MRIs are not great to look for peritoneal disease and very small nodules. And the same thing with a PET scan is that we can see large amounts of tumor that will light up on a PET scan. But when you, when you're looking at these kinds of diseases, we're often see tiny 1 millimeter type nodules that unfortunately don't show up on anything.
When we think about rhabdomyo's sarcoma, You know, we want to try to ensure that we can, we would attempt a procedure that we think we can get negative margins. And um if you think that you're only going to be able to get a debulking procedure or something like that, you really should not attempt a surgical operation.
Um, there's really no if you are worried that there is a mass there, you want to do that three week ultrasound and see if there is a mass there and then you can go back in. But you really do not want to mess up mess around with a torsed ovary, you just want to untwist it, leave it alone and come back another day.
You really don't want to spill around anything because you can get something called growing teratoma syndrome, which can be a real problem, where you just get teratoma throughout the abdomen and it continues to grow and it's not responsive to chemotherapy.
You know that by taking out an ovary, you increase this um menopause by seven years. So you have menopause seven years earlier and you can um affect fertility rate. So it's really important to try and preserve the ovaries if you can.
Our, um, plastic surgical colleagues actually make a neck incision and, um, very much like a first rib type operation for thoracic outlet syndrome, isolate the subclavian artery and the upper roots of the brachial plexus
Clinical & Research Update: Sarcoma w/ Drs. Roshni Dasgupta, Joseph Pressey, Arthur Meyer, Luke Pater
▶Ep 3 · 11:23
clinicalFor chest wall sarcomas, the old adage of needing a rib above and a rib below for margins is not the case anymore; the goal is just to get negative margins if possible↗
▶Ep 3 · 11:23
quoteNow, the old adage used to be that you needed to get, you know, a rib above and a rib below, um, from, from margins, and really that's not the case anymore. We really just want to try to get negative if we can.↗
▶Ep 3 · 12:18
quoteYou really don't wanna dissect. Pericardium off. You don't wanna dissect the diaphragm off the actual tumor if it's, especially if it's adherent. So you really don't know where the margin actually is.↗
▶Ep 3 · 12:18
clinicalWhen tumor is adherent to diaphragm or pericardium, you should not dissect these structures off the tumor because you don't know where the margin is; instead take a portion of the adherent structure with the tumor↗
▶Ep 3 · 14:05
quoteWe always counsel families that we might need to come back as the child grows and hopefully the child with all the adjuvants and multidisciplinary care has a chance to grow up into adulthood.↗
▶Ep 3 · 14:05
clinicalTitanium rib reconstruction systems may need revision as the child grows, particularly during puberty with significant growth spurts↗
▶Ep 3 · 29:18
quoteMRIs are not great to look for peritoneal disease and very small nodules. And the same thing with a PET scan is that we can see large amounts of tumor that will light up on a PET scan. But when you, when you're looking at these kinds of diseases, we're often see tiny 1 millimeter type nodules that unfortunately don't show up on anything.↗
▶Ep 3 · 29:18
clinicalMRIs and PET scans are not great for detecting peritoneal disease and very small nodules (1mm); second-look surgery is necessary to identify disease that imaging cannot detect↗
▶Ep 3 · 29:44
clinicalFor SCCOHT second-look surgery, laparoscopy is used initially to understand extent of disease and determine size of laparotomy incision needed; the operation is never done with laparoscopy alone↗
▶Ep 3 · 29:50
quoteWe're not, we're never gonna do this operation with just a laparoscope.↗
▶Ep 3 · 30:40
clinicalComplete cytoreduction for SCCOHT includes removing all visible disease, with particular attention to peritoneal reflection in pouch of Douglas and surface of rectum where tumor can hide after spill↗
▶Ep 3 · 30:49
quoteWith peritoneal, with spill, this can sort of really get to any portion of the peritoneum, taking particular attention to look at the peritoneal reflection in the pouch of Douglas↗
▶Ep 3 · 32:25
quoteFor those of you who haven't done HEC in the past, it's really important that you have a good multidisciplinary team, um, to do high tech because there are a lot of contingencies and issues that you need to mitigate for. It's not adult HEG.↗
▶Ep 3 · 32:25
clinicalHIPEC in pediatric patients requires a multidisciplinary team experienced in this procedure; it is not the same as adult HIPEC↗
▶Ep 3 · 32:42
quoteWe've probably done. Now, probably about 70 to 80 high-tech cases in this pediatric and young adult population.↗
▶Ep 3 · 32:59
clinicalHIPEC protocol includes preoperative hyperhydration (1-2x maintenance fluids), warming abdomen to 42°C, cisplatin given in 2/3 dose initially and 1/3 at 45 minutes, continuous shaking for 90-minute dwell time, sodium thiosulfate infusion at 30 minutes to scavenge cisplatin, and 4-5L washout↗
▶Ep 3 · 33:18
quoteWe use cyttalox now, um, to help us find any residual disease that we cannot see. So, um, that is a fluoror that has been approved for ovarian tumors that does bind to a folate receptor.↗
