, fine, but it's a different thing because the next one is torsion, right? So, but it's still, you still want to try to salvage the ovary, but that's a good question. Is there anyone for a teratoma that wouldn't try to shell out the teratoma and leave the ovary? Is there anyone that doesn't do that? Everyone here in the studio does. Uh, it's not always easy. If I could make a comment though, for surgeons who don't feel comfortable or can't do it laparoscopically, you can make a small fan and steel incision and exteriorize the ovary and do a, do a very minimally invasive operation to get it out. So I would argue there's no benefit to laparoscopy. So I think it's more invasive. So if I'm gonna make a tiny incision and glue the bag to it, shrink it down and pull it out. I don't see the advantage of putting a laparoscope in. That's if it's big. If it's small and you need to help elevate it up or bring it to the umbilicus, but what's the advantage of laparoscopy? Look for, well, no, I'm just saying if you get in a situation where you're uncomfortable doing it laparoscopically, don't, do you do it laparoscopically? I would try to, yes, but if I can't do it, then the advantage of the advantage of doing it laparoscopically is that I just don't want people struggle laparoscopically and do a bad job. Hold on, you guys are both, I'm sorry, Andrea, say that again. Um, I'm saying when you do it laparoscopically, even if you don't do the operation laparoscopically, if you at least put a scope in initially to get a lay of the land and make sure that there's nothing unexpected that you haven't noticed on your imaging, make sure there's nothing in the upper abdomen that you're obviously not gonna see from a fan steel or a small. A minimally invasive incision. I think it's important to put the laparoscope in just to make sure it's what you think it is, and you can take nice pictures, but that's very different than doing the operation laparoscope which I agree. I mean, if I put a laparoscope in, it's for exactly that reason just to look. OK, fair enough, um. So, you know, the, the techniques, I don't know what people do here. I've seen Marcella, uh, Baez present a great video of doing it laparoscopically. I know I do it Tony Sandler's technique that that he left, but I make a score across the top and just take a gauze and I sort of peel it and shell it out. I don't know if anyone does it differently than that. OK, perfect. Andrea, let's move on to the next one. While we're working on this talk, um, Whitt and I and Mac are talking about technical feasibility of the different techniques. Um, I. I've, uh, I've, I've only tried one way, so I have nothing to compare it to. I've only tried it doing this way with the thing still pulling it out and swiping it, and that's always been easy for me. I've never tried it laparoscopically. Um, so if you do it laparoscopically, do you drain it laparoscopically, drain the fluid out? Yeah, if it's really large, you can drain it laparoscopically. Sometimes. If it's not too terribly large, it's nice to have the fluid in there to create a, a differentiating plane between the teratoma and the ovary itself. You don't get worried about, uh, if there's a malignancy seeding. Well, I don't, but maybe I should. I mean, no one, no general surgeon, no general pediatric surgeon, except for maybe, uh, uh, Andrea has a lot of experience with this, you know, my experience is less than 10, so I maybe I. I'm not doing it correctly. I think the good news with this is that um the salvage rate and the reason you can get away with surgery alone is because the salvage rate is almost 100% for those patients that recur. Is that right? So there's, so the chemotherapy is very good. So even if you get a recurrence, that doesn't, uh, compromise the patients as much as like we were talking about with recurrent Wilm's tumor. All right, Andrea, go ahead. OK, so ovarian torsion. So 16 year old female come in with severe abdominal pain in the pelvis. Uh, you get an ultrasound immediately and shows a large cystic mass with a suspicion of torsion. And as many of you know, when you're reading these ultrasound reports, the, the, the blood flow and the, the description of the torsion can vary depending on your ultrasonographer and their experience. And then the next morning, you decide to do a laparoscopic uh drainage and detortion and possibly an oophorectomy. So in this, in these torsion cases, obviously we're always thinking about preserving the ovary and we wanna know what are the alternatives. Um, the other questions I wanted to bring up is, should you do these cases in the middle of the night? Uh, is there a bias towards doing them the next morning, um, because there will or will not be, uh, any difference in loss of the ovary, and can you drain or aspirate it without contamination, which we've already talked about previously. So, ovarian torsion of course is most common in teenage girls, but what, the way it's being seen is to be an urgent and not an emergent situation if you're always aiming to preserve the ovary, and I think as far as updates that when I was a fellow, I was that if it's black, you take it out and now what we're learning from some of our