Maintaining oncologic integrity with minimally invasive resection of pediatric embryonal tumors

• Published in: Surgery 2018-08, Vol.164 (2), p.333-343
• Main Authors: Phelps, Hannah M., Ayers, Gregory D., Ndolo, Josephine M., Dietrich, Hannah L., Watson, Katherine D., Hilmes, Melissa A., Lovvorn, Harold N.
• Format: Article
• Language: English
• Subjects: Child, Preschool; Early Diagnosis; Female; Humans; Infant; Male; Minimally Invasive Surgical Procedures; Neoadjuvant Therapy; Neoplasms, Germ Cell and Embryonal - diagnostic imaging; Neoplasms, Germ Cell and Embryonal - mortality; Neoplasms, Germ Cell and Embryonal - surgery; Neuroblastoma - mortality; Neuroblastoma - surgery; Registries; Tennessee - epidemiology; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Prenatal
• ISSN: 0039-6060; 1532-7361
• DOI: 10.1016/j.surg.2018.03.020

Embryonal tumors arise typically in infants and young children and are often massive at presentation. Operative resection is a cornerstone in the multimodal treatment of embryonal tumors but potentially disrupts therapeutic timelines. When used appropriately, minimally invasive surgery can minimize treatment delays. The oncologic integrity and safety attainable with minimally invasive resection of embryonal tumors, however, remains controversial. Query of the Vanderbilt Cancer Registry identified all children treated for intracavitary, embryonal tumors during a 15-year period. Tumors were assessed radiographically to measure volume (mL) and image-defined risk factors (neuroblastic tumors only) at time of diagnosis, and at preresection and postresection. Patient and tumor characteristics, perioperative details, and oncologic outcomes were compared between minimally invasive surgery and open resection of tumors of comparable size. A total of 202 patients were treated for 206 intracavitary embryonal tumors, of which 178 were resected either open (n = 152, 85%) or with minimally invasive surgery (n = 26, 15%). The 5-year, relapse-free, and overall survival were not significantly different after minimally invasive surgery or open resection of tumors having a volume less than 100 mL, corresponding to the largest resected with minimally invasive surgery (P = .249 and P = .124, respectively). No difference in margin status or lymph node sampling between the 2 operative approaches was detected (p = .333 and p = .070, respectively). Advantages associated with minimally invasive surgery were decreased blood loss (P < .001), decreased operating time (P = .002), and shorter hospital stay (P < .001). Characteristically, minimally invasive surgery was used for smaller volume and earlier stage neuroblastic tumors without image-defined risk factors. When selected appropriately, minimally invasive resection of pediatric embryonal tumors, particularly neuroblastic tumors, provides acceptable oncologic integrity. Large tumor volume, small patient size, and image-defined risk factors may limit the broader applicability of minimally invasive surgery.