10.1245/ASO.2004.04.021
Annals of Surgical Oncology 11:340-343 (2004)
© 2004 Society of Surgical Oncology
Minimally Invasive Surgery in Pediatric Cancer Patients
William W. Spurbeck, MD,
Andrew M. Davidoff, MD,
Thom E. Lobe, MD,
Bhaskar N. Rao, MD,
Kurt P. Schropp, MD and
Stephen J. Shochat, MD
From the Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee; and Department of Surgery, University of Tennessee College of Medicine, Memphis, Tennessee.
Correspondence: Address correspondence and reprint requests to: William W. Spurbeck, MD, 1095 Island Place East, Memphis, TN 38103; E-mail: drspurbeck{at}yahoo.com
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ABSTRACT
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Background: The specific use of minimally invasive surgery (MIS) in pediatric cancer patients is limited. We evaluated the 5-year experience at a single institution with MIS in children with malignancies.
Methods: A retrospective review was undertaken of all MIS performed between November 1995 and October 2000.
Results: A total of 101 pediatric oncology patients underwent 113 MIS procedures—64 laparoscopic (57%) and 49 thoracoscopic (43%)—during this period. Laparoscopy was performed for diagnostic purposes in 27 cases (42%) and was successful in 25 (93%) cases. Laparoscopic tumor resection was performed in seven cases (11%). Thirty additional laparoscopic procedures (47%) were attempted for complications of the malignancy or its treatment. Four of these cases were converted to open laparotomies. Indications for thoracoscopy included the evaluation of a mediastinal mass (n = 7) or biopsy or resection of pulmonary lesions (metastatic, n = 31; infectious, n = 9). Fourteen cases (29%) had to be converted to open thoracotomy procedures, generally because of the inability to localize a lesion. The other 35 procedures were successful. The overall complication rate was 5%. No trocar site recurrences or infections were observed.
Conclusions: We conclude that MIS in pediatric cancer patients is a safe and effective diagnostic modality. The role of MIS for primary tumor resection remains to be defined.
Key Words: Thoracoscopy • Laparoscopy • Minimally invasive • Pediatric malignancy
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INTRODUCTION
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Minimally invasive surgery (MIS) in the adult population is well established for many operative procedures, including those involving the diagnosis, treatment, and staging of malignancies. Use of these minimally invasive techniques in the pediatric population has lagged behind, especially in pediatric cancer patients. The reasons are diverse and include concerns over loss of tactile ability, familiarity with advanced endoscopic techniques, and lack of equipment appropriate to the pediatric population. Studies suggest that MIS results in an overall decrease in pain and need for postoperative narcotics, as well as decreased morbidity with shorter hospital stays and better cosmesis.1 However, no prospective randomized studies have investigated the utility of MIS in pediatric cancer patients relative to standard open techniques.2
MIS in children is a rapidly expanding field with many diagnostic and therapeutic indications, with utility not only as an adjuvant for patients undergoing cancer therapy, but also as a primary treatment of malignancy. Both laparoscopy and thoracoscopy have been well described and have been proven effective in the treatment of many nonmalignant states, including appendectomy, fundoplication, cholecystectomy, location of nonpalpable testes, and laparoscopic pull-through for Hirschsprung’s disease and imperforate anus. Although its potential utility in the adult population continues to be described for the treatment of colon, gastric, and ovarian cancers, data are lacking concerning solid tumor resection in the pediatric population. Despite this, there is sufficient evidence that MIS can be an effective approach to the biopsy of solid tumors for tissue diagnosis, determination of resectability and staging, evaluation of metastatic or recurrent disease, second-look operations, and diagnosis of infectious complications.3 Solid-tumor resection is not yet supported in most cases. The purpose of this retrospective review was to evaluate the 5-year experience at a single institution with MIS in children with malignancy.
