Emily Christison-Lagay - Academia.edu (original) (raw)

Papers by Emily Christison-Lagay

Journal of Pediatric Surgery, Apr 1, 2022

BACKGROUND Testicular germ cell tumors are uncommon tumors that are encountered by pediatric surg... more BACKGROUND Testicular germ cell tumors are uncommon tumors that are encountered by pediatric surgeons and urologists and require a knowledge of appropriate contemporary evaluation and surgical and medical management. METHOD A review of the recommended diagnostic evaluation and current surgical and medical management of children and adolescents with testicular germ cell tumors based upon recently completed clinical trials was performed and summarized in this article. RESULTS In this summary of childhood and adolescent testicular germ cell tumors, we review the initial clinical evaluation, surgical and medical management, risk stratification, results from recent prospective cooperative group studies, and clinical outcomes. A summary of recently completed clinical trials by pediatric oncology cooperative groups is provided, and best surgical practices are discussed. CONCLUSIONS Testicular germ cell tumors in children are rare tumors. International collaborations, data-sharing, and enrollment of patients at all stages and risk classifications into active clinical trials will enhance our knowledge of these rare tumors and most importantly improve outcomes of patients with testicular germ cell tumors. LEVEL OF EVIDENCE This is a review article of previously published and referenced level 1 and 2 studies, but also includes expert opinion level 5, represented by the American Pediatric Surgical Association Cancer Committee.

Journal of Pediatric Surgery, Nov 1, 2020

Minimally invasive nephrectomy is performed routinely for adult renal tumors and for many benign ... more Minimally invasive nephrectomy is performed routinely for adult renal tumors and for many benign pediatric conditions. Although open radical nephroureterectomy remains the standard of care for Wilms tumor and most pediatric renal malignancies, there are an increasing number of reports of minimally invasive surgery (MIS) for those operations as well. The APSA Cancer Committee performed a systematic review to better understand the risks and benefits of MIS in pediatric patients with renal tumors. Methods: The search focused on MIS for renal tumors in children and followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist. The initial database search identified 491 published articles, and after progressive review of abstracts and full-length articles, 19 were included in this review. Results: There were two direct comparison studies where open surgery and MIS were compared. The remaining studies reported only on minimally invasive nephrectomy. Across all studies, there were a total of 151 patients, 126 of which had Wilms tumor and 10 patients had RCC. 104 patients had MIS, with 47 patients having open surgery. In the two studies in which open surgery and MIS were directly compared, more lymph nodes were harvested during open surgery (median = 2 (MIS) vs 5 (open); mean = 2.47 (MIS) vs 3.8 (open)). Many noncomparison studies reported the harvest of 2 of fewer lymph nodes for Wilms tumor. Several MIS patients were also noted to have intraoperative spill or positive margins. Survival between groups was similar. Conclusions: There is a lack of evidence to support MIS for pediatric renal tumors. This review demonstrates that lymph node harvest has been inadequate for MIS pediatric nephrectomy and there appears to be an increased risk for intraoperative spill. Survival data are similar between groups, but follow-up times were inconsistent and patient selection was clearly biased, with only small tumors being selected for MIS. Type of study: Review article. Level of evidence: III.

Surgical Oncology Clinics of North America, Apr 1, 2021

Differentiated thyroid carcinomas are rare in young children but represent almost 10% of all mali... more Differentiated thyroid carcinomas are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. Differentiated thyroid carcinoma in children is more likely to demonstrate nodal involvement and is associated with higher recurrence rates than seen in adults. Decisions regarding extent of surgical resection are based on clinical and radiologic features, cytology, and risk assessment. Total thyroidectomy and compartment-based resection of involved lymph node basins form the cornerstone of treatment. The use of molecular genetics to inform treatment strategies and the use of targeted therapies to unresectable progressive disease is evolving.

