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Dr. Sabine Irtan - Best of the Best in Pediatric Surgery 2025

Video Published 2025-03-19 Updated 2026-08-01

Timestops (4)

Study Background and Objectives

Patient Cohort and Residue Findings

MIBG Positivity and Survival Outcomes

Clinical Implications for Neuroblastoma Surgery

Topic Overview

Dr. Sabine Irtan presents findings from the HR-NBL1/SIOPEN trial examining post-surgical tumor residues in 283 children with stage 4 neuroblastoma. The study demonstrates that radiologically detected residues impact survival only when MIBG-positive: patients with MIBG-positive residues had 25-27% five-year event-free survival versus 51% for those without MIBG uptake, a difference exceeding 20%. Notably, surgeon-reported complete resection correlated poorly with imaging findings—nearly half of cases the surgeon described as complete still showed residual tumor on post-operative imaging.

Key Takeaways

Half of neuroblastoma patients had residual tumor post-surgery (<1mL median), but only MIBG-positive residues impacted survival outcomes.
MIBG-positive residues reduced 5-year EFS to 25-27% vs 51% for MIBG-negative/no residue, a >20% survival difference.
Surgeon-reported complete resection correlated poorly with imaging: 50% had radiologic residue despite operative report claiming none.
Complete macroscopic resection remains the surgical goal, but metastatic response is a critical prognostic cofactor in stage 4 disease.
Post-operative MIBG scanning identifies metabolically active residues that may guide radiotherapy strategies in high-risk neuroblastoma.

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Sabine Irtan — guest
Speaker 3 — guest

Chapters

0:00Introduction and Study Rationale — Introduction of the IPSO paper on MIBG-positive post-surgical residues in stage 4 neuroblastoma. Dr. Irtan frames the controversy around surgery's role and notes prior work by Kewarm (2020) lacked systematic radiological assessment of residues.
1:21Study Design and Patient Characteristics — Description of the HR-NBL1/SIOPEN cohort: 283 patients aged 0-18 with stage 4 neuroblastoma who had surgery and complete imaging. Median residue volume 0.27 mL; 28 patients had only microcalcifications. Residues present in half of patients, linked to IDRF in 71% and MIBG-positive in 70.5%.
2:58Survival Outcomes and External Validation — Radiological residue alone did not impact survival, but MIBG-positive residues reduced five-year EFS to 25-27% versus 51% for MIBG-negative/no residue. External validation in the full HR-NBL cohort confirmed these findings. Conclusion: complete resection remains a goal, but metastatic response is a critical cofactor.
4:59Discussion: Surgeon vs. Radiologist Assessment — Discussant notes prior COG data showed zero correlation between operative reports and imaging. Dr. Irtan confirms discrepancy: half of surgeon-reported complete resections still had imaging-detected residue, and one-third of reported residues were not visible on imaging.