clinicalPost-HIPEC patients receive 24 hours of hyperhydration in ICU; main counseled toxicities are ileus and kidney function issues, though the Cincinnati protocol has not seen significant renal toxicity↗
▶Ep 3 · 35:15
quoteWe've been lucky because our, our protocol. We really haven't seen any significant kidneys in these postoperative patients↗
▶Ep 3 · 35:50
quoteWe tend to go right into her, her next cycle of chemotherapy as soon as they've recovered bowel function. And so we, um, generally are able to get them there between 4 to 7 days postoperatively↗
▶Ep 3 · 35:50
clinicalSCCOHT patients can resume next cycle of chemotherapy 4-7 days postoperatively after HIPEC once bowel function recovers↗
▶Ep 3 · 55:18
quoteWhen we think about rhabdomyo's sarcoma, You know, we want to try to ensure that we can, we would attempt a procedure that we think we can get negative margins. And um if you think that you're only going to be able to get a debulking procedure or something like that, you really should not attempt a surgical operation.↗
▶Ep 3 · 55:18
clinicalFor rhabdomyosarcoma, surgery should only be attempted if negative margins are achievable; if only debulking is possible, local control should be done with radiation only↗
▶Ep 3 · 55:41
clinicalThe goal of delayed primary excision (DPE) for rhabdomyosarcoma is to achieve at least R1 disease (microscopic residual only)↗
▶Ep 3 · 56:33
clinicalScapular disarticulation provides excellent access for high chest wall tumors, allowing the chest to be opened like a book↗
▶Ep 3 · 56:33
quoteOur orthopedic colleagues helped us with a complete scapular. Disarticulation and therefore we're able to really take basically open the chest like a book↗
▶Ep 3 · 56:47
clinicalFor tumors near subclavian vessels and brachial plexus, a neck incision (similar to first rib operation for thoracic outlet syndrome) allows isolation of these structures from above before thoracotomy↗
▶Ep 3 · 56:47
quoteOur, um, plastic surgical colleagues actually make a neck incision and, um, very much like a first rib type operation for thoracic outlet syndrome, isolate the subclavian artery and the upper roots of the brachial plexus↗
▶Ep 3 · 57:34
clinicalFor high chest wall defects covered by scapula, bony reconstruction is not needed; Gore-Tex mesh with trapezius flap rotation provides adequate coverage↗
▶Ep 3 · 57:44
quoteBecause it was so high up and covered by the scapula, you didn't really need any bony. Uh, reconstruction in that area↗
▶Ep 3 · 1:03:07
quoteHaving everybody's thoughts and including the family's discussion in this patient, in this case, this patient's mother was very against radiation therapy↗
▶Ep 3 · 1:03:16
quoteI think really all these cases talk about how well and how important it is to have multidisciplinary discussions and inputs↗
Roshni's statements about Osteosarcoma21 statements
Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
▶Ep 2 · 2:08
quoteAbout 40% of patients, you can get a. Durable cure response after 5 years. If you have complete metastatic site clearance, you can make these patients long-term survivors.↗
▶Ep 2 · 2:08
clinicalAbout 40% of patients can achieve a durable cure response after 5 years with complete metastatic site clearance.↗
▶Ep 2 · 2:23
clinicalComplete surgical resection of all metastatic tumor sites is an independent positive prognostic factor and affects overall survival, not just disease recurrence.↗
▶Ep 2 · 2:35
quoteOur data actually from one of our PSA studies shows that even at the size of 1 millimeter, you can get about 60% of 1 millimeter nodules contained malignant disease.↗
▶Ep 2 · 2:35
clinicalIn patients with metastatic osteosarcoma, even 1-millimeter nodules can contain malignant disease in about 60% of cases.↗
▶Ep 2 · 2:47
clinicalThe bigger the nodule is, the more likely it contains malignancy, but all the way down to 1 millimeter, tumor can be found.↗
▶Ep 2 · 3:13
clinicalThoracotomy has historically been standard of care because surgeons can use fingers and hands to feel tiny nodules.↗
▶Ep 2 · 3:19
quoteYou will find about 30 to 40% more lung nodules with your fingers and looking than you actually find on CAT scan, even with our special MP scanning and our like thin cut CT scans.↗
▶Ep 2 · 3:19
clinicalManual palpation during thoracotomy finds about 30 to 40% more lung nodules than are detected on CT scan, even with thin-cut CT scans.↗
▶Ep 2 · 3:50
clinicalICG can be used with thoracotomy to find deeper nodules, though depth of penetration is a limitation.↗
▶Ep 2 · 4:15
opinionIt is uncertain whether removing tiny 1-millimeter nodules actually provides a survival advantage.↗
▶Ep 2 · 4:41
clinicalVATS is minimally invasive with shorter length of stay, and repeat thoracoscopy typically encounters fewer adhesions compared to repeat thoracotomy.↗
▶Ep 2 · 4:58
clinicalVATS often requires some sort of localization process and good interventional radiology support.↗
▶Ep 2 · 5:34
clinicalIn oligometastatic disease (patients with fewer than 4 nodules on each side), there was no difference in mortality between open resection and thoracoscopy.↗
▶Ep 2 · 5:34
quoteUm, which really tells you that an oligometastatic disease, meaning that patients who have less than 4 nodules on each side, there was no difference in terms of mortality.↗
▶Ep 2 · 5:44
clinicalThe survival curves for thoracotomy and thoracoscopy in oligometastatic disease are essentially identical, meaning the optimal operation is unknown.↗
▶Ep 2 · 5:52