Journal of Pediatric Surgery, Nov 1, 2020

Background: Minimally invasive surgery has broad applicability to pediatric diseases, including p... more Background: Minimally invasive surgery has broad applicability to pediatric diseases, including pediatric cancer resection. Neuroblastic tumors of childhood are highly variable in presentation, and so careful selection of appropriate candidates for minimally invasive resection is paramount to achieving safe and durable surgical and oncological outcomes. Methods: The American Pediatric Surgical Association Cancer Committee developed questions seeking to better define the role of minimally invasive surgery for neuroblastic tumors. A search using PubMed, Medline, Embase, Web of Science, ProQuest Dissertations, and Clinical Trials was performed for articles published from 1998 to 2018 in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. Results: The evidence identified is all retrospective in nature. Minimally invasive surgical resection of neuroblastic tumors is safe for carefully selected smaller (4-6 cm) image defined risk factor (IDRF)-negative abdominal tumors when oncologic principles are followed. Size is a less-well defined criterion for thoracic neuroblastic tumors. Open approaches for both abdominal and thoracic tumors may be preferable in the presence of IDRF's. Conclusion: Small tumors without IDRF's are reasonable candidates for minimally invasive resection. Surgical oncologic guidelines should be closely followed. The quality of data supporting this systematic review is poor and highlights the need for refinement in the study of such surgical techniques to improve knowledge and outcomes for patients with neuroblastic tumors.

Journal of Pediatric Surgery, Mar 1, 2022

BACKGROUND/PURPOSE Cancer predisposition syndromes (CPS) are a heterogeneous group of inherited d... more BACKGROUND/PURPOSE Cancer predisposition syndromes (CPS) are a heterogeneous group of inherited disorders that greatly increase the risk of developing malignancies. CPS are particularly relevant to pediatric surgeons since nearly 10% of cancer diagnoses are due to inherited genetic traits, and CPS often contribute to cancer development during childhood. MATERIALS/METHODS The English language literature was searched for manuscripts, practice guidelines, and society statements on "cancer predisposition syndromes in children". Following review of these manuscripts and cross-referencing of their bibliographies, tables were created to summarize findings of the most common CPS associated with surgically treated pediatric solid malignancies. RESULTS Pediatric surgeons should be aware of CPS as the identification of one of these syndromes can completely change the management of certain tumors, such as WT. The most common CPS associated with pediatric solid malignancies are outlined, with an emphasis on those most often encountered by pediatric surgeons: neuroblastoma, Wilms' tumor, hepatoblastoma, and medullary thyroid cancer. Frequently associated non-tumor manifestations of these CPS are also included as a guide to increase surgeon awareness. Screening and management guidelines are outlined, and published genetic testing and counseling guidelines are included where available. CONCLUSION Pediatric surgeons play an important role as surgical oncologists and are often the first point of contact for children with solid tumors. In their role of delivering a diagnosis and developing a follow-up and treatment plan as part of a multidisciplinary team, familiarity with common CPS will ensure evidence-based practices are followed, including important principles such as organ preservation and intensified surveillance plans. This review defines and summarizes the CPS associated with common childhood solid tumors encountered by the pediatric surgeon, as well as common non-cancerous disease stigmata that may help guide diagnosis. TYPE OF STUDY Summary paper. LEVEL OF EVIDENCE 5.

Journal of Pediatric Surgery, Nov 1, 2020

Background: Differentiated thyroid carcinomas (DTCs) are rare in young children but represent alm... more Background: Differentiated thyroid carcinomas (DTCs) are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. Methods: This article reviews the recent literature describing surgical therapeutic approaches to pediatric DTC, associated complications, and long-term recurrence and survival outcomes. Results: Similar to adult thyroid cancers, pediatric DTCs are more common in females and are associated with thyroid nodules, family history of thyroid cancer, radiation exposure, iodine deficiency, autoimmune thyroid disease, and genetic syndromes. Management of thyroid cancers in children involves ultrasound imaging, fine needle aspiration, and surgical resection with treatment decisions based on clinical and radiological features, cytology and risk assessment. Conclusions: Total thyroidectomy and compartment based resection of clinically involved lymph node basins form the cornerstone of treatment of DTC. There is an evolving literature regarding the use of molecular genetics to inform treatment strategies and the use of targeted therapies to treat iodine refractory and surgically unresectable progressive disease. Type of study: Summary review. Level of evidence: This is a review article of previously published Level 1-5 articles that includes expert opinion (Level 5).

