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Tiny Tools Remove Huge Tumor

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NEW YORK, NY (Ivanhoe Newswire) - Imagine being told you have a five pound tumor growing inside you.  Now imagine getting that news when you're 13.  That's exactly what happened to one girl, but a minimally invasive option, usually reserved for adults, helped the talented teen.

She can work the keys of a piano, light up the strings of a violin and perform in unison with her siblings. For Anna Cole music is a way of life. It's also the reason Anna's mom knew something was wrong with her daughter. 

"I'm a musician, and I notice posture, and I noticed that she had a little curvature, a little hump on her right side," Chee-hwa Cole, Anna's Mom, told Ivanhoe.

Anna's dad, a cardiologist, didn't think much of it.

"Even though I'm a doctor, I'm not a doctor to my kids. I'm a dad to my kids." Chris Cole, said

Still, he suggested she see the pediatrician. Scans showed the 13-year-old had a five-pound tumor the size of a volleyball growing in her chest! 

"We said, ‘it's a tumor', and her first question was, ‘am I going to die?'" Chee-hwa said.

"I just started crying because I was kind of scared," Anna revealed.

Doctor Steven Rothenberg said removing tumors with a minimally-invasive approach is the best way, but Anna's tumor was different.

"The size of it made most physicians feel that there was no way they could do it using these small incisions," Steve Rothenberg, Chief of pediatric surgery and Clinical Professor of surgery at Columbia University College of Physicians and Surgeons, said.

The standard procedure involves making a 14 inch incision across the chest and a long, painful recovery. Instead, Dr. Rothenberg tried a minimally invasive technique. Using tiny instruments, he extracted Anna's tumor from her chest – dodging blood vessels, her lung and spine.

"I had to keep trying to circle the tumor to get all the aspects," Dr. Rothenberg explained.

Then, he chopped up the tumor and used a bag to pull it out piece by piece. The entire surgery was performed through four tiny incisions. Anna's tumor was not cancerous and she felt good enough to play at a piano recital just a week after her surgery!

"If we'd done an open thoracotomy, she wouldn't be able to do this for months," Dr. Rothenberg said.

"I had been looking forward to it, and I didn't want to miss it just because of my surgery," Anna said.

A dedicated musician who won't let anything interfere with a performance.

In addition to offering shorter recovery and less pain, minimally-invasive approaches also lower the risk of scarring and chest deformities like scoliosis. Dr. Rothenberg says he can always fall back on an open, traditional surgery if he needs to when performing a minimally-invasive procedure.

RESEARCH SUMMARY

BACKGROUND: A tumor is an abnormal mass of tissue. Tumors are a classic sign of inflammation, and can be benign or malignant (cancerous). In general, tumors occur when cells divide excessively in the body. Typically, cell division is strictly controlled. New cells are created to replace older ones or to perform new functions. Cells that are damaged or no longer needed die to make room for healthy replacements. If the balance of cell division and death is disturbed, a tumor may form.There are dozens of different types of tumors. Their names usually reflect the kind of tissue they arise in, and may also tell you something about their shape or how they grow. For example, a medulloblastoma is a tumor that arises from embryonic cells (a blastoma) in the inner part of the brain (the medulla). Diagnosis depends on the type and location of the tumor. Tumor marker tests and imaging may be used; some tumors can be seen or felt. (www.medterms.com)

MINIMALLY INVASIVE SURGERY: Traditional open surgical techniques are being replaced by new technology in which a small incision is made and a rigid or flexible endoscope is inserted, enabling internal video imaging. Endoscopic procedures are commonly performed on nasal sinuses, intervertebral disks, fallopian tubes, shoulders, and knee joints, as well as on the gall bladder, appendix, and uterus. In minimally invasive procedures, the doctor makes one or more incisions, each about a half-inch long, to insert a tube. The number of incisions depends on the type of surgery. The tube or tubes let the doctor slip in tiny video cameras and specially designed surgical instruments to perform the procedure. When minimally invasive surgery is performed, the patient is likely to lose less blood and have less postoperative pain, fewer and smaller scars, and a faster recovery than open surgery. (www.mayoclinic.com, www.britannica.com)