quoteYou know, sort of from a cancer surgeon perspective, you're like, I need to get all the tumor out all the time, but when you actually look at the data, maybe those small little nodules that you're feeling with a grain of sand don't actually make that much difference, and we don't know.↗
▶Ep 2 · 6:03
epidemiologicalThe multi-institution study had significant selection bias and institutional selection bias, with patients unlikely to receive thoracoscopy if they had many nodules.↗
▶Ep 2 · 6:34
clinicalMetastatic disease is typically addressed after 4 cycles of chemotherapy, and residual nodules at that point are unlikely to change with additional chemotherapy.↗
▶Ep 2 · 7:02
clinicalPractice for bilateral lung metastases is highly varied, with options including median sternotomy, staged thoracotomies, or bilateral thoracoscopies.↗
▶Ep 2 · 7:13
clinicalMost practitioners perform staged procedures for bilateral disease, particularly with thoracotomy, typically 4 to 6 weeks apart to allow a cycle of chemotherapy in between.↗
Roshni's statements about Ovarian Cyst10 statements
quoteCysts diagnosed prenatally have a fairly wide differential. The cysts can be related to an ovary. Which it probably is in this case, since we're talking about ovarian pathology today. A mesenteric cyst, a duplication cyst, a complex meconium cyst or a renal cyst. But regardless, there isn't really much to do in utero.↗
▶Ep 3 · 0:25
clinicalCysts diagnosed prenatally have a differential including ovarian cyst, mesenteric cyst, duplication cyst, complex meconium cyst, or renal cyst.↗
▶Ep 3 · 1:00
clinicalThere is not much to do in utero for prenatally diagnosed pelvic cysts.↗
▶Ep 3 · 1:10
clinicalFor a thriving neonate with a truly cystic mass, serial imaging at about 12 weeks is appropriate if it is a simple cyst, which should get smaller in that timeframe.↗
▶Ep 3 · 1:35
clinicalIf abnormal ovaries or no ovaries are seen on imaging, intrauterine torsion may have occurred, leaving a free floating cyst.↗
▶Ep 3 · 4:02
clinicalParaovarian cysts are hard to differentiate from follicular cysts on imaging.↗
▶Ep 3 · 4:10
clinicalThe big concern with paraovarian cysts is torsion of the fallopian tube itself, not just the ovary.↗
▶Ep 3 · 4:20
clinicalParaovarian cysts are usually in the mesosalpinx.↗
▶Ep 3 · 4:25
clinicalIf paraovarian cysts are greater than 3 centimeters, enucleation is recommended to prevent torsion of the tube.↗
▶Ep 3 · 4:35
opinionIf paraovarian cysts are smaller than 3 centimeters, most people do not intervene, but they can be opened and drained if desired.↗
Roshni's statements about Ovarian Torsion19 statements
opinionGeneral surgeons do not do a good job in ovarian preservation compared to gynecology colleagues.↗
▶Ep 6 · 0:19
quoteAnd as general surgeons, we do not do a good job in ovarian preservation, so it's something that we really need to think about. Um, our gynecology colleagues do a much better job, um, and we are seeing we're we're seeing a change in that our practice, but it's, um, still not good in terms of how many ovaries that general surgery takes out compared to, um, gynecology.↗
▶Ep 6 · 1:56
epidemiologicalOophorectomy rates were higher in non-teaching hospitals, younger patients, and in the south.↗
▶Ep 6 · 1:56
epidemiologicalRecent data from last year show that one quarter of patients with ovarian torsion still get oophorectomies despite evidence against it.↗
▶Ep 6 · 2:44
quoteSo even if they are if they pinks up, great, but even if it's black, like that picture right there, you should leave it alone.↗
▶Ep 6 · 2:44
clinicalEven if the ovary remains black after waiting 5 or 10 minutes or longer, it should be left alone.↗
▶Ep 6 · 3:06
clinicalOvaries have dual blood supply and almost all are salvageable, so they should not be taken out.↗
▶Ep 6 · 3:06
quoteOvarian ovaries have dual blood supply, they do pink up and almost all of them are salvageable. So, um, you definitely do not want to take them out.↗
▶Ep 6 · 3:26
clinicalA torsed ovary should be untwisted, left alone, and the surgeon can come back another day if needed.↗
▶Ep 6 · 3:26
clinicalIf there is concern for a mass, a three-week ultrasound should be performed and the surgeon can return to the operating room if needed.↗
▶Ep 6 · 3:26
quoteUm, there's really no if you are worried that there is a mass there, you want to do that three week ultrasound and see if there is a mass there and then you can go back in. But you really do not want to mess up mess around with a torsed ovary, you just want to untwist it, leave it alone and come back another day.↗
▶Ep 6 · 3:55
clinicalTaking out an ovary increases early menopause by seven years.↗
▶Ep 6 · 3:55
clinicalRemoving an ovary can affect fertility rate.↗
▶Ep 6 · 3:55
quoteYou know that by taking out an ovary, you increase this um menopause by seven years. So you have menopause seven years earlier and you can um affect fertility rate. So it's really important to try and preserve the ovaries if you can.↗
▶Ep 6 · 5:02
clinicalPexy is not indicated in the majority of patients with ovarian torsion.↗
▶Ep 6 · 5:02
clinicalIf the child is not sick, the ovary can be left in place regardless of appearance after detorsion.↗
▶Ep 6 · 5:02
clinicalFollow-up ultrasound is indicated, especially if there is concern for a mass.↗
▶Ep 6 · 5:28
epidemiologicalGynecologists are much more likely to perform ovarian preservation than pediatric general surgeons.↗
▶Ep 6 · 5:43
opinionOvarian preservation should be considered even in neoplastic tumors and ovarian torsion where the ovary might be salvageable.↗