Injury Epidemiology

Background Expert consensus recommends prescription opioid safety counseling be provided when pre... more Background Expert consensus recommends prescription opioid safety counseling be provided when prescribing an opioid. This may be especially important for youth with preexistent alcohol and other drug (AOD) use who are at higher risk of developing opioid use disorder. This study examined the frequency that adolescent trauma patients prescribed opioids at hospital discharge received counseling and if this differed by adolescents’ AOD use. Method This study was embedded within a larger prospective stepped-wedge type III hybrid implementation study of AOD screening across a national cohort of pediatric trauma centers. Data were collected during 2018–2021 from admitted adolescent trauma patients (12–17 yo) at seven centers. Patient data were extracted from the electronic health record (EHR) on any prescribed discharged opioids, documentation of counseling delivered on prescribed opioid, who delivered counseling, and patients’ AOD screening results. Additionally, adolescents received an o...

Trauma Surgery & Acute Care Open

ObjectivesThe primary objective of this study was to examine opioid prescription frequency and id... more ObjectivesThe primary objective of this study was to examine opioid prescription frequency and identify differences across a national cohort of pediatric trauma centers in rates of prescribing opioids to injured adolescents at discharge.MethodsThis was a retrospective observational study using electronic health records of injured adolescents (12–17 years) admitted to one of 10 pediatric trauma centers.ResultsOf the 1345 electronic health records abstracted, 720 (53.5%, 95% CI 50.8 to 56.2) patients received opioid prescriptions at discharge with variability across sites (28.6%–72%). There was no association between patient factors and frequency of prescribing opioids. Center’s trauma volume was significantly positively correlated with a higher rate of opioid prescribing at discharge (r=0.92, p=0.001). There was no significant difference between the frequency of opioid prescriptions at discharge among alcohol and other drugs (AOD)-positive patients (53.8%) compared with AOD-negative ...

Endocrinology and Metabolism Clinics of North America, Jun 1, 2014

Thyroid cancer surgery Central neck dissection Modified radical neck dissection Pediatric thyroid... more Thyroid cancer surgery Central neck dissection Modified radical neck dissection Pediatric thyroid cancer KEY POINTS Surgery is the treatment of choice for most patients with thyroid cancer. Surgical experience is directly related to favorable outcomes. Several aspects of thyroid cancer surgery are controversial and expert judgment is required.

Journal of Pediatric Surgery, May 1, 2012

Background: Abdominal wall defects in children are not always amenable to primary repair and may ... more Background: Abdominal wall defects in children are not always amenable to primary repair and may require a patch. The ideal material has yet to be established. We sought to evaluate our experience using the bioabsorbable material Surgisis (Cook Surgical, Bloomington, IN) for abdominal closure. Methods: A retrospective chart review of abdominal wall defects repaired with Surgisis in our institution from 2000 to 2010 was performed. Data extracted included cause of defect, age at operation, possibility of skin coverage, recurrence, length of follow-up, and rate of wound infection. Results: Thirteen patients were identified. Cause of defect was gastroschisis (n = 2), ventral hernia after diaphragmatic hernia repair (n = 2), and omphalocele (n = 9). At median follow-up of 60 months (range, 10-90), 5 (38%) of 13 patients recurred, and 1 patient recurred twice. All recurrences required subsequent patch closure. Six instances of wound infection required antibiotics. None required patch removal. There was a trend toward more frequent recurrence among infants undergoing patch repair (3/4 recurrences in this group) than neonates (1/4 recurrences) or children older than 18 months (1/5 recurrences). Conclusion: Our data suggest that Surgisis is moderately successful in the repair of pediatric abdominal wall defects. We noted a trend toward a higher recurrence rate in infants. Further studies investigating timing of repair and alternative biosynthetic materials are warranted.

Journal of Pediatric Surgery, Jul 1, 2023

Journal of Pediatric Surgery, Sep 1, 2020

Although most children with cancer can be cured of their disease, a subset of patients with adver... more Although most children with cancer can be cured of their disease, a subset of patients with adverse tumor types or biological features, and those with relapsed or refractory disease have significantly worse prognosis. Furthermore, current cytotoxic therapy is associated with significant late effects. Precision oncology, using molecular therapeutics targeted against unique genetic features of the patient's tumor, offers the potential to transform the multimodal therapy for these patients. Potentiated by advances in sequencing technology and molecular therapeutic development, and accelerated by large-scale multi-institutional basket trials, the field of pediatric precision oncology has entered the mainstream. These novel therapeutics have important implications for surgical decision making, as well as pre-and postoperative care. This review summarizes the current state of precision medicine in pediatric oncology including the active North American and European precision oncology clinical trials. Level of evidence: Treatment study Level V.