DR. STEVEN S. ROTHENBERG: A world leader in the field of endoscopic surgery in infants and children, he has pioneered many of the procedures using minimally invasive techniques. He has authored over 100 publications on minimally invasive surgery in children and has given over 200 lectures on the subject nationally and internationally. He is also an editor for the Journal of Laparoendoscopic and Advanced Surgical Techniques. Rothenberg is Chief of Pediatric Surgery and Chairman of the Department of Pediatrics at the Rocky Mountain Hospital for Children in Denver, Co. He is also an Associate Clinical Professor of Surgery at the University of Colorado. Dr. Rothenberg completed medical school and general surgery residency at the University of Colorado in Denver. He then spent a year in England doing a fellowship in General Thoracic Surgery, returning to complete a two year Pediatric Surgery fellowship at Texas Children's Hospital in Houston. He returned to Colorado in 1992 where he has been in private practice for the last 15 years. (www.orlive.com)

INTERVIEW

Dr. Steve Rothenberg, Chief of Pediatric Surgery at Rocky Mountain Hospital for Children, Spaciality Minimally Invasive Surgery for Children talks about removing a large tumor from a child's chest using a minimally invasive procedure. You have been doing this for quite a while you were one of the pioneers in this.

Dr. Rothenberg:  Minimally Invasive surgery really started right around 1990 and it started just after that in pediatric surgery but not many pediatric surgeons adopted the techniques.

We started doing it when I returned to Denver in 1992 we started doing the first cases.
So did you first start doing it using the tools used for adults?

Dr. Rothenberg:  Right, the instrumentation that was available in the early 1990's was although much better than doing a big open incision was still very large. The diameter of most of the instruments were ten millimeters and many of the tools were even bigger than that and they were very long. So many of the instruments were actually bigger than many of my patients and it made it very difficult to adopt these techniques to kids.

How did you go about building new instruments?

Dr. Rothenberg:  Initially we used what was available and once there were a few of us who had some volume we got some of the instrument companies to talk to us. Basically every time I would go to a meeting I would kind of beat them over the head and say you need to start building things for pediatric surgeons because I think if we make the right tools more pediatric surgeons will do this. Then one or two of the companies showed some interest and they just came and spent a lot of time in my operating room and we would talk about instrument design and what would help. And gradually over the last fifteen years we've now developed some really excellent pediatric size instruments so that I can do a patient as small as under a Kelo or under two pounds to as large as two hundred pounds.

Is that your smallest under two pounds?

Dr. Rothenberg:  Actually the smallest one I think I have done is a little bit smaller than that, probably about a pound and a half.

What did that baby need?

Dr. Rothenberg:  The baby needed an abdominal operation, the baby had an intestinal obstruction and we were able to go in and relieve it laparoscopically.

Why is this so important, what's the difference?

Dr. Rothenberg: When you talk about adults and minimally invasive surgery everybody talks about you really have less pain after surgery. So because you have less pain and there is less tissue damage there is quicker recovery. It's kind of like if you go in and have your gallbladder taken out you don't need to stay in the hospital overnight you can go back to work in a couple of days and you have significantly less pain and you're back to full activity quicker. So that's the general benefit and the same is true in kids is that if you are able to operate using these techniques they have much less pain after surgery. They don't have to go back to work but the sooner the kid gets out of the hospital the quicker the rest of the family can get back to their normal routine and back to work. So you have the same social economic savings as you do in adults. And then I think the more important thing in kids, and also there's a cosmetic benefit, by having these tiny incisions when I operate on babies using these two and three millimeter instruments when they come back at two or three years of age you can't see their incision at all. And so cosmetically it's much, much better. But then there's another piece that when we operate on a child either through an abdominal incision or through a chest incision we create tissue damage that then lives with them the rest of their life. In the case of an abdominal operation you develop scar tissue after that, that can later cause a bowel obstruction or other problems. And by doing it laparoscopically we have almost completely eliminated the development of these adhesions or scar tissue. So these kids don't get bowel obstructions anymore so it's a huge long life kind of lifetime saving that we're keeping them from the morbidity of that incision the rest of their life. And the same is true for chest incision or thoracotomy incision or an open incision is probably the most morbid incision that we do in a kid. And we know if you do an open chest incision in a baby or a small child that child has a twenty, thirty percent chance of developing shoulder girdle weakness, chest wall deformity and scoliosis. And even though it may not be clinically significant enough for them to have to wear a brace or have surgery it's definitely there if you really look for it and measure it. And by doing these operations thoracoscopically we've eliminated that because we don't have the same morbidity from the incisions.

Why are some doctors still hesitant to do minimally invasive?