Roshni's statements about Ovarian Tumors40 statements
clinicalNeoplastic ovarian masses are classified into three types based on tissue of origin: epithelial ovarian tumors, stromal/sex cord tumors, and germ cell tumors (from the yolk sac).↗
▶Ep 3 · 1:35
quoteThankfully, malignancy from any of these neoplastic processes are rare, overall making up only 2% of cancers in children.↗
▶Ep 3 · 1:35
epidemiologicalMalignancy from neoplastic ovarian processes is rare, making up only 2% of cancers in children overall.↗
▶Ep 3 · 1:45
clinicalOvarian malignancy is more common in the 10-19 year age group and any malignant lesion under age 5 is reportable.↗
▶Ep 3 · 2:00
clinicalPeutz-Jeghers syndrome is associated primarily with granulosa cell tumors and sex cord tumors.↗
▶Ep 3 · 2:10
clinicalOllier and Maffucci syndromes are associated with ovarian tumors.↗
▶Ep 3 · 2:18
clinicalChediak-Higashi and McCune-Albright syndromes are also associated with ovarian tumors.↗
▶Ep 3 · 3:00
clinicalWorkup for suspected ovarian tumor with precocious puberty includes renal panel, CBC, estradiol, progesterone, tumor markers, and ultrasound.↗
▶Ep 3 · 3:50
clinicalCT scan advantages for ovarian mass evaluation include better determination of tumor location and extent, and superior detection of calcifications compared to MRI.↗
▶Ep 3 · 4:10
clinicalCT scan disadvantage is radiation exposure to the child.↗
▶Ep 3 · 4:18
clinicalMRI provides better tissue detail, can help distinguish ovarian from parovarian masses, and is excellent at detecting lymph nodes.↗
▶Ep 3 · 5:01
clinicalTumor markers commonly associated with ovarian tumors include AFP, beta-hCG, CA-125 (for epithelial tumors), inhibin A and B, hormones (estradiol, progesterone), LDH, CBC, and renal function tests.↗
▶Ep 3 · 5:40
clinicalElevated inhibin B is associated with granulosa cell tumor, a sex cord tumor that causes virilizing effects.↗
▶Ep 3 · 6:34
clinicalCA-125 can be elevated in benign conditions such as endometriosis and other inflammatory conditions, sometimes to levels that overlap with malignancy.↗
▶Ep 3 · 7:15
clinicalPrimordial germ cells form in the first week of gestation, and by week three they form the wall of the yolk sac and migrate along the mesentery of the hindgut.↗
▶Ep 3 · 7:45
clinicalGerm cell tumors can be gonadal (when germ cells migrate to the gonads) or extragonadal (sacrococcygeal teratomas, mediastinal lesions).↗
▶Ep 3 · 8:10
clinicalWithin gonadal germ cell tumors, if cells differentiate properly, extraembryonic differentiation produces choriocarcinomas and yolk sac tumors, while embryonic differentiation produces teratomas and mixed germ cell tumors.↗
▶Ep 3 · 8:50
clinicalIf germ cells do not differentiate properly, they are classified as seminomas in boys and dysgerminomas in girls.↗
▶Ep 3 · 9:20
epidemiologicalAbout 20% of germ cell tumors are malignant.↗
▶Ep 3 · 9:35
epidemiologicalDysgerminomas are the most common malignant histology, comprising 30% of germ cell tumors, and can be bilateral.↗
▶Ep 3 · 9:48
clinicalDysgerminomas have a unique laboratory pattern: elevated LDH, but in a pure dysgerminoma AFP and beta-hCG can be normal; hypercalcemia may also be present.↗
▶Ep 3 · 11:12
clinicalFor germ cell tumors, lymph nodes should be examined intraoperatively but only removed if enlarged or suspicious; standard lymph node dissection is not required.↗
▶Ep 3 · 11:12
clinicalGerm cell tumor staging requires peritoneal washings, examination of the entire peritoneal cavity, omental resection only if suspicious nodules are present, and unilateral salpingo-oophorectomy (salpingectomy only if fallopian tube is involved).↗
▶Ep 3 · 11:50
clinicalAny portion of the ovary that can be preserved should be considered during germ cell tumor resection.↗
▶Ep 3 · 12:42
guidelineCOG staging for germ cell tumors: stage I is limited to the ovary with negative washings; stage II includes capsular rupture with negative washings; stage III is lymph node involvement; stage IV is distant metastasis.↗
▶Ep 3 · 13:31
clinicalStage I germ cell tumors can be managed with surgery alone and observation if the tumor is not ruptured.↗
▶Ep 3 · 14:00
clinicalIf a germ cell tumor is ruptured during laparoscopic resection and tumor is spilled, the patient is required to receive chemotherapy.↗
▶Ep 3 · 16:30
clinicalFor mature teratomas with a cystic component, it is safe to decompress the cyst first to improve access and increase chances of ovarian preservation.↗
▶Ep 3 · 16:55
quoteYou do not need to close the ovarian capsule. People will say you do, you do not. There's no data to show that you need to. It'll just form all by itself.↗
▶Ep 3 · 16:55
clinicalThe ovarian capsule does not need to be closed after shelling out a teratoma; there is no data showing closure is necessary and it will form by itself.↗
▶Ep 3 · 17:10
clinicalA plastic bowel bag can be glued to the ovarian mass and a needle inserted through it to avoid spillage during teratoma resection.↗
▶Ep 3 · 17:23
quoteYou really don't want to spill around anything because you can get something called growing teratoma syndrome, which can be a real problem, where you just get teratoma throughout the abdomen and it continues to grow and it's not responsive to chemotherapy.↗
▶Ep 3 · 17:23
clinicalSpillage of teratoma contents can cause growing teratoma syndrome, where teratoma grows throughout the abdomen and is not responsive to chemotherapy.↗
▶Ep 3 · 18:31
clinicalStaging for epithelial ovarian tumors requires pelvic washings, abdominal examination, omentectomy, primary tumor removal, and lymph node dissection.↗