Annals of Oncology, Jun 1, 2020

Background: The term germline is commonly used to refer to any non-tumor control sample analyzed ... more Background: The term germline is commonly used to refer to any non-tumor control sample analyzed in tumorenormal paired sequencing experiments. Blood is the most commonly utilized control, and variants found in both tumor and blood are considered germline. However, somatic variants accumulate within an organism from embryogenesis throughout life. The resultant mosaicism is extensive and calls into question the assumption that blood, or any somatic tissue, represents the germline. Misclassification of germline and somatic variants has critical consequences for individual patient care and enormous impact on our health care system, given potential screening, counseling, and treatment implications of misidentifying germline variants. Patients and methods: Whole-exome sequencing was performed on six separate specimens from each of two patients with papillary thyroid carcinoma, and three specimens each from eight additional patients forming a validation cohort. Tumor variants were compared with each individual non-tumor control and with composite control sets generated as approximations of true germline. For the index patient, parental blood was also sequenced to assess whether patientonly samples could approximate a trio-derived germline. Results: Using different non-tumor control tissues results in altered germlineesomatic designation of tumor variants. In patient 1, 82% of variants are labeled germline using blood control, compared with 75.8%, 61.5%, and 49.6% using lymph node, thyroid, and thymus, respectively. In patient 2, the thyroid control resulted in the greatest percentage of germline calls (70.0%), followed by thymus (56.0%), lymph node (50.1%), and blood (44.1%). Composite control sets built from multiple samples can approximate the germline, even in the absence of parental DNA. Conclusions: Misclassification of germlineesomatic origin has potential consequences for patient care, informing screening, trial eligibility, prophylactic interventions, and family planning. This study demonstrates the need for caution in interpreting germlineesomatic designation if these data are to inform clinical decisions and suggests that improved design of controls can overcome current limitations.

Journal of pediatric surgery case reports, Apr 1, 2018

Papillary cystadenoma of the epididymis (PCE) is the second most common benign neoplasm of the ep... more Papillary cystadenoma of the epididymis (PCE) is the second most common benign neoplasm of the epididymis [1]. It is very uncommon and has never been reported in a prepubertal male. It may occur sporadically, but more often occurs in association with von Hippel-Lindau (VHL) disease [2]. There have been over 60 reports of patients with such tumors, with the youngest patient being 16 years old. We present the case of a 12-year old male with a history of stage IV neuroblastoma. He presented with a left paratesticular mass that was discovered on routine follow up physical exam with his pediatric oncologist. He was asymptomatic at the time of presentation with no signs or symptoms of hypoandrogenism. A computed tomography scan of the abdomen and pelvis was negative for lymphadenopathy and additional disease sites. Given the patient's history of stage IV neuroblastoma, there was suspicion of yolk sac tumor or metastases; he underwent an open radical left orchiectomy. Frozen section was consistent with yolk sac tumor, however final pathology revealed normal testicle with PCE. To date, this patient is the youngest reported patient with this diagnosis; furthermore papillary cystadenoma of the epididymis has never been reported in a patient with neuroblastoma.

Journal of pediatric surgery case reports, Jun 1, 2014

Journal of Pediatric Surgery, Jun 1, 2015

Purpose-We evaluated prognostic factors among young patients with early stage melanoma, with part... more Purpose-We evaluated prognostic factors among young patients with early stage melanoma, with particular attention to survival, recurrence, and development of a second primary melanoma. Methods-We retrospectively reviewed patients (age <22 years) with pathologically confirmed in-situ and stage 1 non-Spitzoid melanoma treated at our institution from 1980-2010, assessing demographics, clinical presentation, treatment, disease-specific survival, recurrence-free survival, and probability of developing a second primary melanoma.

Surgical Oncology Clinics of North America, 2019

Minimally invasive surgical (MIS) approaches are being increasingly used in a wide variety of tum... more Minimally invasive surgical (MIS) approaches are being increasingly used in a wide variety of tumor types but there are no pediatric trials comparing MIS and open approaches, so great caution should be taken to ensure that oncologic principles are upheld. Although thoracoscopic approaches to tumor biopsy are now considered the preferred method of obtaining tissue, MIS approaches to certain tumors (eg, metastatic osteosarcoma) are contraindicated in the pediatric surgical literature. Challenges to MIS approaches to pediatric tumors include small working space for large tumors, the need for a large incision for extraction, that heterogeneity of tumor types defies a uniform approach, and a low case volume per tumor type for most surgeons.