GYN colleagues is that many of these black colored ovaries are actually do have follicles in them that are viable and that ovarian preservation should be the goal. This is sort of the old criteria that we had for looking at um whether it's malignant or not malignant, whether the cyst was bigger than 8 centimeters, trying to decide what to do for it. And now we're moving more towards preserving it because again in these, in these situations, you're always concerned if you have a cyst, if it's malignant, is it not? And this is just a really excellent review that was done in Indianapolis, looking at the components that help you decide whether you're gonna drain it, whether you're gonna detourse it, whether you're gonna take it out. Um, the solid component, the size being more than 10 centimeters and the positive markers are really the key as well as the calcifications. In addition, as far as ovarian preservation, your ability to preserve the ovary is gonna depend on these things over here on the left, the size of the mass, the size of the cyst being less than or greater than 10 centimeters, the presence or absence of the torsion, or if it's really just a a a torsion or they're having. Pain because of the size of the cyst and then the approach of being laparoscopic or not laparoscopic, uh, that is also gonna determine whether you have ovarian preservation. And again, the goal is for ovarian preservation, but these things can inhibit your ability to do that. So what about if you go ahead and do an oophorectomy, how much of what's gonna be in the specimen, how many of those specimens are gonna actually have ovarian tissue in them? And it turns out that most of them will have normal ovarian tissue, so these are all comers. These are cysts that have been removed for torsion, uh, but Uh, the, in the, uh, surgeon's opinion, the ovary was, uh, dead and therefore they removed the whole ovary and in that case, you have 76% of them that had normal tissue in them, but you have 13, only 13% that had no ovarian tissue and only only 11% where it was actually completely necrotic. So, microscopically, it looks very different uh than it does in the, in the norm in the um growth setting when you as a surgeon are looking at the, at the ovary. So if you do the ovarian preservation and you just, uh, detour set, do you do an orthopraxy, and this is part of the discussion that we should have? How many Pepsi and if you do decide to do that, what are the consequences and most of the papers report pain uh in the girls as being consequence of doing a Pepsi and, uh, ovarian sparing, which usually is short-lived, usually only lives, uh, the pain resolves in a week or so. Uh, and also to remember that these black colored force. Ovaries and the ability for us to preserve ovarian function is related to age. So in our patients that are all pediatric patients, we wanna be really aggressive about trying to preserve the ovary. However, in older adults, there really aren't as many active follicles and it becomes a little uh less likely that you could preserve ovarian function. Um, and this is just a very old paper on the technique just showing how old this technique is as far as, uh, removing the cyst and preserving the ovary, uh, and this is the way I do it and try to remove what is torsed and leave what is remaining abnormal, uh, ovary, even if it's just a very thin layer, there are gonna be some follicles in there that. That will be able to be preserved. And here is an image of what looks sort of like a black colored ovary, I purposely put it in black and white, so you could see how black it was an attempt to try to preserve something that even in that area you could just over here on the left side by the fallopian tube, if you just want to preserve a little bit of that, you're gonna preserve enough follicles uh for function. So the recommendation for detortion without complete oophorectomy is the present recommendation, uh, and, uh, that's pretty much it. We'll go to questions and discussion. Yeah, let's do that. So I, I have a question. Let, let's go back now. So, uh, Jason, sorry, man, I'm gonna start with you. Uh, let's just go around the bend here. You get called. By the resident or the fellow that says, there is a patient here, she's 13 years old. She has a right lower quadrant pain. We have an ultrasound that shows uh uh 8 centimeter ovary, ovarian with a uh cystic ovary, OK? Heterogeneous, OK? Uh. Question is, how do you decide how fast you go in? Does an ultrasound help you? What is your usual timing if you're concerned about an ovarian torsion? Do you rush in or do you use the ultrasound to help you? Do you think the ultrasound adds anything? Um, and then I want to go rapid fire around the table, so I would, I would get tumor markers sent off. We won't get them back in time, but I get them off before I go to the OR, and I typically go to the OR in a more urgent fashion. I'm not gonna wait till 7:30 a.m. What if the ultrasound says there's good blood flow? I can't get 7:30 a.m. OR time anyway, so I'm going to do it at night. So, uh, Lou, good blood flow on the, uh, I'm, I'm taking care of it the next day, as long as the blood flow's fine. I'm, I have an operative approach