Background and Aims

Background:

In some conditions the sequence of local treatment in patients with abdominal high-risk neuroblastoma differs for various reasons. As consequence, some patients have to undergo surgery after abdominal irradiation. Aim of this study was to analyse the course of such patients from a surgical standpoint.

Methods

Methods:

We retrospectively analyzed data of patients with high-risk abdominal neuroblastoma who underwent surgery at our institution between 08/2006 and 10/2019 after having been irradiated beforehand. Data evaluation included patients’ and tumor characteristics, surgical results and oncological outcome.

Results

Results:

We identified 12 patients meeting the inclusion criteria. All patients had received irradiation at other institutions before being referred to us. Irradiation had been applied because i) tumors had been judged as unresectable (n=3), ii) in cases of incomplete resections (n=8), or iii) in case of relapses. Median age at surgery was 5.9 years (1.4- 14.7). Gross Total Resection was accomplished in 11/12 patients. Major surgical complications occurred in 9 patients: vascular reconstructions including patching or vascular replacement were necessary in 9 patients, one patient had to undergo autotransplantation of a kidney, in that same patient the other kidney lost function because of arterial stenosis and had to be removed. After a median follow-up of 2.5 years (0.4– 14.1), 10 children are alive without evidence of disease, one patient is under treatment for tumor recurrence and 1 patient died of disease. Histological workup revealed vital tumor compounds in 9/12 patients with a median tumor vitality rate of 70% (0-90).

Conclusions

Conclusions:

Children with abdominal high-risk tumors judged to be unresectable should receive a central surgical review before radiotherapy is applied as the only planned local therapy. Whenever possible, surgery should precede irradiation within the concept of local therapy in affected patients.

Background and Aims

An abdominal approach alone is often not sufficient for resection of neuroblastic tumors, because in complex cases these tumors are often extending into the thoracic compartment. Literature addressing the thoraco-abdominal approach for resection of abdominal neuroblastoma in children is scarce. The aim of this study was to evaluate the efficacy of this approach based on our experience in a reference pediatric onco-surgical center.

Methods

Between March 2003 and December 2020 eighteen patients (12 female, 6 male) with neuroblastic tumors (12 neuroblastomas, 5 ganglioneuroblastomas, 1 ganglioneuroma) underwent tumor resection through a two-cavity approach. A retrospective review of patient’s records was carried out.

Results

The median age at operation was 48 months (5-132). The surgical access was realized via thoraco-abdominal approach (n=6), transverse laparotomy with incision of the diaphragm (n=9), transverse laparotomy with lateral thoracotomy (n=2), and transverse laparotomy with thoracoscopy (n=1). Gross total resection (GTR) was achieved in 13 patients, a near-GTR (>95%) in 4 cases and an incomplete resection (>90%) in 1 case. The median duration of surgery was 307.5 minutes (99-990), the median intraoperative blood loss was 62 ml/kg (12.5-180). Median length of stay on intensive care was 4.6 days (1-14). Median length of hospital stay was 16.5 days (6-60). Postoperative complications occurred in 8 patients, 2 patients required surgical reintervention (1 reconstruction of the aorta,1 surgical hemostasis).

Conclusions

The two-cavity approach for resection of neuroblastic tumors in children is a feasible technique with no added morbidity, which allows complete tumor resection in complex cases and avoids two separate operations with equal results in selected cases.

Background and Aims

High-risk neuroblastoma (HRN) presents a therapeutic challenge despite multimodal treatment. Management protocols recommend surgery soon after completion of induction chemotherapy (surgery according to protocol; PS). In our centre, surgery is postponed if there is significant risk of damage to the kidney (delayed surgery; DS). The aim of our study was to review the surgical management of HRN in a UK regional centre and assess whether DS impacts long-term outcomes.

Methods

We conducted a retrospective review of consecutive HRN patients that underwent surgery at a single quaternary paediatric oncology unit between January 2008 and December 2019. We collected demographic and clinical data, including details of surgical management. Analysis was performed to determine whether DS affected peri-operative outcomes, as well event-free survival (EFS) and overall survival (OS).

Results

A total of 84 HRN children (35 males; 42%) underwent surgery in our centre. Median age (range) at diagnosis was 2.5 (1.5-4.3) years. Tumour resection was performed within 5 weeks following completion of induction chemotherapy in 49 patients (58%; PS group) and was delayed in 35 patients (42%); 13 due to poor response (15%; excluded) and 22 due to risk of renal injury (27%; DS group). Median time (range) from completion of chemotherapy to surgery in the DS group was 19 (8-79) weeks (p<0.0001 vs. PS). Complete tumour resection was achieved in 20 DS patients (91%; p=0.7 vs. PS) with no requirement for unplanned nephrectomy, and no differences in intra/post-operative complications between groups. EFS in DS patients was 59% and OS was 64% and were similar to those in the PS group [EFS: 61%, OR (95%CI): 0.9 (0.3-2.5), p=0.9 vs. DS; OS: 71%, OR (95%CI): 0.6 (0.2-1.9), p=0.4].

Conclusions

Surgery for HRN can be delayed to mitigate the risk of intra-operative renal injury with no effect on resectability, peri-operative and long-term outcomes.

Background and Aims

To evaluate the impact of initial management in outcomes for low- and intermediate-risk neuroblastoma at our centre.

Methods

Retrospective data over a 10-year period (2009-2019). We analysed patients managed through three different groups - observation, primary surgery or surgery following chemotherapy. Primary outcomes included overall survival (OS) and event free survival (EFS) over a 5-year follow up period. Secondary outcomes measured were surgical complications.

Results

A total of 43 patients were identified as low (32 patients) and intermediate (11 patients) risk neuroblastoma (24 males, 19 females). The median age at diagnosis was 5 months (range 0 to 98 months). Overall survival at follow up was 95% and event-free survival was 72%. A total of 28 (65%) operations were performed as both primary surgery and surgery following chemotherapy, with 12 (43%) post-operative complications observed in 11 patients.

The observation group were all patients with low risk neuroblastoma. There were 10 (31%) patients in this group. Three went on to require further intervention and 1 neonate died.

Primary surgery was performed in a total of 16 patients, 12 patients (38%) with low risk and 4 patients (36%) with intermediate risk neuroblastoma. There was an overall 50% surgical complication rate. All were disease free at follow up.

Chemotherapy was commenced in 17 patients, 10 (31%) low risk and 7 (63%) intermediate risk neuroblastoma. Eleven patients had surgery, all but one patient had ongoing Image Defined Risk Factors (IDRF). Three (17%) patients had surgical complications. Sixteen patients were in remission and one died during follow up.

Conclusions

Patients with low and intermediate risk neuroblastoma have excellent prognosis. Patients with low risk neuroblastoma were almost equally divided in to the three initial treatment arms. Primary surgical intervention was associated with a higher rate of immediate surgical morbidity.