Journal of Pediatric Surgery, Apr 1, 2022

BACKGROUND Testicular germ cell tumors are uncommon tumors that are encountered by pediatric surg... more BACKGROUND Testicular germ cell tumors are uncommon tumors that are encountered by pediatric surgeons and urologists and require a knowledge of appropriate contemporary evaluation and surgical and medical management. METHOD A review of the recommended diagnostic evaluation and current surgical and medical management of children and adolescents with testicular germ cell tumors based upon recently completed clinical trials was performed and summarized in this article. RESULTS In this summary of childhood and adolescent testicular germ cell tumors, we review the initial clinical evaluation, surgical and medical management, risk stratification, results from recent prospective cooperative group studies, and clinical outcomes. A summary of recently completed clinical trials by pediatric oncology cooperative groups is provided, and best surgical practices are discussed. CONCLUSIONS Testicular germ cell tumors in children are rare tumors. International collaborations, data-sharing, and enrollment of patients at all stages and risk classifications into active clinical trials will enhance our knowledge of these rare tumors and most importantly improve outcomes of patients with testicular germ cell tumors. LEVEL OF EVIDENCE This is a review article of previously published and referenced level 1 and 2 studies, but also includes expert opinion level 5, represented by the American Pediatric Surgical Association Cancer Committee.

Journal of Pediatric Surgery, Nov 1, 2020

Minimally invasive nephrectomy is performed routinely for adult renal tumors and for many benign ... more Minimally invasive nephrectomy is performed routinely for adult renal tumors and for many benign pediatric conditions. Although open radical nephroureterectomy remains the standard of care for Wilms tumor and most pediatric renal malignancies, there are an increasing number of reports of minimally invasive surgery (MIS) for those operations as well. The APSA Cancer Committee performed a systematic review to better understand the risks and benefits of MIS in pediatric patients with renal tumors. Methods: The search focused on MIS for renal tumors in children and followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) checklist. The initial database search identified 491 published articles, and after progressive review of abstracts and full-length articles, 19 were included in this review. Results: There were two direct comparison studies where open surgery and MIS were compared. The remaining studies reported only on minimally invasive nephrectomy. Across all studies, there were a total of 151 patients, 126 of which had Wilms tumor and 10 patients had RCC. 104 patients had MIS, with 47 patients having open surgery. In the two studies in which open surgery and MIS were directly compared, more lymph nodes were harvested during open surgery (median = 2 (MIS) vs 5 (open); mean = 2.47 (MIS) vs 3.8 (open)). Many noncomparison studies reported the harvest of 2 of fewer lymph nodes for Wilms tumor. Several MIS patients were also noted to have intraoperative spill or positive margins. Survival between groups was similar. Conclusions: There is a lack of evidence to support MIS for pediatric renal tumors. This review demonstrates that lymph node harvest has been inadequate for MIS pediatric nephrectomy and there appears to be an increased risk for intraoperative spill. Survival data are similar between groups, but follow-up times were inconsistent and patient selection was clearly biased, with only small tumors being selected for MIS. Type of study: Review article. Level of evidence: III.

Surgical Oncology Clinics of North America, Apr 1, 2021

Differentiated thyroid carcinomas are rare in young children but represent almost 10% of all mali... more Differentiated thyroid carcinomas are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. Differentiated thyroid carcinoma in children is more likely to demonstrate nodal involvement and is associated with higher recurrence rates than seen in adults. Decisions regarding extent of surgical resection are based on clinical and radiologic features, cytology, and risk assessment. Total thyroidectomy and compartment-based resection of involved lymph node basins form the cornerstone of treatment. The use of molecular genetics to inform treatment strategies and the use of targeted therapies to unresectable progressive disease is evolving.