Key claims

0:40Patients with high-risk neuroblastoma require chemotherapy, immunotherapy, radiotherapy, and surgery to be cured. — Sabine Irtan
0:48The role of surgery in high-risk neuroblastoma remains controversial. — Sabine Irtan
0:52Kewarm's 2020 JCO paper stated that complete macroscopic excision of the primary tumor improved both overall and event-free survival in 1,531 patients with stage 4 neuroblastoma. — Sabine Irtan
1:08Kewarm's study based success of intervention and judgment on post-operative residue on the operative report, with no systematic radiological assessment. — Sabine Irtan
1:48The study included 283 patients (108 females, 175 males) diagnosed at a median age of 35 months. — Sabine Irtan
1:57The primary tumor site was the abdomen in 95% of patients. — Sabine Irtan
2:02The tumor origin was the adrenal gland in 81% of patients. — Sabine Irtan
2:06Post-operative imaging was performed at a median of 62 days after surgery and was mainly CT scan or MRI. — Sabine Irtan
2:17Residue was present in half of the patients. — Sabine Irtan
2:20The median volume of the residue was 0.27 mL. — Sabine Irtan
2:25In 28 patients the residue was a microcalcification. — Sabine Irtan
2:29Excluding patients with microcalcifications, the median residue volume was 1.04 mL. — Sabine Irtan
2:29Only 11% of patients had a residue of more than 5 mL. — Sabine Irtan
2:40The residue was linked to the presence of IDRF in 71% of patients. — Sabine Irtan
2:40MIBG positivity of the residue was present in 70.5% of patients with a post-operative MIBG available. — Sabine Irtan
2:58Radiological post-operative residue showed no impact on event-free survival and overall survival. — Sabine Irtan
3:08MIBG-positive residue had an impact on event-free survival and overall survival with a difference of more than 20% of survival. — Sabine Irtan
3:20Patients with MIBG-positive residue had 25% and 27% five-year event-free survival. — Sabine Irtan
3:20Patients with no residue or no MIBG-positive residue had 51% five-year event-free survival. — Sabine Irtan
3:20The survival difference between MIBG-positive and MIBG-negative residue groups was confirmed for five-year overall survival. — Sabine Irtan
3:45External validation on the entire high-risk neuroblastoma cohort in patients with stage 4 neuroblastoma who had surgery and post-surgical MIBG evaluation confirmed the results. — Sabine Irtan
4:04The survival difference between MIBG-positive residue and no/MIBG-negative residue was present even for patients with partial or minimal metastatic response, with a 10% survival difference. — Sabine Irtan
4:26Half of patients operated on in expert centers have a tumor residue objectively identified on post-operative images of less than 1 mL. — Sabine Irtan
4:36The residue was MIBG-positive in around 20% of patients. — Sabine Irtan
4:40Radiologically detected post-operative tumor residues impact outcomes only if active disease was demonstrated through post-operative MIBG scanning. — Sabine Irtan
4:54Complete resection should be maintained as a major surgical goal. — Sabine Irtan
4:59Metastatic response is an important prognostic cofactor. — Sabine Irtan
5:19In COG data, there was zero correlation between what the surgeon said they resected and what was actually present on post-operative imaging. — Speaker 3
5:43For patients where the surgeon reported leaving nothing, almost half had residue on post-operative images. — Sabine Irtan
5:57For patients where the surgeon reported leaving residue, imaging found residue in two-thirds and no residue in one-third. — Sabine Irtan

Open questions

How should radiotherapy strategies be modified based on MIBG-positive post-operative residues?
What is the optimal approach when surgeon-reported resection status conflicts with imaging findings?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

MIBG-Positive Residue Predicts Survival in Stage 4 Neuroblastoma, Radiological Residue Alone Does Not

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Core brief · AI-written, human-reviewed

What This Study Establishes

In 283 patients with stage 4 high-risk neuroblastoma treated on the HR-NBL1/SIOPEN protocol, post-operative tumor residue detected on imaging had no impact on event-free or overall survival unless that residue was MIBG-positive 2:58. MIBG-positive residue reduced five-year event-free survival to 25-27%, compared to 51% in patients with no residue or MIBG-negative residue 3:20 3:20. The survival difference exceeded 20% and was confirmed in external validation 3:08 3:45.

Half of patients operated in expert centers had radiologically identified residue, with a median volume of 0.27 mL (1.04 mL excluding microcalcifications) 2:17 2:20 2:29. Only 11% had residue exceeding 5 mL 2:29. MIBG positivity was present in approximately 20% of patients with residue 4:36. The residue was linked to image-defined risk factors in 71% of cases 2:40.

The Surgeon-Radiologist Discrepancy

Surgeon-reported complete resection correlated poorly with imaging: nearly half of patients whose surgeons reported leaving nothing had residue on post-operative imaging 5:43. Conversely, when surgeons reported leaving residue, imaging confirmed it in two-thirds but found none in one-third 5:57. This discrepancy—also documented in COG data showing zero correlation between operative reports and imaging 5:19—argues against relying on operative assessment alone.

Clinical Implications

Radiologically detected postoperative tumor residues impact outcomes only if active disease was demonstrated through post-operative MIBG scanning 2:58. This finding may inform radiotherapy field design: MIBG-negative residue likely represents fibrotic or necrotic tissue without prognostic significance. Complete resection remains the surgical goal 4:54, but metastatic response is a critical cofactor 4:59. The survival difference between MIBG-positive and MIBG-negative residue persisted even in patients with partial or minimal metastatic response, with a 10% survival difference 4:04.