that I'm gonna try to do tissue preserving surgery anyway. And in the specimens, the studies that Andrea pointed out, these were not cases that were taken necessarily emergently to the operating room. So these were probably all comers and most of them were not taken urgently. So I think that there's viable. Tissue they're not going to the OR right away. So your answer is if the ultrasound shows blood flow, you're going to do it the next day. You're not coming in at 2 in the morning, Greg. Uh, we work with our gynecology team anyway, so that's more complicated de facto, de facto, but most of us would probably deal with it right away, right away, OK. Are you going to give the same answer? Yeah Right away. What if the ultrasound shows good blood flow symptomatic right away, Mark. Samir, OK, I was under the impression that good blood flow means absolutely nothing. Uh, Dan's nodding his head. Go ahead, Dan. What are you, I would just say right away because I don't trust the ultrasound to tell me whether there's good blood flow or not. OK, Mac. So I've had pediatric radiologists who presidents of their national organization say ultrasound does not help you in this setting, right? OK. Uh, and, well, after hearing the discussion, all right, I'm sure I've done that in the past. Andrea, clarify this for us. I was on R4. activity and specificity is in the 50, 60% range. So you, you gotta, you gotta just go on your instinct, I think. I think the ultrasound, if they say there's blood flow or not blood flow, I, I take little stock in that. If the kid's in a lot of pain, you need to do it right away, in my opinion, if, you know, if it looks like they can be OK to. Morning then you could do it there, but I, I'm never surprised one way or the other whether there's blood flow or not in the, uh, in the stock. So, uh, go ahead. And I think torsion, so not torsion secondary to mass, but torsion secondary to long ligaments, uh, where we might be swollen. Will you detour and then ultrasound in a few weeks and check it? Rather than trying to dissect it out as you were describing, oh yeah, me too. You're saying if there's no cyst associated with it, you do. He's saying, yeah, he wants basically do PEi. Uh, what do you do with there's no cyst to deal with. Yes, I try to, I try to PEI them. Um, I used to not Pepsi all of them and then I had a patient that I didn't PEI and then she came back again with a torsion on the other ovary, and then we are in a situation where there was one ovary that had been, um, mostly removed and we have a second torsion, so I, I, I Pexi them for that reason. Uh, I wanna make one comment back about the ultrasound. We just did a podcast that we'll be releasing with Jennifer Dietrich, uh, adolescent gynecologist who I, I never understood why the ultrasound didn't, why they, I mean, if they have blood flow, they have blood flow. It has to do with, I think the way she explained it was. It's twisted. If it's twisted, just because there's blood flow doesn't mean it's not twisted. It may mean at that point in time, it might have been not so tight, so there was some blood flow getting through, but a minute later when you lift up the ultrasound probe, it could be back again tight. So it doesn't tell you anything about torsion. It just tells you that at that point in time, it's, it's not complete occlusion of the blood flow. Is that, is that your understanding, Andrea? Yes, yes, it, it's, and it certainly is dependent on the, the pressure that the oceanographer is using, the, you know, how much the bladder is filled, etc. etc. OK. What about Pepsi? It, I bet you sounds like some people Pepsi and some people don't pull it. Who, who, so I'll tell you my answer first. I Pepsi if I don't see a cyst. If there's something to deal with, I don't Pepsi. If I see a normal ovary that was twisted, then I do a PEI. I'm curious, what do you do, Dan? Same, pretty much the same thing. I used to routinely Pepsi. I do not do that anymore. OK, not routine Pepsi. So I'm not sure if I'm using the word Pexy the same way that generally there's a long, uh, ligament and then you can try to foreshorten that ligament. That's a great point. Yeah, that's what I've done. Uh, does anyone do that? Shortening of the, is it the tubal ovarian ligament? What's the, the shortening of the ligament? It's the broad ligament. Uh, I was taught the same thing. What do you do? I see a cyst. I don't don't see a cyst. Yeah, same thing, IPEy. I just basically tag the two ovaries together posterior behind the uterus. Interesting. Does anyone else do that? Because that's actually where they naturally lie. If you think about it. You don't put it out laterally and actually for fertility reasons, as I talked to one of our reproductive endocrinologists. And that's how I came up with that. Well, I worry about that a little bit, but it's not been an issue. Don't do it that often, but it's, it's tucked up underneath there. I can't imagine it'd be hard for a loop of bowel to get down there. Are you asking about the involved ovary? Based upon what Andrea said, since she saw it occur on the contralateral side, should we be doing a PEy on the other side as well? Yeah, so if you, so if you just tack the