Journal of Pediatric Surgery, Nov 1, 2020

Background: Minimally invasive surgery has broad applicability to pediatric diseases, including p... more Background: Minimally invasive surgery has broad applicability to pediatric diseases, including pediatric cancer resection. Neuroblastic tumors of childhood are highly variable in presentation, and so careful selection of appropriate candidates for minimally invasive resection is paramount to achieving safe and durable surgical and oncological outcomes. Methods: The American Pediatric Surgical Association Cancer Committee developed questions seeking to better define the role of minimally invasive surgery for neuroblastic tumors. A search using PubMed, Medline, Embase, Web of Science, ProQuest Dissertations, and Clinical Trials was performed for articles published from 1998 to 2018 in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines. Results: The evidence identified is all retrospective in nature. Minimally invasive surgical resection of neuroblastic tumors is safe for carefully selected smaller (4-6 cm) image defined risk factor (IDRF)-negative abdominal tumors when oncologic principles are followed. Size is a less-well defined criterion for thoracic neuroblastic tumors. Open approaches for both abdominal and thoracic tumors may be preferable in the presence of IDRF's. Conclusion: Small tumors without IDRF's are reasonable candidates for minimally invasive resection. Surgical oncologic guidelines should be closely followed. The quality of data supporting this systematic review is poor and highlights the need for refinement in the study of such surgical techniques to improve knowledge and outcomes for patients with neuroblastic tumors.

Journal of Pediatric Surgery, Mar 1, 2022

BACKGROUND/PURPOSE Cancer predisposition syndromes (CPS) are a heterogeneous group of inherited d... more BACKGROUND/PURPOSE Cancer predisposition syndromes (CPS) are a heterogeneous group of inherited disorders that greatly increase the risk of developing malignancies. CPS are particularly relevant to pediatric surgeons since nearly 10% of cancer diagnoses are due to inherited genetic traits, and CPS often contribute to cancer development during childhood. MATERIALS/METHODS The English language literature was searched for manuscripts, practice guidelines, and society statements on "cancer predisposition syndromes in children". Following review of these manuscripts and cross-referencing of their bibliographies, tables were created to summarize findings of the most common CPS associated with surgically treated pediatric solid malignancies. RESULTS Pediatric surgeons should be aware of CPS as the identification of one of these syndromes can completely change the management of certain tumors, such as WT. The most common CPS associated with pediatric solid malignancies are outlined, with an emphasis on those most often encountered by pediatric surgeons: neuroblastoma, Wilms' tumor, hepatoblastoma, and medullary thyroid cancer. Frequently associated non-tumor manifestations of these CPS are also included as a guide to increase surgeon awareness. Screening and management guidelines are outlined, and published genetic testing and counseling guidelines are included where available. CONCLUSION Pediatric surgeons play an important role as surgical oncologists and are often the first point of contact for children with solid tumors. In their role of delivering a diagnosis and developing a follow-up and treatment plan as part of a multidisciplinary team, familiarity with common CPS will ensure evidence-based practices are followed, including important principles such as organ preservation and intensified surveillance plans. This review defines and summarizes the CPS associated with common childhood solid tumors encountered by the pediatric surgeon, as well as common non-cancerous disease stigmata that may help guide diagnosis. TYPE OF STUDY Summary paper. LEVEL OF EVIDENCE 5.

Journal of Pediatric Surgery, Nov 1, 2020

Background: Differentiated thyroid carcinomas (DTCs) are rare in young children but represent alm... more Background: Differentiated thyroid carcinomas (DTCs) are rare in young children but represent almost 10% of all malignancies diagnosed in older adolescents. Methods: This article reviews the recent literature describing surgical therapeutic approaches to pediatric DTC, associated complications, and long-term recurrence and survival outcomes. Results: Similar to adult thyroid cancers, pediatric DTCs are more common in females and are associated with thyroid nodules, family history of thyroid cancer, radiation exposure, iodine deficiency, autoimmune thyroid disease, and genetic syndromes. Management of thyroid cancers in children involves ultrasound imaging, fine needle aspiration, and surgical resection with treatment decisions based on clinical and radiological features, cytology and risk assessment. Conclusions: Total thyroidectomy and compartment based resection of clinically involved lymph node basins form the cornerstone of treatment of DTC. There is an evolving literature regarding the use of molecular genetics to inform treatment strategies and the use of targeted therapies to treat iodine refractory and surgically unresectable progressive disease. Type of study: Summary review. Level of evidence: This is a review article of previously published Level 1-5 articles that includes expert opinion (Level 5).

Injury Epidemiology

Background Expert consensus recommends prescription opioid safety counseling be provided when pre... more Background Expert consensus recommends prescription opioid safety counseling be provided when prescribing an opioid. This may be especially important for youth with preexistent alcohol and other drug (AOD) use who are at higher risk of developing opioid use disorder. This study examined the frequency that adolescent trauma patients prescribed opioids at hospital discharge received counseling and if this differed by adolescents’ AOD use. Method This study was embedded within a larger prospective stepped-wedge type III hybrid implementation study of AOD screening across a national cohort of pediatric trauma centers. Data were collected during 2018–2021 from admitted adolescent trauma patients (12–17 yo) at seven centers. Patient data were extracted from the electronic health record (EHR) on any prescribed discharged opioids, documentation of counseling delivered on prescribed opioid, who delivered counseling, and patients’ AOD screening results. Additionally, adolescents received an o...

