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Multiple Surgeons Consult on Procedures for Pediatric Solid Tumor Program

Research involvement further drives positive outcomes for children, adolescents with rare tumor types

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Physicians reviewing scans together

Duke’s Pediatric Solid Tumor program offers special expertise in the removal of rare solid tumors—particularly in the abdominal and thoracic regions—including Wilms tumor, rhabdomyosarcoma, and other cancers. Although tumor boards are common at children’s hospitals (and are standard practice at Duke), Jonathan C. Routh, MD, MPH, Chief of Duke Children’s Surgery and a pediatric urologist, says the Duke program takes this multidisciplinary approach a step further with its practice of bringing in multiple fellowship-trained specialists to perform every surgery.
 
“Our team approach to taking care of these children happens every single time,” Routh says. “Because these cases are so rare, it’s very challenging for any one surgeon to accrue the impressive degree of expertise on our team. By concentrating our experience, we are able to dramatically improve the care of every child we see, with many hundreds of rare cases between the people who are involved in each surgery at Duke.”
 
This approach has dramatically improved surgical outcomes for pediatric solid tumor cases, including tumor rupture and positive margin rates as compared to peer institutions nationwide. “For Wilms tumor, for example, our positive margin and rupture rate is less than 1%, but that rate is typically 10% to 15% in published trials,” Routh adds.
 
The pediatric team tailors each surgery to the individual child’s needs and the details of each specific tumor, collaborating when needed with adult surgical partners at Duke to come up with the most minimally invasive care plan possible. These rare diseases require a specific surgical expertise for pediatric patients to be able to excise the tumor while preserving as much of the organ as possible so that it can function normally after the procedure. For more aggressive tumors, which may require a complex laparoscopic or robotic-assisted approach, Routh invites an adult-focused specialist to join the surgery. 

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Commitment to Reseach

In addition to the combined expertise in the OR, the commitment to research at Duke is unique in North Carolina, Routh says: “From a pediatric surgical oncology perspective, Duke is very involved in the ongoing national and international research trials and study design. Our work is really driving a lot what's going on nationally.”
 
As an example of this innovation and leadership, Elisabeth T. Tracy, MD, a Duke pediatric surgeon, sits on the national Children’s Oncology Group (COG) Renal Tumor Committee and is a leader in the Pediatric Surgical Oncology Research Collaborative. Likewise, Routh sits on the COG’s Soft Tissue Sarcoma Committee and recently completed a term as the President of the Pediatric Urologic Oncology Working Group.
 
Here are a few examples of the commitment to research at Duke:

  • Wilms tumors. Routh explains that a vast majority of children with Wilms tumors are treated on a COG research study in the United States. “By helping to shape those trials, our group is effectively shaping the way that kids with this disease are treated,” he says, adding that the standard of care for abdominal and thoracic cancers varies widely and depends on tumor type.  Drs. Routh and Tracy have written extensively on organ-sparing and minimally invasive treatments for Wilms tumor, neuroblastoma, and other pediatric cancers.
  • Paratesticular rhabdomyosarcoma. Routh and COG Soft Tissue Sarcoma Committee colleagues wrote up the world's biggest experience with this uncommon tumor type in a December 2020 issue of the International Journal of Cancer. “Ten years ago, we would frequently need to actually excise not just the tumor, but a large amount of surrounding tissue to ensure that the cancer doesn’t recur. But when the COG did its analysis on paratesticular rhabdomyosarcoma, we found out that there was no real survival benefit to doing that, so we can now perform a much less morbid surgery for the child or adolescent and still ensure that they have a good outcome.”