Pelvic Tumors

Pelvic tumors usually have favorable biologic characteristics but are complicated by encasement of iliac vessels or infiltration of the lumbosacral plexus. A

Figure 14.4.4

A lower mid-line incision gives good exposure for resection of pelvic neuroblastomas.Proximal identification of the iliac vessels and ureters is facilitated. Resection of pelvic tumors is associated with a high rate of permanent nerve injury and nerve stimulation should be done with these dissections.

low midline incision down to the pubic symphysis gives good exposure and allows control of the distal aorta and vena cava. Both lower extremities should be prepped into the field and covered with clear plastic so that nerve stimulation may be done. The ipsi-lateral internal iliac vessels, if encased, may be ligated and resected. Foot drop is a common complication after resection of large pelvic lesions and should be discussed with the family pre-operatively. One study reported a 35% rate of permanent neurologic injuries after pelvic neuroblastoma resection. Also, incomplete resection does not preclude long-term remission (Shamberger et al. 1998).

11.4.7 Conclusion

As part of the worldwide effort to reduce toxicity of neuroblastoma treatment while improving overall survival, the role of surgery continues to evolve. The necessity, timing, and the extent of tumor resection should be critically evaluated. Although much progress has been made, surgical intervention is still required to establish the stage, and therefore risk status, of most neuroblastoma patients. A reduction in therapeutic intensity is now possible in intermediate-risk neuroblastoma as surgery assumes a larger role. For specific neuroblastomas diagnosed in the pre- or neonatal period, elimination of primary tumor surgery is being prospectively evaluated by the COG. Finally, as systemic therapy is being refined, local control and possibly survival in high-risk tumors have been correlated with gross total resection. The pediatric surgeon's input will continue to be a vital component of the disease management team effort.

0 0

Post a comment