Trauma Surgery & Acute Care Open

ObjectivesThe primary objective of this study was to examine opioid prescription frequency and id... more ObjectivesThe primary objective of this study was to examine opioid prescription frequency and identify differences across a national cohort of pediatric trauma centers in rates of prescribing opioids to injured adolescents at discharge.MethodsThis was a retrospective observational study using electronic health records of injured adolescents (12–17 years) admitted to one of 10 pediatric trauma centers.ResultsOf the 1345 electronic health records abstracted, 720 (53.5%, 95% CI 50.8 to 56.2) patients received opioid prescriptions at discharge with variability across sites (28.6%–72%). There was no association between patient factors and frequency of prescribing opioids. Center’s trauma volume was significantly positively correlated with a higher rate of opioid prescribing at discharge (r=0.92, p=0.001). There was no significant difference between the frequency of opioid prescriptions at discharge among alcohol and other drugs (AOD)-positive patients (53.8%) compared with AOD-negative ...

Endocrinology and Metabolism Clinics of North America, Jun 1, 2014

Thyroid cancer surgery Central neck dissection Modified radical neck dissection Pediatric thyroid... more Thyroid cancer surgery Central neck dissection Modified radical neck dissection Pediatric thyroid cancer KEY POINTS Surgery is the treatment of choice for most patients with thyroid cancer. Surgical experience is directly related to favorable outcomes. Several aspects of thyroid cancer surgery are controversial and expert judgment is required.

Journal of Pediatric Surgery, May 1, 2012

Background: Abdominal wall defects in children are not always amenable to primary repair and may ... more Background: Abdominal wall defects in children are not always amenable to primary repair and may require a patch. The ideal material has yet to be established. We sought to evaluate our experience using the bioabsorbable material Surgisis (Cook Surgical, Bloomington, IN) for abdominal closure. Methods: A retrospective chart review of abdominal wall defects repaired with Surgisis in our institution from 2000 to 2010 was performed. Data extracted included cause of defect, age at operation, possibility of skin coverage, recurrence, length of follow-up, and rate of wound infection. Results: Thirteen patients were identified. Cause of defect was gastroschisis (n = 2), ventral hernia after diaphragmatic hernia repair (n = 2), and omphalocele (n = 9). At median follow-up of 60 months (range, 10-90), 5 (38%) of 13 patients recurred, and 1 patient recurred twice. All recurrences required subsequent patch closure. Six instances of wound infection required antibiotics. None required patch removal. There was a trend toward more frequent recurrence among infants undergoing patch repair (3/4 recurrences in this group) than neonates (1/4 recurrences) or children older than 18 months (1/5 recurrences). Conclusion: Our data suggest that Surgisis is moderately successful in the repair of pediatric abdominal wall defects. We noted a trend toward a higher recurrence rate in infants. Further studies investigating timing of repair and alternative biosynthetic materials are warranted.

Journal of Pediatric Surgery, Jul 1, 2023

Journal of Pediatric Surgery, Sep 1, 2020

Although most children with cancer can be cured of their disease, a subset of patients with adver... more Although most children with cancer can be cured of their disease, a subset of patients with adverse tumor types or biological features, and those with relapsed or refractory disease have significantly worse prognosis. Furthermore, current cytotoxic therapy is associated with significant late effects. Precision oncology, using molecular therapeutics targeted against unique genetic features of the patient's tumor, offers the potential to transform the multimodal therapy for these patients. Potentiated by advances in sequencing technology and molecular therapeutic development, and accelerated by large-scale multi-institutional basket trials, the field of pediatric precision oncology has entered the mainstream. These novel therapeutics have important implications for surgical decision making, as well as pre-and postoperative care. This review summarizes the current state of precision medicine in pediatric oncology including the active North American and European precision oncology clinical trials. Level of evidence: Treatment study Level V.

