What is the value of tumor resection in kids with high risk neuroblastoma?

In a recent review of available literature on the subject of the impact of surgical resection on the outcome of patients with high risk NB, I came across this report by Englum et al in Pediatric Blood and Cancer.  

The authors looked at the impact of gross total resection (GTR) vs less than gross total resection on overall survival in 87 patients operated on in 14 different institutions.  Although no significant difference in OS (~50%) between the two groups could be found, the data did show a significant improvement in OS when more than 90% resection of the tumor was performed.

When the data was broken down by subgroups based on extent of resection, the results were as follows: 5-year survival was 53% after GTR, 64% after more than 90% resection , 35% after less than 90% resection, and 14% after biopsy only or no surgery.

As with all retrospective studies, it is difficult to tease out potential confounding variables that determine outcome in these patients, especially with a condition as complex as neuroblastoma.  This study does, however, add some more information that can help us when deciding how hard to continue to push when that last bit of tumor just will not come off that IVC safely!

Do we really need screening UGI's before G tube placement?

The logic behind performing screening UGI studies before g tube placement has always escaped me.  I understand the rationale behind screening for malro before a Nissen +/- g tube, since reflux could be due to some level of partial obstruction from malro; but why UGI's for g tubes without reflux?  It certainly is not a useful test to screen for reflux.  We definitely do not need to know where the stomach is before place a g tube, so why the radiation exposure?

A study by Abbas et al noted that the incidence of unexpected malro identified by screening UGI's performed for patients undergoing a routine gastrostomy tube placement is 1.7% (5/229).

Even if one accepts that avoiding a potential catastrophic event in 2 patients is worth the risk of radiation (300 cGy/UGI study) to the other 98, this logic should be applicable to all preop patients (since the need for a g tube does not necessarily select out a population at higher risk of malrotation).

So why do we not screen all preop patients with UGI's?(not suggesting that we should, for the trolls out there!).

Some more data to help support what we do (or don't do).