▶Ep 3 · 18:55
clinicalFor epithelial tumors, lymph node dissection boundaries are the pelvic iliacs to the renal artery (para-aortic nodes below the renals).↗
▶Ep 3 · 19:23
epidemiologicalAbout 30% of normal-appearing lymph nodes in epithelial ovarian cancer are positive on pathology, which will upstage the patient.↗
▶Ep 3 · 19:23
quoteAbout 30% of nodes that look normal that you're feeling in epithelial ovarian cancer can be positive and that will upstage you.↗
▶Ep 3 · 20:00
clinicalBorderline epithelial tumors can recur, so patients require close serial follow-up over many years.↗
▶Ep 3 · 20:26
clinicalFor borderline epithelial tumors, ovarian-sparing surgery can be performed initially, and if pathology confirms borderline tumor, the ovary can either be removed in a second operation or the patient can be watched with close surveillance.↗
▶Ep 3 · 21:00
clinicalThere is no perfect tumor marker for ovarian masses; studies from the Midwest Pediatric Surgery Consortium show that a panel of tumor markers is helpful, but no single marker perfectly predicts malignancy.↗
Roshni's statements about Pediatric Oncology94 statements
Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
▶Ep 376 · 2:08
clinicalAbout 40% of patients can achieve a durable cure response after 5 years with complete metastatic site clearance.↗
▶Ep 376 · 2:08
quoteAbout 40% of patients, you can get a. Durable cure response after 5 years. If you have complete metastatic site clearance, you can make these patients long-term survivors.↗
▶Ep 376 · 2:23
clinicalComplete surgical resection of all metastatic tumor sites is an independent positive prognostic factor and affects overall survival, not just disease recurrence.↗
▶Ep 376 · 2:35
quoteOur data actually from one of our PSA studies shows that even at the size of 1 millimeter, you can get about 60% of 1 millimeter nodules contained malignant disease.↗
▶Ep 376 · 2:35
clinicalIn patients with metastatic osteosarcoma, even 1-millimeter nodules can contain malignant disease in about 60% of cases.↗
▶Ep 376 · 2:47
clinicalThe bigger the nodule is, the more likely it contains malignancy, but all the way down to 1 millimeter, tumor can be found.↗
▶Ep 376 · 3:13
clinicalThoracotomy has historically been standard of care because surgeons can use fingers and hands to feel tiny nodules.↗
▶Ep 376 · 3:19
quoteYou will find about 30 to 40% more lung nodules with your fingers and looking than you actually find on CAT scan, even with our special MP scanning and our like thin cut CT scans.↗
▶Ep 376 · 3:19
clinicalManual palpation during thoracotomy finds about 30 to 40% more lung nodules than are detected on CT scan, even with thin-cut CT scans.↗
▶Ep 376 · 3:50
clinicalICG can be used with thoracotomy to find deeper nodules, though depth of penetration is a limitation.↗
▶Ep 376 · 4:15
opinionIt is uncertain whether removing tiny 1-millimeter nodules actually provides a survival advantage.↗
▶Ep 376 · 4:41
clinicalVATS is minimally invasive with shorter length of stay, and repeat thoracoscopy typically encounters fewer adhesions compared to repeat thoracotomy.↗
▶Ep 376 · 4:58
clinicalVATS often requires some sort of localization process and good interventional radiology support.↗
▶Ep 376 · 5:34
clinicalIn oligometastatic disease (patients with fewer than 4 nodules on each side), there was no difference in mortality between open resection and thoracoscopy.↗
▶Ep 376 · 5:34
quoteUm, which really tells you that an oligometastatic disease, meaning that patients who have less than 4 nodules on each side, there was no difference in terms of mortality.↗
▶Ep 376 · 5:44
clinicalThe survival curves for thoracotomy and thoracoscopy in oligometastatic disease are essentially identical, meaning the optimal operation is unknown.↗
▶Ep 376 · 5:52
quoteYou know, sort of from a cancer surgeon perspective, you're like, I need to get all the tumor out all the time, but when you actually look at the data, maybe those small little nodules that you're feeling with a grain of sand don't actually make that much difference, and we don't know.↗
▶Ep 376 · 6:03
epidemiologicalThe multi-institution study had significant selection bias and institutional selection bias, with patients unlikely to receive thoracoscopy if they had many nodules.↗
▶Ep 376 · 6:34
clinicalMetastatic disease is typically addressed after 4 cycles of chemotherapy, and residual nodules at that point are unlikely to change with additional chemotherapy.↗
▶Ep 376 · 7:02
clinicalPractice for bilateral lung metastases is highly varied, with options including median sternotomy, staged thoracotomies, or bilateral thoracoscopies.↗
▶Ep 376 · 7:13
clinicalMost practitioners perform staged procedures for bilateral disease, particularly with thoracotomy, typically 4 to 6 weeks apart to allow a cycle of chemotherapy in between.↗
Ovarian Tumors with Dr. Roshni Dasgupta
▶Ep 384 · 0:55
clinicalNeoplastic ovarian masses are classified into three types based on tissue of origin: epithelial ovarian tumors, stromal/sex cord tumors, and germ cell tumors (from the yolk sac).↗
▶Ep 384 · 1:35
epidemiologicalMalignancy from neoplastic ovarian processes is rare, making up only 2% of cancers in children overall.↗
▶Ep 384 · 1:35
quoteThankfully, malignancy from any of these neoplastic processes are rare, overall making up only 2% of cancers in children.↗
▶Ep 384 · 1:45
