*Contributed equally
Laparoscopic surgery for malignant solid tumors is still in the stage of clinical exploration. Neuroblastoma is a common solid tumor in children. The present study discussed significance and feasibility of complete resection of stage III neuroblastoma by laparoscopic surgery and its safety and effectiveness was compared with traditional surgery. For children suffering from neuroblastoma with large tumor volume and vascular invasion, preoperative chemotherapy can be given and minimally invasive laparoscopic surgery can be one option to be considered when the tumor volume is <6 cm. During the operation, the tumor tissue can be removed by segmental resection and the removal of as much tumor tissue as possible is an important factor in improving the prognosis. Laparoscopic minimally invasive surgery is associated with minimal surgical trauma and quick recovery of patients, and children can receive postoperative chemotherapy as early as possible, which is conducive to good recovery. Basically, the prerequisite and requirements for performing this operation are professional laparoscopic skills and an experienced team.
Neuroblastoma is the most common solid tumor in children (
At present, there are few literature reports on the successful treatment of stage III-IV neuroblastoma by laparoscopy. The present study discussed the significance and feasibility of complete resection of stage III neuroblastoma by laparoscopic surgery while comparing its safety and effectiveness with traditional surgery.
A 4-year-old girl was admitted to the First Affiliated Hospital of Xiamen University on 26 February 2021 with a 6-month history of right intercostal pain. Physical examination revealed that right abdominal distention and a hard mass could be palpable under the right lower costa. Abdominal enhancement computed tomography scan (CT) on 1 March 2021 had revealed a large malignant mass in the right retroperitoneal and adrenal area, with a size of 8.9x6.5x4.6 cm. The possibility of neuroblastoma was taken into consideration; it had caused an serious effect on the inferior vena cava, bilateral renal veins and right renal artery and multiple enlarged lymph nodes retroperitoneally (
The procedure was as follows (
Laparoscopic surgery for malignant solid tumors in children is still in the stage of clinical exploration. The adrenal gland is the most common site of neurogenic tumors in children. Due to the deep anatomical location and narrow space of adrenal tumors, traditional laparotomy requires a large incision and is truly difficult to expose. Laparoscopic technology has a broad surgical field which can accurately determine the location of the tumor and the relationship with the surrounding tissues; surgical trauma is small, postoperative recovery is fast and patients can also receive chemotherapy and radiotherapy earlier following surgery compared with conventional surgery and thus is gradually gaining favor among surgeons. At present, a series of problems related to neuroblastoma and the indications of laparoscopic surgery are still a hot topic.
The survival of patients with high risk neuroblastoma has improved significantly with the use of intensive multimodality treatment regimens including chemotherapy, surgery, radiation therapy, myeloablative chemotherapy followed by stem cell rescue and immunotherapy (
Abdominal neurogenic tumors are often concealed, large and easy to invade the surrounding tissues and blood vessels, resulting in the difficulty of laparoscopy. The indications and complications of laparoscopic surgery are still the focus of attention. With the development of laparoscopic technology, reports of successful laparoscopic neurogenic tumor resection in children have gradually increased and satisfactory surgical results have been achieved. However, there are few literature reports on the successful treatment of stage III-IV neuroblastoma by laparoscopy. Complications of laparoscopic surgery of neurogenic tumors mainly include intraoperative bleeding, conversion to laparotomy, renal atrophy or renal infarction, diaphragm injury and intestinal obstruction (
In laparoscopic surgery, the tumor is removed by splitting it into small pieces. In the present case, the tumor was difficult to expose and the right kidney artery and vein passed through the tumor. Even if open surgery was performed, the tumor needed to be split and segmented. Depending on the surgeon's experience in laparoscopic technology, combined with preoperative IDRFs, an ultrasound knife was used to split the tumor along the blood vessels, remove the tumor in pieces and complete lymph node dissection, so as to achieve the same effect as open surgery. Meanwhile, the patient could suffer less trauma and experience fast recovery. Ultrasonic knife was used for precise dissection. When cutting tumor tissue with ultrasonic knife, a high enough temperature (controlled at 100˚C) inactivated the tumor cells in the cutting plane. At the same time, the tumor bed was washed with sterilized water. This can effectively prevent the spread of tumor cells during tumor resection. It was safe and effective to split and free the tumor along the blood vessels without spreading pollution and the wound surface was clean and dissected clearly. In addition, TRIPORT was used through the umbilical fossa and the protective sleeve was used to protect the incision to avoid tumor planting and, at the same time, it was convenient to remove the specimen while the tumor was cut into small pieces. The incision scar was not obvious (
To sum up, for children suffering from neuroblastoma with large tumor volume and vascular invasion, preoperative chemotherapy can be given and minimally invasive laparoscopic surgery can be one of options to be considered when the tumor size is <6 cm. During the operation, the tumor tissue can be removed by segmental resection and the removal of as much tumor tissue as possible is an important factor to improve the prognosis. Laparoscopic minimally invasive surgery has little trauma and quick recovery and children can receive postoperative chemotherapy as early as possible, which is conducive to good recovery. Basically, the prerequisite and requirements for performing this operation are professional laparoscopic skills and an experienced team.