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MATERIALS AND METHODS
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This study involved the retrospective analysis of all minimally invasive operations, defined as all laparoscopic and thoracoscopic cases, performed between November 1995 and October 2000 at St. Jude Children’s Research Hospital. Patient records were reviewed, and data were collected, including patient age, sex, operative indications and procedure, conversion to open procedure, accuracy, and complications.
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RESULTS
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A total of 101 pediatric oncology patients underwent 113 MIS procedures—64 laparoscopic (57%) and 49 thoracoscopic (43%)—during this period. The patient population consisted of 42 boys and 59 girls, with a mean age of 12.6 years (range, 6 months to 27 years).
Laparoscopy was performed for diagnostic purposes in 27 cases (42%) and was successful in 25 (93%) cases. Indications for diagnostic laparoscopy included biopsy of a new abdominal mass (n = 10), identification of metastatic or recurrent disease (n = 15), and evaluation for resectability (n = 2). In the 25 cases in which biopsies were attempted, a tissue diagnosis was obtained in 23 cases (92%; Table 1). Evaluation of resectability was successful in the two remaining cases. Nondiagnostic material was obtained in one case of an ovarian biopsy, and another procedure was converted to a laparotomy because of adhesions.
Laparoscopic tumor resection was performed in seven cases (11%), including splenectomy (n = 2), oophorectomy (n = 2), adrenalectomy (n = 2), and partial hepatectomy (n = 1; Table 2). Thirty additional laparoscopic procedures (47%) were attempted for complications of the malignancy or its treatment. These included cholecystectomy (n = 11), oophoropexy (n = 6), Nissen fundoplication (n = 6), splenic cyst marsupialization (n = 1), lysis of adhesions (n = 2), placement of a gastric feeding tube (n = 2), and evaluation of pneumoperitoneum (n = 2). No specific site of perforation was identified in either case (Table 3).
Forty-six patients underwent 49 thoracoscopic procedures. Indications for thoracoscopy included the evaluation of a mediastinal mass (n = 7) or biopsy or resection of pulmonary lesions with the endoscopic stapler (metastatic, n = 31; infectious, n = 9). Additional procedures were performed to correct a persistent air leak (n = 1) and chyle leak (n = 1). Fourteen cases (29%) had to be converted to open thoracotomy procedures, generally because of inability to localize a lesion. The other 35 procedures were successful; diagnostic material was obtained (n = 26), metastases were resected (n = 7), or a leak was stopped (n = 2; Table 4).
There were no mortalities associated with either laparoscopy or thoracoscopy. There were three laparoscopic (bowel perforation, n = 1; liver hematoma, n = 2) and three thoracoscopic (intraoperative desaturation, n = 2; bleeding, n = 1) complications, for an overall complication rate of 5%. No trocar site recurrences or infections were observed. Four laparoscopic cases were converted to open laparotomies. The reasons for conversion to laparotomy included subcapsular bleeding and liver hematoma in a patient with chronic myelogenous leukemia after cholecystectomy for acute cholecystitis. The second patient was diagnosed as having a pineal blastoma and gastroesophageal reflux disease–associated aspiration pneumonia and required Nissen fundoplication. This case was converted to open laparotomy secondary to poor visualization resulting from a ventriculoperitoneal shunt and hepatomegaly. Another patient undergoing biopsy to investigate recurrence of mesothelioma was converted secondary to adhesions. Finally, an enterotomy resulted after attempted enterolysis in a patient with recurrent bowel obstructions after previous surgical resection of a Wilms’ tumor. The reasons for conversion in the thoracoscopy group to open thoracotomy included an inability to localize or visualize the lesion (n = 8); adhesions, including one case of hemorrhage caused by adhesions to the anterior chest wall (n = 3); an inadequate resection specimen (n = 2); and decreased intraoperative saturations (n = 1). None of the cases converted to open thoracotomy because of poor localization involved preoperative needle localization, nor was there a consistent pattern to their location within the lung.