clinicalOvarian malignancy is more common in the 10-19 year age group and any malignant lesion under age 5 is reportable.↗
▶Ep 384 · 2:00
clinicalPeutz-Jeghers syndrome is associated primarily with granulosa cell tumors and sex cord tumors.↗
▶Ep 384 · 2:10
clinicalOllier and Maffucci syndromes are associated with ovarian tumors.↗
▶Ep 384 · 2:18
clinicalChediak-Higashi and McCune-Albright syndromes are also associated with ovarian tumors.↗
▶Ep 384 · 3:00
clinicalWorkup for suspected ovarian tumor with precocious puberty includes renal panel, CBC, estradiol, progesterone, tumor markers, and ultrasound.↗
▶Ep 384 · 3:50
clinicalCT scan advantages for ovarian mass evaluation include better determination of tumor location and extent, and superior detection of calcifications compared to MRI.↗
▶Ep 384 · 4:10
clinicalCT scan disadvantage is radiation exposure to the child.↗
▶Ep 384 · 4:18
clinicalMRI provides better tissue detail, can help distinguish ovarian from parovarian masses, and is excellent at detecting lymph nodes.↗
▶Ep 384 · 5:01
clinicalTumor markers commonly associated with ovarian tumors include AFP, beta-hCG, CA-125 (for epithelial tumors), inhibin A and B, hormones (estradiol, progesterone), LDH, CBC, and renal function tests.↗
▶Ep 384 · 5:40
clinicalElevated inhibin B is associated with granulosa cell tumor, a sex cord tumor that causes virilizing effects.↗
▶Ep 384 · 6:34
clinicalCA-125 can be elevated in benign conditions such as endometriosis and other inflammatory conditions, sometimes to levels that overlap with malignancy.↗
▶Ep 384 · 7:15
clinicalPrimordial germ cells form in the first week of gestation, and by week three they form the wall of the yolk sac and migrate along the mesentery of the hindgut.↗
▶Ep 384 · 7:45
clinicalGerm cell tumors can be gonadal (when germ cells migrate to the gonads) or extragonadal (sacrococcygeal teratomas, mediastinal lesions).↗
▶Ep 384 · 8:10
clinicalWithin gonadal germ cell tumors, if cells differentiate properly, extraembryonic differentiation produces choriocarcinomas and yolk sac tumors, while embryonic differentiation produces teratomas and mixed germ cell tumors.↗
▶Ep 384 · 8:50
clinicalIf germ cells do not differentiate properly, they are classified as seminomas in boys and dysgerminomas in girls.↗
▶Ep 384 · 9:20
epidemiologicalAbout 20% of germ cell tumors are malignant.↗
▶Ep 384 · 9:35
epidemiologicalDysgerminomas are the most common malignant histology, comprising 30% of germ cell tumors, and can be bilateral.↗
▶Ep 384 · 9:48
clinicalDysgerminomas have a unique laboratory pattern: elevated LDH, but in a pure dysgerminoma AFP and beta-hCG can be normal; hypercalcemia may also be present.↗
▶Ep 384 · 11:12
clinicalGerm cell tumor staging requires peritoneal washings, examination of the entire peritoneal cavity, omental resection only if suspicious nodules are present, and unilateral salpingo-oophorectomy (salpingectomy only if fallopian tube is involved).↗
▶Ep 384 · 11:12
clinicalFor germ cell tumors, lymph nodes should be examined intraoperatively but only removed if enlarged or suspicious; standard lymph node dissection is not required.↗
▶Ep 384 · 11:50
clinicalAny portion of the ovary that can be preserved should be considered during germ cell tumor resection.↗
▶Ep 384 · 12:42
guidelineCOG staging for germ cell tumors: stage I is limited to the ovary with negative washings; stage II includes capsular rupture with negative washings; stage III is lymph node involvement; stage IV is distant metastasis.↗
▶Ep 384 · 13:31
clinicalStage I germ cell tumors can be managed with surgery alone and observation if the tumor is not ruptured.↗
▶Ep 384 · 14:00
clinicalIf a germ cell tumor is ruptured during laparoscopic resection and tumor is spilled, the patient is required to receive chemotherapy.↗
▶Ep 384 · 16:30
clinicalFor mature teratomas with a cystic component, it is safe to decompress the cyst first to improve access and increase chances of ovarian preservation.↗
▶Ep 384 · 16:55
quoteYou do not need to close the ovarian capsule. People will say you do, you do not. There's no data to show that you need to. It'll just form all by itself.↗
▶Ep 384 · 16:55
clinicalThe ovarian capsule does not need to be closed after shelling out a teratoma; there is no data showing closure is necessary and it will form by itself.↗
▶Ep 384 · 17:10
clinicalA plastic bowel bag can be glued to the ovarian mass and a needle inserted through it to avoid spillage during teratoma resection.↗
▶Ep 384 · 17:23
clinicalSpillage of teratoma contents can cause growing teratoma syndrome, where teratoma grows throughout the abdomen and is not responsive to chemotherapy.↗
▶Ep 384 · 17:23
quoteYou really don't want to spill around anything because you can get something called growing teratoma syndrome, which can be a real problem, where you just get teratoma throughout the abdomen and it continues to grow and it's not responsive to chemotherapy.↗
▶Ep 384 · 18:31
clinicalStaging for epithelial ovarian tumors requires pelvic washings, abdominal examination, omentectomy, primary tumor removal, and lymph node dissection.↗
▶Ep 384 · 18:55
clinicalFor epithelial tumors, lymph node dissection boundaries are the pelvic iliacs to the renal artery (para-aortic nodes below the renals).↗
▶Ep 384 · 19:23
epidemiologicalAbout 30% of normal-appearing lymph nodes in epithelial ovarian cancer are positive on pathology, which will upstage the patient.↗
▶Ep 384 · 19:23
quoteAbout 30% of nodes that look normal that you're feeling in epithelial ovarian cancer can be positive and that will upstage you.↗