two ovaries together behind the uterus, you take care of them both, right. That's, I, I, that's, I've never heard of that. That's very cool. I tacked the ovaries behind the uterus, uh, in the setting of, of, uh, Hodgkin's or a malignancy where they're gonna radiate both pelvis, uh, but in these situations and I pull them in a little bit, but I don't actually go all the way behind the uterus. I pull them in a little bit, but not all the way behind the uterus. And you do the contralateral side? Yeah, I do the contralateral side. Um, 00, Whitt wants to know what are you Pepsi too? Um, just the, the pelvic side wall, just, uh, you know, and we're back. I hope everyone had a nice little break. We had lunch here. I don't know what meal you had where you are, but, uh, we're gonna continue on with the show. I apologize for, uh, rushing you out there, Andrea. So we, we, uh, are gonna move, we're gonna change the order a little bit. Let Andrea go ahead and do, uh, her last, uh, rapid fire, which is soft tissue sarcoma, and then actually we'll introduce our other virtual speaker. I'm gonna leave you in suspense right now. We'll introduce, uh. You afterwards. So, uh, Andrea, why don't you go ahead and talk to us about soft tissue sarcoma? Can you hear me? Yeah, perfect. OK, OK. So these soft tissue sarcomas are quite rare and so we'll take this opportunity to give folks an update just on what's new as far as surgical therapies in these soft tissue sarcomas, and half of them are rhabdomyosarcomas, but the other half are the non-rhabdos, so we'll spend a couple of minutes on each one. So we're talking about a very, the very rare sarcomas, and the important thing to remember is that these in rhabdomyosarcoma. We'll talk about first, the prognosis varies depending on site and so the, the patients that we see the most often, of course, are the abdominal, pelvic, retroperineal ones, and those are the ones that have the worst survival over here under other and then the best survivors are the orbital rhabdomyosarcomas and because I know people don't deal with these every day, I'm gonna just very quickly go through how we stage them with uh favorable. Sites. So if you have a favorable site, this is basically vaginal rhabdos, persticular rhabdos. Those are stage 1 and stage 23, and 4 are unfavorable sites with various amounts of disease. But what I'd like you to remember is that, you know, we basically don't see a lot of stage 1 patients. So even if you have a small tumor in the extremity or the abdomen, the best that patient can do is a stage 2. A group, the grouping, it depends on the surgical extent. So you as a surgeon determine the clinical group. If you remove everything, it's a group 1. If you leave microscopic residual behind, it's a group 2, and if you can't get it out and you just do a biopsy, it's a group 3. So the stage and the group combined are what determines how the patient's outcome is and as you can see in this Kaplan-Myer curve, the group 1 and 2 patients have an excellent prognosis and the group 3 patients are the ones that do a little bit more poorly. I do want to emphasize here that this doesn't mean. That the, the good surgeons, quote unquote, they're ones that can get it down to group 2. This is basically a biologic determination. If there's a large tumor that a surgeon can't resect, it's gonna be a group 3, and you trying to resect that with a lot of morbidity is not going to make that patient's outcome any better. So first case, this is a 5 year old with a mass on the forearm. It's 4 centimeters in size, and as we know, 5 centimeters is the cutoff for sort of a low or a high-risk patient. So if a 4 centimeter tumor in a 5 year old, uh, we're, we're gonna talk about this later, it's not for you to answer out loud, but just to think in your head whether you would resect it. This particular patient had their 4 centimeter tumor resected in an outside hospital. It turned out to be alveolar rhabdo. The margins were positive, uh, and of course, the forearm of a 5 year old is gonna be quite small. Uh, the, on the CT scan, the axillary nodes were clinically negative, so they came to us and we did a re-excision and a sentinel lymph node biopsy, which none of the nodes were positive and so they did not need radiation therapy to the axilla. So the, the, this is the same case and sort of the way we should be approaching it. And if you have a 5 year old with a 4 centimeter mass, even though it's less than 5 centimeters, we all know as pediatric surgeons that that's a huge mass in the forearm of a 5 year old. And to make an attempt to try to resect that is probably not gonna be worthwhile, and you should probably just do a biopsy and see what you have. But in addition, as far as updates are concerned, the one thing I wanna emphasize with Rhabdo on this update is that now we are requiring sentinel lymph node biopsies for all of these patients. So if you have a patient with a trunk or extremities rhabdomyosarcoma, you have to do a sentinel lymph node biopsy. Um, and once you do the sentinel lymph node biopsy, the, the difference in rhabdo as far as the other diseases that we're used to such as melanoma, is that you do not do a completion node dissection, you