Not applicable.
All data generated or analyzed during this study are included in this published article
GH analysed the data and wrote the original draft. GY was responsible for data acquisition and participated in the writing of the original manuscript. GH an GY agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. WH and YS made substantial contributions to conception and acquisition of data. ML made substantial contributions to analysis and interpretation of data. SL made substantial contributions to conception and design of the study, replied to the reviewers' comments and took responsibility for communication with the journal. ML and WH confirm the authenticity of all the raw data. All authors read and approved the final manuscript.
The study was conducted in accordance with the principles of the Declaration of Helsinki and the study protocol was approved by the ethics committee of Xiamen University.
The data and pictures used in the present study were authorized by the parents of the child.
The authors declare that they have no competing interests.
CT images of the same site before and after operation. (A and B) Abdominal CT scan on March 1, 2021 revealed a large tumor surrounding the right renal artery, vein and vena cava. (C and D) The volume of tumor was reduced after three times of chemotherapy. (E and F) Following surgery and five courses of chemotherapy, abdominal CT showed no tumor recurrence. ☆ indicates tumor tissue. CT, computed tomography scan.
Comparison of PET images in the same location preoperative and postoperative. (A-1 and A-2) Preoperative PET-CT image. (A-3 and A-4) Postoperative PET-CT image. (B) Systemic PET-CT reexamination after six courses of postoperative chemotherapy showed no tumor recurrence or metastasis. ☆ indicates tumor tissue. PET, positron emission tomography; CT, computed tomography scan.
Operation process and postoperative abdominal appearance. (A) Duodenum dissociated to fully expose surgical field. (B) The tumor surrounded the right renal vein. (C) The tumor tissue was dissected, the tumor surrounding the right renal vein was segmented and the right renal vein was isolated. (D) After dissociating the inferior vena cava, the tumor tissue was exposed by gently pulling the inferior vena cava. (E) Tumor tissue behind the vena cava was dissected and the enlarged lymph nodes were dissected. (F) Tumor surrounding the right renal artery was cleaved and excised. (G) Tumor tissue located in the right adrenal gland was resected. (H) Inferior vena cava and bilateral renal veins after resection of tumor tissue. (I) Abdominal appearance on day 10 after surgery.
Preoperative and postoperative chemotherapy schedule and time.
Dates, year.month.day | Cycles | Plan | Evaluation |
---|---|---|---|
2021.3.27-2021.4.3 | 1 | VCR + CDDP + VP16 + CTX | |
2021.4.18-2021.4.22 | 2 | IFOS + CBP + ADR | |
2021.5.09-2021.5.16 | 3 | VCR + CDDP + VP16 + CTX | Complete assessment |
Surgery and postoperative evaluation | |||
2021.7.24-2021.7.31 | 4 | VCR + CDDP + VP16 + CTX | |
2021.8.23-2021.8.28 | 5 | IFOS + CBP + THP | |
2021.9.14-2021.9.21 | 6 | VCR + CDDP + VP16 + CTX | |
2021.10.11-2021.1016 | 7 | IFOS + CBP + THP | |
2021.11.02-2021.11.09 | 8 | VCR + CDDP + VP16 + CTX | |
2021.12.03-2021.12.07 | 9 | IFOS + CBP + THP | Complete assessment end of chemo |
Chemotherapy drug doses: VCR (vincristine) 1.5 mg/m2. days 1 and 8, CTX (cytoxan) 1.0 g/m2. days 1 and 2, CDDP (cisplatin) 25 mg/m2. days 1-5, VP16 (etoposide) 100 mg/m2. day 1-5, IFOS (ifosfamide) 1.5 g/m2. day 1-5, THP (pirarubicin) 30 mg/m2. day 1, CBP (carboplatin) 550 mg/m2. day 2.