In all laparoscopic and thoracoscopic cases, sufficient material was obtained for diagnosis except for the case that involved an ovarian biopsy. All material obtained was adequate for subsequent cytogenetic, immunohistochemical, or other pathologic study, and there was no effect of biopsy techniques on the final pathologic evaluation. Postoperative ileus and atelectasis were minimal. The average time to begin oral intake after surgery averaged <48 hours, and only one patient took more than 3 days to have a return of bowel function.
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DISCUSSION
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The biopsy of an intra-abdominal mass in a child is an important initial step in the multimodality approach to many pediatric solid tumors. MIS allows direct visualization of the tissue, visualizes hemostasis, and reveals more anatomical details. Combined with the fact that many of these children will perhaps be undergoing multiple procedures, MIS theoretically allows for minimal inflammation, fewer adhesions, decreased pain, and quicker recovery, facilitating subsequent initiation of chemotherapy and second-look or delayed primary surgery. Most of these data are extrapolated from adult studies and a few small series in children, identifying the need for more data in the pediatric population.
Pediatric malignancies are often sensitive to chemotherapy and require only initial tissue biopsy for diagnosis as part of a multidisciplinary approach to their treatment. Excellent results in diagnostic accuracy with laparoscopic or thoracoscopic biopsy techniques have been reported for a variety of malignancies. Points of debate still revolve around the excision of solid organ malignancies, with the potential for tumor spill and port-site recurrences.4 In addition, questions have been raised concerning the potential alteration of the pathologic margins and the subsequent impairment of appropriate histological evaluation of tumor specimens after morcellation.
Reasons that many surgeons have been slow to adopt the minimally invasive approach to children include questionable long-term benefits, higher costs, technical difficulties, and questionable increased complication rates. In a poll by Holcomb (G.W. Holcomb III, MD, unpublished data, 1999), leaders in the field of pediatric surgical oncology and advanced endoscopy investigated the roles of both laparoscopy and thoracoscopy in the pediatric surgery population. There was a consensus that both laparoscopic and thoracoscopic biopsy were safe and effective for tissue diagnosis of intra-abdominal and thoracic lesions. This included excisional biopsy of peripheral lung nodules for the evaluation and treatment of infection or metastatic disease. An exception to this was in patients with metastatic osteogenic sarcoma. Radiographic evaluation is known to underestimate the number of lesions, thus necessitating tactile evaluation.5 Most patients with metastatic osteogenic sarcoma are not believed to be good candidates for therapeutic thoracoscopic resection and require open thoracotomy, which we still recommend for initial exploration. An additional exception is resectable abdominal Wilms’ tumor. Biopsy of resectable Wilms’ tumor with spillage results in upstaging, which necessitates more aggressive adjuvant therapy.
The diagnostic accuracy of MIS in tissue diagnosis is reportedly high. For example, the diagnostic accuracy in thoracoscopic evaluation of mediastinal masses ranges from 86% to 100%.6 The accuracy rate at this institution for laparoscopic tumor biopsy was comparable, at 93%. Eleven percent of cases were performed for solid tumor removal without complications, including adrenalectomy, splenectomy, oophorectomy, and partial hepatectomy. Thirty additional procedures were performed for complications of the malignancy or its treatment, including cholecystectomy, oophoropexy, Nissen fundoplication, splenic cyst marsupialization, enterolysis, feeding-tube placement, and evaluation of pneumoperitoneum. There was a very small conversion rate to open laparotomy; only four cases were converted to open procedures, as described previously.