Dr. Rothenberg: I think initially it was because some of the physicians weren't convinced it was better. The common that I would often here is well you know kids don't have to go back to work so why do you have to do it. Or I do mine through a very small incision anyway so what's really the benefit. But that's really kind of gone through the wayside, people are not really buying that anymore and I think most physicians really don't believe it. The biggest reason is that it's learning new techniques and some of them are technically demanding. It can be very difficult to do some of these techniques using minimally invasive approaches. So it takes another skill set and it takes a lot of dedication and it takes a dedicated team. The whole hospital sort of needs to be involved and dedicated to working in this particular arena because you need to have all the equipment. You need to have the appropriate support people. Where I am we're very fortunate in that the hospital has been very supportive and so we have state of the art operating rooms and equipment that makes it easier to try and approach some of these more complex cases.

Why did a lot of doctors not want to do this with Anna?

Dr. Rothenberg:  Well I think the feeling was she had a massive tumor in her chest and based on the way it was growing and the fact that she had actually done quite well I think most of us were pretty convinced it was a benign tumor. Meaning it was only bad because it was getting so big and compressing her lung and her heart and everything else. But I think the size of it made most physicians feel that there was no way they could do it using these small incisions, one issue is that the surgery would be very technically demanding doing it thoracoscopically. You're operating around giant blood vessels and around the lung and a lot of surgeons, pediatric surgeons aren't comfortable doing that using the minimally invasive approach. And then the other would be even if you were able to resect this mass off her chest wall how would you get it out? You still have this giant mass. And so there are very few surgeons who would think about approaching it this way.

What was the size of it?

Dr. Rothenberg:  It was about the size of a volleyball.

She was a thirteen year old?

Dr. Rothenberg:
  I think she was eleven when we did it.

Is she a tiny girl?

Dr. Rothenberg:  She is very slight, she's a beautiful girl but she was very thin and slight and so it took up over half the space in her left chest.

How much did that weigh?

Dr. Rosenberg: That tumor I think weighed almost five pounds.

Have you ever seen something that big in such a small girl?

Dr. Rosenberg:  It had been a long time, but not in that small of a child. It's amazing that she did so well for so long with that big of a mass in her chest.

What did you think when you first saw her scans?

Dr. Rosenberg:  I thought it was a really big mass.

Did you have any hesitation that you could get it out?

Dr. Rosenberg:  No, you know my feeling is that you can always make an open incision. You know that you can always fall back on making a really big incision but that with rare exception it's always worth trying to approach it using minimally invasive techniques first because the benefits to the child are so great. And that's how I talk to parents about it even some procedures when we've been the first ones in the world to do them. Some of the ones we've done in babies and other things and I feel that I have adequate skills to do that I just explain to the parents what I think the benefits are. And the benefits are avoiding that giant incision. So in Anna's case I told the parents I felt based on the kind of tumor it was that we wouldn't be compromising her care by using minimally invasive techniques. And secondly that I felt that I stood a good chance of being able to do it and that if I couldn't I could always convert to an open surgery. Some surgeons concern is that they will run in to problems of bleeding or something else that if you don't have a big open incision it's very hard to control and I think they're uncomfortable with that. And we've sort of developed techniques where I feel that we're operating in a safe environment and we can keep those variables under control.

Go ahead and explain to us.

Dr. Rosenberg: This is a frame of Anna's CAT scan and here you can see this giant mass, here's the giant mass that's occupying in this particular view four fifths of her chest. It only went up about two thirds the way up her chest but this is the normal chest so this is what it should look like and this big white piece here is the mass. So that's what we were dealing with and why most people felt this couldn't be done orthoscopically. So now we'll go from that. This is a AP view where we've got a chronal section and that just showed the tumor. So here is where we put the scope in and here is the tumor right here. You can see this giant mass it's compressed the lung completely out of the way. This right here is her spine, these are what we call intercostal vessels or vertebral vessels that are coming off of it. And the tumor had a really broad base that was attached back along her spine, along her vertebral column. So what we're doing now is using instrumentation to kind of open up that plain and cut through the overlying layer that's covering the tumor, it's called the plura and again the aorta is right here the large blood vessel that takes blood from the heart to the rest of the body. Here's one down here so that's all compressed out of the way.

How big is this instrument?

