Introduction to the supplement on pediatric surgical oncology

Solid tumors make up about one-third of cancers in children less than 15 years of age and almost half of cancers that occur in older adolescents aged 15–19 years. Most solid tumors need resection for cure at some point during treatment. What surgeons do (or do not do), and how and when a surgery is performed, not only affects patients directly but also can influence the need for, type, and dosing of adjuvant therapies, including both chemotherapy and radiation therapy. In addition, as overall, outcomes for children with cancer have improved significantly over the last 60 years, one consequence of improved survival is that many patients are now living with the long-term consequences of therapy, including surgery. Pediatric surgeons can impact both the oncologic outcomes and morbidities of therapy. A surgeon's responsibilities for children with solid tumors generally include obtaining adequate tumor tissue for diagnosis, accurate staging, molecular analysis, and banking. Conducting the definitive "appropriate" surgical procedure, with considerations given to the timing of surgery, the extent of resection, the surgical approach, and the potential surgical complications is also critical. Oncologic risk stratification has been increasingly refined over the years to a point where patients are all currently assigned groups based on clinical and biologic factors that anticipate the risk of cancer recurrence and that are increasingly accurate and precise. Surgeons need to understand and appreciate these risk groupings, and understand their implications regarding the role of surgery. Generally, less aggressive surgery is offered for those with low-risk disease (sometimes even no surgery), and more aggressive surgery (usually) for those with high-risk disease and/or disease likely to be refractory to adjuvant therapy. Surgical decisions can influence oncologic outcomes and intensity of therapy, with its associated long-term consequences. Surgeons should understand and follow the recommendations of protocols, understand the implications of risk factors and how they affect outcome, understand that the goal of surgery, including the timing and extent, is not always an upfront gross total resection, and understand the long-term consequences of surgery and how surgical choices and actions can influence the use of adjuvant therapies, as surgery is being considered. Surgical decisions will be different for different histologies and different risk groups; "one size" does not fit all. Innovative surgical techniques and imaging adjuvants are being rapidly developed, but need to be studied carefully on protocols. Advances in surgical technique, immunotherapy, and precision medicine are being made at a very rapid pace. It is important that surgeons be aware of these advances, their indications, and potential side effects. There is a lot to know, and it is always changing! Surgeons play a crucial role in the outcome of children with solid tumors, yet most surgeons have relatively little experience treating such patients, with most pediatric surgeons caring for fewer than two pediatric solid tumor patients, with any tumor histology, per year. Surgeons also play an important role in supportive and palliative care, and the utility of centralization of surgery is currently being debated. This Supplemental Issue on Pediatric Surgical Oncology in Pediatric Blood & Cancer is meant to provide a quick but comprehensive resource to bridge these gaps, as well as to provide an overview of the surgical approach to pediatric solid tumor patients for pediatric cancer caregivers broadly. The authors declare no conflicts of interest.