just get radiation therapy. So back to this patient, so we do the sentinel lymph node biopsy, none of the nodes are positive, so no radiation therapy. Now, the, if, since it's alveolar rhabdo, they will get chemo, they, they should get chemotherapy after you did the biopsy, and now this is, this is usually gonna be down to a 1 centimeter mass. It's very easy to resect with negative margins. The next case is a 2 year old where has an excisional biopsy, uh, again, the margins were positive. The surgeon knew, didn't know what it was and sort of knew that they would be positive and went back to do a re-excision, and that's the time of re-excision that you need to do your sentinel lymph node mapping. And in this case, the, the sentinel lymph nodes were positive and that patient received axillary radiation therapy and chemotherapy. So the lymphatic mapping is something I know we've all learned, but as far as Rhabdo, it's been one of those things that's been optional, and now it's being required. So, 40 to 50% of the biopsy nodes are positive. The clinically negative nodes may also be positive, so that's why we're doing the sentinel node biopsy, and we know that positive nodes have a worse prognosis and require radiation therapy. So we're gonna switch to non-rhabdo soft tissue sarcoma, so the, the changes in non-rhabdos, and what I want you to remember is the histological grade is now critical. We know that large tumors, you should biopsy first and try chemotherapy, but the histologic grade is what you should be paying attention to and not just the diagnosis. And, and the other difference is that we've identified sarcomas that are chemotherapy insensitive and sensitive, and that changes the treatment. So, I'm just gonna briefly want you to focus on this tumor grade part of this slide, which is the current recommended treatment for soft tissue sarcomas. If you have a low-grade tumor, all you're gonna do is resect that patient and they're only gonna get observed. There's no need for radiation or chemotherapy. If you resect a low-grade tumor and you have positive margins, they will get adjuvant radiation therapy. Uh, so this is something. That um we've shown, and I'm not gonna share all the data because of time reasons, but that is the, now the new recommended treatment. The other thing I wanna point out on here is if you have an unresectable tumor that's huge, that you want to treat that patient with preoperative radiation therapy, uh, and preoperative chemotherapy, but first, uh we were first only recommending preoperative chemo, now we're recommending both chemo and radiation. So small tumors less than 5 centimeters, uh, go ahead and resect those, try to get a negative margin, and to know that the chemosensitivity tumor, the chemo sensitive tumors are the ones that you, if you can't resect, you'd be enthusiastic about giving chemotherapy first, that's the synovial and undifferentiated. The chemo insensitive, uh, tumors, sorry, that's a type I should say insensitive, are the alveolar soft part, the malignant epithelioid clear cell, and anything else that's sort of other. Those are the ones that you as a surgeon, the radiation therapist really will be the primary treater of those, uh, disorders, and all of those are high grade, none of those are low-grade tumors. And then of course the high risk patients to get the uh preoperative radiation and chemotherapy. So when endowed biopsy, remember that the uh the Italians did a very nice study showing that a 5 centimeter tumor in a small child less than 3 years old is about the same as a 3 centimeter tumor in a in a in a. Bigger patient, so you really wanna think about more 3 centimeters as your cutoff for excision as opposed to 5 centimeters if you're dealing with a toddler. Always do a sentinel lymph node biopsy if clinically the lymph nodes are negative by imaging, and remember that they're gonna radiate the lymph node base and you do not have to do a completion node dissection. Find out what the grade of the tumor is if you're resecting a non-habdo tumor because those are the ones you can cure with surgery alone. Uh, and if you have negative margins, those patients don't need chemotherapy. The chemo insensitive tumors are the ones that you wanna be very aggressive with surgically, uh, to try to extirpate, extirpate those as much as possible. Thanks. Perfect. And Andrea, thank you very much. And uh and, and there's a uh quick question. I think we're about a half an hour behind, so we're gonna move ahead. Does anyone have a quick comment or question? Core biopsy versus open experience. You hear that, Andrea? Oh, he asked about a core biopsy. Core biopsies are acceptable. Uh, you'll, you'll need to have your pathologist check the core before the interventional radiologist is finished to make sure that it's not all necrotic, but as long as you get 3 or 4 good cores that are not necrotic, those are acceptable. Very good. Any other questions or comments? Andrea, thank you so much. I know that you probably have to go, but, uh, if you could stay, OK, if you can come back later, we'd love to have you as part of the discussion, but thank you so much for taking time out of your day. Thank you. All right.