▶Ep 384 · 20:00
clinicalBorderline epithelial tumors can recur, so patients require close serial follow-up over many years.↗
▶Ep 384 · 20:26
clinicalFor borderline epithelial tumors, ovarian-sparing surgery can be performed initially, and if pathology confirms borderline tumor, the ovary can either be removed in a second operation or the patient can be watched with close surveillance.↗
▶Ep 384 · 21:00
clinicalThere is no perfect tumor marker for ovarian masses; studies from the Midwest Pediatric Surgery Consortium show that a panel of tumor markers is helpful, but no single marker perfectly predicts malignancy.↗
Clinical & Research Update: Sarcoma w/ Drs. Roshni Dasgupta, Joseph Pressey, Arthur Meyer, Luke Pater
▶Ep 685 · 11:23
clinicalFor chest wall sarcomas, the old adage of needing a rib above and a rib below for margins is not the case anymore; the goal is just to get negative margins if possible↗
▶Ep 685 · 11:23
quoteNow, the old adage used to be that you needed to get, you know, a rib above and a rib below, um, from, from margins, and really that's not the case anymore. We really just want to try to get negative if we can.↗
▶Ep 685 · 12:18
quoteYou really don't wanna dissect. Pericardium off. You don't wanna dissect the diaphragm off the actual tumor if it's, especially if it's adherent. So you really don't know where the margin actually is.↗
▶Ep 685 · 12:18
clinicalWhen tumor is adherent to diaphragm or pericardium, you should not dissect these structures off the tumor because you don't know where the margin is; instead take a portion of the adherent structure with the tumor↗
▶Ep 685 · 14:05
clinicalTitanium rib reconstruction systems may need revision as the child grows, particularly during puberty with significant growth spurts↗
▶Ep 685 · 14:05
quoteWe always counsel families that we might need to come back as the child grows and hopefully the child with all the adjuvants and multidisciplinary care has a chance to grow up into adulthood.↗
▶Ep 685 · 29:18
clinicalMRIs and PET scans are not great for detecting peritoneal disease and very small nodules (1mm); second-look surgery is necessary to identify disease that imaging cannot detect↗
▶Ep 685 · 29:18
quoteMRIs are not great to look for peritoneal disease and very small nodules. And the same thing with a PET scan is that we can see large amounts of tumor that will light up on a PET scan. But when you, when you're looking at these kinds of diseases, we're often see tiny 1 millimeter type nodules that unfortunately don't show up on anything.↗
▶Ep 685 · 29:44
clinicalFor SCCOHT second-look surgery, laparoscopy is used initially to understand extent of disease and determine size of laparotomy incision needed; the operation is never done with laparoscopy alone↗
▶Ep 685 · 29:50
quoteWe're not, we're never gonna do this operation with just a laparoscope.↗
▶Ep 685 · 30:40
clinicalComplete cytoreduction for SCCOHT includes removing all visible disease, with particular attention to peritoneal reflection in pouch of Douglas and surface of rectum where tumor can hide after spill↗
▶Ep 685 · 30:49
quoteWith peritoneal, with spill, this can sort of really get to any portion of the peritoneum, taking particular attention to look at the peritoneal reflection in the pouch of Douglas↗
▶Ep 685 · 32:25
clinicalHIPEC in pediatric patients requires a multidisciplinary team experienced in this procedure; it is not the same as adult HIPEC↗
▶Ep 685 · 32:25
quoteFor those of you who haven't done HEC in the past, it's really important that you have a good multidisciplinary team, um, to do high tech because there are a lot of contingencies and issues that you need to mitigate for. It's not adult HEG.↗
▶Ep 685 · 32:42
quoteWe've probably done. Now, probably about 70 to 80 high-tech cases in this pediatric and young adult population.↗
▶Ep 685 · 32:59
clinicalHIPEC protocol includes preoperative hyperhydration (1-2x maintenance fluids), warming abdomen to 42°C, cisplatin given in 2/3 dose initially and 1/3 at 45 minutes, continuous shaking for 90-minute dwell time, sodium thiosulfate infusion at 30 minutes to scavenge cisplatin, and 4-5L washout↗
▶Ep 685 · 33:18
quoteWe use cyttalox now, um, to help us find any residual disease that we cannot see. So, um, that is a fluoror that has been approved for ovarian tumors that does bind to a folate receptor.↗
clinicalPost-HIPEC patients receive 24 hours of hyperhydration in ICU; main counseled toxicities are ileus and kidney function issues, though the Cincinnati protocol has not seen significant renal toxicity↗
▶Ep 685 · 35:15
quoteWe've been lucky because our, our protocol. We really haven't seen any significant kidneys in these postoperative patients↗
▶Ep 685 · 35:50
clinicalSCCOHT patients can resume next cycle of chemotherapy 4-7 days postoperatively after HIPEC once bowel function recovers↗
▶Ep 685 · 35:50
quoteWe tend to go right into her, her next cycle of chemotherapy as soon as they've recovered bowel function. And so we, um, generally are able to get them there between 4 to 7 days postoperatively↗
▶Ep 685 · 55:18
clinicalFor rhabdomyosarcoma, surgery should only be attempted if negative margins are achievable; if only debulking is possible, local control should be done with radiation only↗
▶Ep 685 · 55:18