Dr. Rothenberg: This instrument right here the diameter of that instrument is five millimeters. So that's about a quarter of an inch and it's an electrocautery and this is one of the large blood vessels that are going in to it so all of these instruments are five millimeters in diameter. Its two and a half sonometers are an inch so it's half a sonometer. And then gradually you can see this is the whole surface that we had to disconnect where it was attached back to the chest wall and the spine and we're gradually working all the way around it. And so I had to keep kind of circling the tumor trying to get at all the aspects. And you can see it's so big it's very hard to manipulate and it's very hard to see where the attachments are and there were some big blood vessels. And now that we've got it completely off we're putting it in to a bag and the reason for doing that is so that we can bring the bag out through a smaller incision and remove it piecemeal.

How many times did you have to bring the bag out?

Dr. Rothenberg: What you do is you get it in the bag and then you bring the neck of the bag out through the small incision. This incision right here and that incision is probably about two inches wide. Now if I had done this open I would have had an incision from here all the way down to here it would have been the only way to approach the tumor. Then once I brought the neck of the bag out I actually reached inside through the small incision and in to the bag and cut the tumor in to pieces and then I brought it out piecemeal. So once I brought the neck of the bag out that's all I did and then I kept reaching in and breaking up the tumor and getting it out.

How many pieces did you break in to?

Dr. Rothenberg: I had probably dozens, I mean there was a lot.

What was the most dangerous part of the surgery?

Dr. Rothenberg:  The most dangerous part of this surgery was dissecting it off of the spine and getting it off of the aorta where there were two large blood vessels that were coming directly up in to the tumor.

Was there any time when you thought you might have to make a large incision?

Dr. Rothenberg:  There were times when it got very difficult and where especially around the large blood vessels that if we would run in to a problem that I knew we might have to. But really we never reached a point where it seemed like we might have to. In a case like this you just have to be very patient and it takes as long as it takes and just keep going at it steadily.

How many hours?

Dr. Rothenberg: Anna's surgery I think took about three and a half hours.

Did it shorten the time of surgery with this?

Dr. Rothenberg: I think so, I think this would have been a very long open case. For one of the things it takes much longer to open the chest and then to close it again.

How much longer?

Dr. Rothenberg:
  Open this might have taken about an hour more.

So what do we see here?

Dr. Rothenberg:
This is the larger incision we ended up making to bring the tumor out and I did it low because the space between the ribs is larger there so we had a little more room to work. And then these are actually, because there are scabs on it but these are the incisions we used to do the surgery so there's one here, one here and one here. And these two were five millimeter incisions although again because of the scabs it's hard to tell. This one was a little bit larger, that was a ten millimeter incision or about a half inch and at one point we used a device, a stapler that required that big of an incision.

So go to where she's playing
.

Dr. Rothenberg:
  This video was given to me by Anna's dad and this is about ten days after surgery. And  Anna had a recital which was very important to her in which she was scheduled to play at.

Does that just amaze you?

Dr. Rothenberg:
First of all it amazes me that she can play the piano that well but when you think about the fact that she just had this huge operation and this is less than ten days after and she's able to move with that much dexterity. If we had done an open thoracotomy she wouldn't have been able to do this for months.

Do you want to talk about the importance of why you brought the bag back out.

Dr. Rothenberg:
  Based on everything we saw on all the scans and the way this tumor had grown very slowly over what we presume was a long period of time and that Anna was actually doing very well I assumed the tumor was benign, not malignant. Meaning that it wasn't invading in to other tissues and there wasn't a high risk that it would spread and go somewhere else. But we didn't know for sure until we got it out. And so the reason for putting it in the bag is that by bringing the neck of the bag out through the incision and then only cutting the tumor inside the bag is that way we would prevent tumor from spreading anywhere in the chest or anywhere at the incision sites. So by putting the tumor in the bag and bringing the neck of the bag out as we cut in to the tumor we eliminated any risk that we might spread malignant tumor cells anywhere in her chest that might cause her to have a recurrence or have the tumor spread somewhere else.

How often will she have to come back to see you to make sure nothing is growing there again?

Dr. Rothenberg:
  We re-scanned her six months or a year after surgery and that's all she needs. She's fixed and cured.

FOR MORE INFORMATION, PLEASE CONTACT:

Steven Rothenberg
Chief of pediatric surgery RMHC
Clinical Professor of surgery
Columbia University College of physicians and surgeons.
(303) 839-6001
Dr.Rothenberg@pediatricsurgeon.com

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