Preparation for Surgery for Supratentorial Primitive Neuroectodermal Tumors in Children

Indications for Surgery

Surgical resection is the first line of treatment for supratentorial PNETs. The goals of surgery are:

• Tissue diagnosis: A primary goal of surgery is to obtain neoplastic tissue for histopathology.
• Treat symptoms: The removal of tumor mass will relieve symptoms it has caused  (including hydrocephalus).
• Decrease tumor burden: Every attempt should be made to safely resect the maximal amount of tumor volume as a part of the multimodal treatment to effect tumor control. Later resection of the tumor may obviate the need for a permanent shunt.

Preoperative Orders

• NVS: Done initially every hour after admission, even if the child appears stable. Once the child becomes symptomatic and has to be admitted, unexpected rapid deterioration may occur.
• Steroids: Children with symptomatic elevated ICP are managed with high-dose dexamethasone prior to surgery.
• Hydrocephalus: If emergent CSF diversion is required prior to resection of the tumor, a temporary EVD is preferred to a ventricular shunt. A decision about a permanent shunt can be made after the tumor has been resected. If an EVD is inserted, CSF is drained to a pressure of 15 to 20 cm H2O to prevent collapse of the drained lateral ventricle.
• IVF rate: If an IV is inserted because the child is unstable, isotonic IV fluids are given at 60% of maintenance.
• No antibiotics: Antibiotics are not started preoperatively.
• Surgical site preparation: An antiseptic shampoo (the authors use chlorhexidine) is used on the evening prior to surgery and again on the morning of surgery prior to going to the operating room. No hair is clipped or shaved prior to entering the operating room.

Anesthetic Considerations

• Anesthesiology consultation is advisable, since the tumors are often large and blood loss is a major concern.

Ancillary/Specialized Equipment

• Intraoperative ultrasound is often helpful in identifying the tumor in real time, assisting in the initial drainage of a cystic component, and assessing the extent of resection.
• CUSA may be useful in resecting tumor.
• Intraoperative image guidance in selected cases.