quoteWhen we think about rhabdomyo's sarcoma, You know, we want to try to ensure that we can, we would attempt a procedure that we think we can get negative margins. And um if you think that you're only going to be able to get a debulking procedure or something like that, you really should not attempt a surgical operation.↗
▶Ep 685 · 55:41
clinicalThe goal of delayed primary excision (DPE) for rhabdomyosarcoma is to achieve at least R1 disease (microscopic residual only)↗
▶Ep 685 · 56:33
quoteOur orthopedic colleagues helped us with a complete scapular. Disarticulation and therefore we're able to really take basically open the chest like a book↗
▶Ep 685 · 56:33
clinicalScapular disarticulation provides excellent access for high chest wall tumors, allowing the chest to be opened like a book↗
▶Ep 685 · 56:47
clinicalFor tumors near subclavian vessels and brachial plexus, a neck incision (similar to first rib operation for thoracic outlet syndrome) allows isolation of these structures from above before thoracotomy↗
▶Ep 685 · 56:47
quoteOur, um, plastic surgical colleagues actually make a neck incision and, um, very much like a first rib type operation for thoracic outlet syndrome, isolate the subclavian artery and the upper roots of the brachial plexus↗
▶Ep 685 · 57:34
clinicalFor high chest wall defects covered by scapula, bony reconstruction is not needed; Gore-Tex mesh with trapezius flap rotation provides adequate coverage↗
▶Ep 685 · 57:44
quoteBecause it was so high up and covered by the scapula, you didn't really need any bony. Uh, reconstruction in that area↗
▶Ep 685 · 1:03:07
quoteHaving everybody's thoughts and including the family's discussion in this patient, in this case, this patient's mother was very against radiation therapy↗
▶Ep 685 · 1:03:16
quoteI think really all these cases talk about how well and how important it is to have multidisciplinary discussions and inputs↗
Roshni's statements about Sarcoma (Ewing/Rhabdo)21 statements
Update Course Rewind: Thoracotomy vs VATS for Lung Metastases
▶Ep 8 · 2:08
quoteAbout 40% of patients, you can get a. Durable cure response after 5 years. If you have complete metastatic site clearance, you can make these patients long-term survivors.↗
▶Ep 8 · 2:08
clinicalAbout 40% of patients can achieve a durable cure response after 5 years with complete metastatic site clearance.↗
▶Ep 8 · 2:23
clinicalComplete surgical resection of all metastatic tumor sites is an independent positive prognostic factor and affects overall survival, not just disease recurrence.↗
▶Ep 8 · 2:35
clinicalIn patients with metastatic osteosarcoma, even 1-millimeter nodules can contain malignant disease in about 60% of cases.↗
▶Ep 8 · 2:35
quoteOur data actually from one of our PSA studies shows that even at the size of 1 millimeter, you can get about 60% of 1 millimeter nodules contained malignant disease.↗
▶Ep 8 · 2:47
clinicalThe bigger the nodule is, the more likely it contains malignancy, but all the way down to 1 millimeter, tumor can be found.↗
▶Ep 8 · 3:13
clinicalThoracotomy has historically been standard of care because surgeons can use fingers and hands to feel tiny nodules.↗
▶Ep 8 · 3:19
quoteYou will find about 30 to 40% more lung nodules with your fingers and looking than you actually find on CAT scan, even with our special MP scanning and our like thin cut CT scans.↗
▶Ep 8 · 3:19
clinicalManual palpation during thoracotomy finds about 30 to 40% more lung nodules than are detected on CT scan, even with thin-cut CT scans.↗
▶Ep 8 · 3:50
clinicalICG can be used with thoracotomy to find deeper nodules, though depth of penetration is a limitation.↗
▶Ep 8 · 4:15
opinionIt is uncertain whether removing tiny 1-millimeter nodules actually provides a survival advantage.↗
▶Ep 8 · 4:41
clinicalVATS is minimally invasive with shorter length of stay, and repeat thoracoscopy typically encounters fewer adhesions compared to repeat thoracotomy.↗
▶Ep 8 · 4:58
clinicalVATS often requires some sort of localization process and good interventional radiology support.↗
▶Ep 8 · 5:34
quoteUm, which really tells you that an oligometastatic disease, meaning that patients who have less than 4 nodules on each side, there was no difference in terms of mortality.↗
▶Ep 8 · 5:34
clinicalIn oligometastatic disease (patients with fewer than 4 nodules on each side), there was no difference in mortality between open resection and thoracoscopy.↗
▶Ep 8 · 5:44
clinicalThe survival curves for thoracotomy and thoracoscopy in oligometastatic disease are essentially identical, meaning the optimal operation is unknown.↗
▶Ep 8 · 5:52
quoteYou know, sort of from a cancer surgeon perspective, you're like, I need to get all the tumor out all the time, but when you actually look at the data, maybe those small little nodules that you're feeling with a grain of sand don't actually make that much difference, and we don't know.↗
▶Ep 8 · 6:03
epidemiologicalThe multi-institution study had significant selection bias and institutional selection bias, with patients unlikely to receive thoracoscopy if they had many nodules.↗
▶Ep 8 · 6:34
clinicalMetastatic disease is typically addressed after 4 cycles of chemotherapy, and residual nodules at that point are unlikely to change with additional chemotherapy.↗
▶Ep 8 · 7:02
clinicalPractice for bilateral lung metastases is highly varied, with options including median sternotomy, staged thoracotomies, or bilateral thoracoscopies.↗
▶Ep 8 · 7:13
clinicalMost practitioners perform staged procedures for bilateral disease, particularly with thoracotomy, typically 4 to 6 weeks apart to allow a cycle of chemotherapy in between.↗