What Remains Unsettled

Whether attempting more aggressive resection to eliminate MIBG-positive residue improves outcomes, or whether MIBG positivity simply marks biologically aggressive disease resistant to induction therapy, is not addressed by this observational study. The role of post-operative MIBG scanning in routine risk stratification and radiotherapy planning requires prospective validation.

Takeaways from this story

MIBG-positive residue reduces 5-year EFS to 25-27% vs 51% for MIBG-negative/no residue—a >20% survival difference.
Radiological residue without MIBG positivity does not impact survival, suggesting fibrotic rather than viable tumor.
Surgeon-reported resection status correlates poorly with imaging: half of 'complete' resections have radiological residue.
Median residue volume in expert centers is 1.04 mL; only 11% exceed 5 mL, yet MIBG positivity occurs in ~20%.

MIBG-Positive Residue Predicts Survival in Stage 4 Neuroblastoma After Surgery

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Core brief · AI-written, human-reviewed

What post-operative imaging reveals about neuroblastoma residue

In high-risk neuroblastoma, complete surgical resection has been considered a survival determinant, but that conclusion rested on surgeon-reported operative findings rather than systematic imaging 0:52 1:08. This prospective study of 283 children with stage 4 disease (median age 35 months, 95% abdominal primaries) performed post-operative CT or MRI at a median of 62 days after resection 1:48 1:57 2:06. Half had radiologically detectable residue; the median volume was 0.27 mL, and excluding microcalcifications, 1.04 mL 2:17 2:20 2:29. Only 11% had residue exceeding 5 mL 2:29.

Radiological residue alone showed no impact on event-free or overall survival 2:58. MIBG positivity of the residue, however, stratified outcomes sharply: patients with MIBG-positive residue had 25–27% five-year event-free survival versus 51% for those with no residue or MIBG-negative residue—a survival difference exceeding 20% 3:08 3:20 3:20. This held true even in patients with partial or minimal metastatic response, where MIBG-positive residue still conferred a 10% survival decrement 4:04. External validation in the broader high-risk cohort confirmed the finding 3:45.

The surgeon–radiologist discrepancy

When operative reports were compared to imaging, surgeon-reported complete resection correlated poorly with radiological findings: nearly half of "nothing left" cases still showed residue on imaging, and one-third of reported residues were not visible radiologically 5:43 5:57. One of the discussants noted that for patients where the surgeon reported leaving nothing, almost half still had something visible on post-operative images.

Clinical implications

"Radiological detected postoperative tumor residues impact outcomes only if active disease was demonstrated through post-operative MIBG scanning, which could have an impact on future radiotherapy strategies" [q5]. Complete resection remains the surgical goal, but metastatic response is a critical cofactor 4:54 4:59. The distinction between metabolically active and inactive residue—not simply its presence—determines prognosis and may guide radiotherapy planning.

Takeaways from this story

MIBG-positive residue after neuroblastoma resection predicts >20% lower five-year survival; MIBG-negative residue does not affect outcomes.
Half of resections leave radiological residue (median 0.27 mL); only MIBG positivity, not size, determines prognosis.
Surgeon-reported complete resection correlates poorly with imaging: half of "complete" cases show residue on post-op CT/MRI.
Post-operative MIBG scanning may guide radiotherapy targeting by identifying metabolically active residual disease.

