Early results of minimally invasive fluorescent guided pediatric oncology surgery with delivery of indocyanine green during induction of anesthesia.

BACKGROUND: Indocyanine green (ICG) fluoresces in the near infra-red (NIR) spectrum. It is widely used in adult oncological surgery for identification of tumor margins and lymph node sampling. However, deliver of ICG in almost all studies is 24 h or more prior to surgery. This is the first study in children to assess its feasibility in minimally invasive surgery (MIS) for oncological disease following ICG injection during induction of anesthesia. METHODS: This was an open label, prospective, single center, feasibility study recruiting consecutive patients eligible for MIS tumor resection or metastectomy. ICG was injected intravenously at induction of anesthesia. Patient demographics, intraoperative appearances, post-operative histopathology, and surgeon Likert ratings were collected. RESULTS: Fourteen patients were included. Five had lung metastases (Wilms, Osteosarcoma (2), Hodgkin's, melanoma) and 9 had other tumors (neuroblastoma, inflammatory myofibroblastic tumor, ganglioneuroma, phaeochromocytoma, adrenal tumor). Lung metastases were easily identifiable, and all had negative margins. Tumors containing viable disease fluoresced and were completely resected, whilst benign and heavily treated tumors were afluorescent. There were no adverse events relating to ICG or issues with background fluorescence. CONCLUSION: Based on this small sample, injection of ICG during induction of anesthesia is safe and effective in showing tumor margins in patients who have had little or no neoadjuvant chemotherapy as well as in metastectomy in Wilms and osteosarcoma. Further studies are needed to confirm these preliminary results.

Feasibility of laparoscopic tumour nephrectomy in children.

AIMS: The laparoscopic approach to tumour nephrectomy in children is controversial. We therefore reviewed our institution's cases of tumour nephrectomy (laparoscopic, open, and converted) to better understand which is suitable for this approach, what factors prevent it, and whether one can excise tumours greater than the CCLG recommendation of 300 ml. METHODS: All tumour nephrectomies performed between 2002 and 2016 were identified using our surgical database. Further data were gathered from radiology and pathology databases. Those with nonrenal tumours or having a partial nephrectomy were excluded. Tumour maximum diameters, volumes, and ratios to contralateral kidneys were calculated. A Mann-Whitney U was used to compare the groups. RESULTS: Forty-three cases were included. Fifteen procedures were completed laparoscopically (35%), and a further 3 converted. The median age at surgery was 2.5 years (range 0-10) in the laparoscopic group and 2 years (range 0-15) in the open group. There was a significant difference (P < 0.05) between the laparoscopic and open groups for: median maximum diameter (10cm vs 12.25cm), median volume (155 ml vs 459 ml), maximum diameter ratio (1.22 vs 1.75), and volume ratio (3.8 vs 11.2). CONCLUSION: Tumours in the laparoscopic group were significantly smaller, but it was possible to excise tumours more than 300 ml. Difficulties in excision related to tumour size relative to the abdomen. Therefore, a ratio of tumour to contralateral kidney may be a better guide to safe excision than an overall volume cutoff. From our series, the laparoscopic approach is likely to be achievable if the volume ratio is ≤ 8.1. LEVEL OF EVIDENCE: Level 3.