The mediastinum is a common location for intrathoracic masses in children. Primary pulmonary malignancies are rare in children and more often involve metastatic lesions from a distant primary tumor, infection, or inflammation. Thoracoscopy allowed the evaluation of both parenchymal and mediastinal lesions. In both the evaluation and biopsy of mediastinal and pulmonary lesions, preoperative localization and patient positioning are important issues. Gravity should be used to allow the lung and adjacent structures to fall away from the operative site, because a double-lumen endotracheal tube cannot as easily be used in smaller children. Consideration should also be given before biopsy to aspiration of any suspicious lesions to rule out vascular structures. Preoperative needle localization allows the identification of a number of small primary or metastatic lesions throughout the body that are difficult to localize in the absence of palpation. It has been shown in pediatric cancer patients that image-guided needle localization is effective in the identification of these small lesions that would otherwise easily be missed or identified only after extensive dissection. A previous study at this institution that localized small pediatric tumors, most of which were <1 cm3, demonstrated success in localization and biopsy in all cases at many different anatomical sites.7 The combination of thoracoscopy and needle localization allows the resection of small nonpalpable pulmonary lesions not visible through the thoracoscope, thus avoiding the morbidity associated with open thoracotomy. In addition, needle localization provides identification of lesions despite patient positional changes or lung deflation.
Our overall complication rate was low, at 5%, and was limited to a bowel perforation and two liver hematomas in the laparoscopic group. The thoracoscopic complications included two desaturations and one hemorrhage that necessitated open thoracotomy. Our data demonstrate that both laparoscopy and thoracoscopy are effective methods of obtaining a tissue diagnosis and are in some cases therapeutic, with an overall low rate of conversion to an open procedure. A higher rate of conversion, mainly due to an inability to localize the lesion, was noted in the thoracoscopic group. Although our conversion rate was relatively high, at 29%, none of these cases involved needle localization. We are increasingly using needle localization and gaining more experience with it over time; as this has occurred, our conversion rate has decreased significantly. We anticipate greater utility in the future for thoracoscopy as needle-localizing techniques improve the identification of small pulmonary lesions. From this experience, we conclude that MIS in pediatric cancer patients is not only less invasive, but also safe and effective as a diagnostic modality. The role of MIS for primary tumor resection remains to be defined.
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ACKNOWLEDGMENTS
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The acknowledgments are available online in the fulltext version at www.annalssurgicaloncology.org. They are not available in the PDF version.
Supported by the American Lebanese Syrian Associated Charities.
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FOOTNOTES
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Although minimally invasive surgery (MIS) in children has become widely accepted, its specific use in pediatric cancer patients is limited. From our experience, we conclude that MIS in pediatric cancer patients is a safe and effective diagnostic modality. The role of MIS for primary tumor resection remains to be defined.
Received for publication April 23, 2003.
Accepted for publication November 14, 2003.
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REFERENCES
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- Chen MK, Schropp KP, Lobe TE. Complications of minimal-access surgery in children. J Pediatr Surg 1996; 31: 1161–5.[CrossRef][Medline]
- Ehrlich PF, Newman KD, Haase GM, Lobe TE, Wiener ES, Holcomb GW. Lessons learned from a failed multi-institutional randomized controlled study. J Pediatr Surg 2002; 37: 431–6.[CrossRef][Medline]
- Holcomb GW, Tomita SS, Haase GM, et al. Minimally invasive surgery in children with cancer. Cancer 1995; 76: 121–8.[Medline]
- Sartorelli KH, Partrick D, Meagher DP. Port-site recurrence after thoracoscopic resection of pulmonary metastasis owing to osteogenic sarcoma. J Pediatr Surg 1996; 31: 1443–4.[Medline]
- Saenz NC, Conlon KCP, Aronson DC, LaQuaglia MP. The application of minimal access procedures in infants, children, and young adults with pediatric malignancies. J Laparoendosc Adv Surg Tech A 1997; 7: 289–94.[Medline]
- Holcomb GW. Minimally invasive surgery for solid tumors. Semin Surg Oncol 1999; 16: 184–92.[Medline]
- Hardaway BW, Hoffer FA, Rao BN. Needle localization of small pediatric tumors for surgical biopsy. Pediatr Radiol 2000; 30: 318–22.[Medline]
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ABSTRACT
INTRODUCTION