Keywords

neuroblastoma stage 4 neuroblastoma high-risk neuroblastoma surgery complete macroscopic excision radiotherapy chemotherapy immunotherapy CT scan MRI MIBG scanning Sorbonne University Trousseau Hospital COG

Hashtags

#pediatricsurgery #neuroblastoma #pediatriconcology #tumorsurgery #MIGscanning #cancerresearch #childrensurgery #MIBGImaging #SurgicalResection

Transcript

All right, we're gonna go on to uh the next paper from IPSO, uh, Doctor Sabine Utan, uh, and only MIBG postoperative. Uh, uh, MIG positive post-surgery residues impact on outcomes in patients with stage 4 neuroblastoma results from the HRNBL1 yapen trial. Thanks for the opportunity to present this work entitled Only a Mbei Positive Post-surger Residues Impact on Outcomes in Patients with Stage 4 neuroblastoma Results from the high-risk neuroblastoma 1 yopan trial. Patients with er neuroblastoma need a heavy burden of treatment associating chemotherapy, immunotherapy, radiotherapy, and surgery to be cured. The role of surgery in this context remains controversial. In his paper published in GCO in 2020, Kewarm stated that complete macroscopic excision of the primary tumor improved both overall and even free survival in a cohort of 1,531 patients with stage 4 neuroblastoma. The success of the intervention and judgment on the post operative residue was based on the operative report. No systematic radiological assessment of residue has been performed so far. The aim of the study was to evaluate the role of post-surgical radiologically identified tumor residues in children between 0 and 18 years with the iris neuroblastoma ENSS stage 4 treated according to the iris neuroblastoma once I open protocol, who had surgery of the primary tumor and available images at diagnosis, preoperative, and postoperative assessment. We included 283 patients, 108 females, 175 males who had a diagnosis at a median age of 35 months. The primary tumor site was the abdomen in 95. and the tumor origin was the adrenal gland in 81%. The postoperative imaging was performed at a median of 62 days after surgery and was mainly a CT scan or MRI. The residue was present in half of the patients. The median volume of the residue was 0.27 mL. The residue was in 28 patients a microcalcification. If we exclude these patients, the median residue volume was 1.04 mL, and only 11% of the patients had a residue of more than 5 mL. The residue was linked to the presence of IDRF in 71% of patients, and the MIBG positivity of the residue was present in 70.5% of patients with a post-operative MIBG available. We showed no impact of the radiological postoperative residue on EFS and OS. But we had an impact on the MIBG positive residue on EFS and OS with a difference of more than 20% of survival. Patients who had a MBGO residue had 25 and 27% of 5 year EFS, whereas patients with no residue of no MBGO residue at 51% of 5-year EFS and this difference was still true for the 5-year OS. We did an external validation of this result on the entire high risk neuroblastoma cohort in patients with stage 4 neuroblastoma who had a surgery and a post-surgical MIBG evaluation available, and we confirmed these results, especially the patient has a complete response of the metastasis. But this, uh, difference between patients with MIBG positive residue and patients with no residue or no MIBG positive residue. was still present for patients with a partial or minimal response with a 10% survival difference. To conclude, half of the patients operated on expert centers have a tumor residue objectively identified on postoperative images of less than 1 mL. The residue was a MIBG on around 20% of patients. Radiological detected postoperative tumor residues impact outcomes only if active disease was demonstrated through post-operative MIBG scanning, which could have an impact on future radiotherapy strategies. We confirmed that complete resection should be maintained as a major surgical goal. However, metastatic response is an important prognostic cofactor. Thank you for that presentation. Great paper. Um, it continues this long discussion about how important is surgical resection in neuroblastoma. I like this paper because it confirms my bias that it's important. Um, but, uh, when we looked at this with COG data, we looked At the operative reports compared to the imaging and found that there was zero correlation between what the surgeon said they resected and what was actually present on post-operative imaging. Uh, did you actually make that comparison for this study? I think it would be, uh, it, it would be interesting to know. Yeah, yeah, we did that. Thank you very much for the question because it's an important question, and we showed that for the patients. For whom the surgeon said, I left nothing. Uh, almost half of the patients had still something on the postoperative images, and for those patients, the surgeon said, I left something, we found something in 2/3 of the patients and not in 1/3, and 1/3 of the patients and no residue on the on the images, so I completely agree that Between what the surgeon said and what the radiologist says, there's a discrepancy that uh can impact also uh the, the question of should we let a residue or not. Perfect. Um, well, thank you so much for this, uh, presentation. Thank you for, I, I failed to mention, uh, that you're joining us from, uh, Sorbonne University in Trousseau Hospital in Paris, France. So thank you for, for joining us from there. Great presentation.

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