Updates in Evidence-Based Decision Making for Upfront Surgical Interventions in Paediatric Lymphoma

Surgical interventions have been integral to the management principles of paediatric lymphomas, but recent advancement of perioperative care standards and treatment protocols have led to new evidence that alters historical concepts regarding the optimal upfront management of these lesions. In patients presenting with mediastinal disease, general anaesthesia in the upfront setting was previously largely avoided due to significant perioperative cardiorespiratory risks. However, improved risk-determination frameworks and introduction of newer anaesthetic agents into current practice now permit safer conduct of upfront biopsies under deep sedation. This is important as accurate lesional sampling has become even more critical with the growing importance of accurate molecular subtyping. In patients with gastrointestinal lymphoma, upfront resection was advocated to surgically downstage disease and address the risk of impending bowel obstruction. Yet, unnecessarily extensive upfront surgery can delay commencement of systemic therapy, and many of such attempts do not achieve sufficiently clear resection margins. The improved efficacy of newer chemotherapy protocols may reduce the relative benefit of attempted surgical downstaging, but now introduce new issues with risks of delayed stricture formation. This review will evaluate emerging evidence, synthesising potential new practice recommendations for upfront surgical management of paediatric lymphomas, with a focus on mediastinal and gastrointestinal sites.