Annals of Oncology, Jun 1, 2020

Background: The term germline is commonly used to refer to any non-tumor control sample analyzed ... more Background: The term germline is commonly used to refer to any non-tumor control sample analyzed in tumorenormal paired sequencing experiments. Blood is the most commonly utilized control, and variants found in both tumor and blood are considered germline. However, somatic variants accumulate within an organism from embryogenesis throughout life. The resultant mosaicism is extensive and calls into question the assumption that blood, or any somatic tissue, represents the germline. Misclassification of germline and somatic variants has critical consequences for individual patient care and enormous impact on our health care system, given potential screening, counseling, and treatment implications of misidentifying germline variants. Patients and methods: Whole-exome sequencing was performed on six separate specimens from each of two patients with papillary thyroid carcinoma, and three specimens each from eight additional patients forming a validation cohort. Tumor variants were compared with each individual non-tumor control and with composite control sets generated as approximations of true germline. For the index patient, parental blood was also sequenced to assess whether patientonly samples could approximate a trio-derived germline. Results: Using different non-tumor control tissues results in altered germlineesomatic designation of tumor variants. In patient 1, 82% of variants are labeled germline using blood control, compared with 75.8%, 61.5%, and 49.6% using lymph node, thyroid, and thymus, respectively. In patient 2, the thyroid control resulted in the greatest percentage of germline calls (70.0%), followed by thymus (56.0%), lymph node (50.1%), and blood (44.1%). Composite control sets built from multiple samples can approximate the germline, even in the absence of parental DNA. Conclusions: Misclassification of germlineesomatic origin has potential consequences for patient care, informing screening, trial eligibility, prophylactic interventions, and family planning. This study demonstrates the need for caution in interpreting germlineesomatic designation if these data are to inform clinical decisions and suggests that improved design of controls can overcome current limitations.

Journal of pediatric surgery case reports, Apr 1, 2018

Papillary cystadenoma of the epididymis (PCE) is the second most common benign neoplasm of the ep... more Papillary cystadenoma of the epididymis (PCE) is the second most common benign neoplasm of the epididymis [1]. It is very uncommon and has never been reported in a prepubertal male. It may occur sporadically, but more often occurs in association with von Hippel-Lindau (VHL) disease [2]. There have been over 60 reports of patients with such tumors, with the youngest patient being 16 years old. We present the case of a 12-year old male with a history of stage IV neuroblastoma. He presented with a left paratesticular mass that was discovered on routine follow up physical exam with his pediatric oncologist. He was asymptomatic at the time of presentation with no signs or symptoms of hypoandrogenism. A computed tomography scan of the abdomen and pelvis was negative for lymphadenopathy and additional disease sites. Given the patient's history of stage IV neuroblastoma, there was suspicion of yolk sac tumor or metastases; he underwent an open radical left orchiectomy. Frozen section was consistent with yolk sac tumor, however final pathology revealed normal testicle with PCE. To date, this patient is the youngest reported patient with this diagnosis; furthermore papillary cystadenoma of the epididymis has never been reported in a patient with neuroblastoma.

Journal of pediatric surgery case reports, Jun 1, 2014

Journal of Pediatric Surgery, Jun 1, 2015

Purpose-We evaluated prognostic factors among young patients with early stage melanoma, with part... more Purpose-We evaluated prognostic factors among young patients with early stage melanoma, with particular attention to survival, recurrence, and development of a second primary melanoma. Methods-We retrospectively reviewed patients (age <22 years) with pathologically confirmed in-situ and stage 1 non-Spitzoid melanoma treated at our institution from 1980-2010, assessing demographics, clinical presentation, treatment, disease-specific survival, recurrence-free survival, and probability of developing a second primary melanoma.

Surgical Oncology Clinics of North America, 2019

Minimally invasive surgical (MIS) approaches are being increasingly used in a wide variety of tum... more Minimally invasive surgical (MIS) approaches are being increasingly used in a wide variety of tumor types but there are no pediatric trials comparing MIS and open approaches, so great caution should be taken to ensure that oncologic principles are upheld. Although thoracoscopic approaches to tumor biopsy are now considered the preferred method of obtaining tissue, MIS approaches to certain tumors (eg, metastatic osteosarcoma) are contraindicated in the pediatric surgical literature. Challenges to MIS approaches to pediatric tumors include small working space for large tumors, the need for a large incision for extraction, that heterogeneity of tumor types defies a uniform approach, and a low case volume per tumor type for most surgeons.