Pediatric Surgery

Pediatric Surgical Oncology

Pediatric surgical oncology is the surgery of solid tumors in children, from biopsy and port placement to removal of neuroblastoma, Wilms tumor, hepatoblastoma, sarcomas and germ cell tumors at the right moment between chemotherapy cycles. At Biruni Hospital in Istanbul, our pediatric surgeons plan every operation at the tumor board with oncologists, radiologists and pathologists, use keyhole and image-guided techniques when safe, and protect fertility before treatment.

About This Department

Pediatric Surgery

Most solid tumors in children are cured only when surgery removes them completely. Pediatric surgical oncology plans that operation with the whole cancer team.

Pediatric surgical oncology is the surgery of solid tumors in babies, children and teenagers, including neuroblastoma, Wilms tumor, hepatoblastoma, soft tissue sarcomas and germ cell tumors. The surgeon takes the biopsy that confirms the diagnosis, places the port for chemotherapy, removes the tumor at the right moment between chemotherapy cycles and protects the organs a growing child needs. Imaging decides much of this. In neuroblastoma, children whose scans showed image-defined risk factors, such as a tumor wrapped around major vessels, faced 2.45 times the risk of incomplete removal and 2.3 times the risk of surgical complications in a review of 1,132 patients (Parhar and colleagues, Pediatric Surgery International, 2020). Planning around these factors changes the timing and the approach. This page explains the tumors we treat, biopsy, neuroblastoma surgery, ports and central lines, keyhole and image-guided techniques, fertility protection, recovery, and how families from abroad arrange pediatric cancer surgery at Biruni Hospital in Istanbul.

Image-defined risk factors checked on scans before neuroblastoma surgery

2.3

Times higher risk of surgical complications when those risk factors are present

Percent five-year event-free survival for localized neuroblastoma without risk factors

Free

Review of your child's scans and pathology by our pediatric tumor board

Free consultation

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What the specialty covers

The surgeon's role in childhood cancer
Step	What the surgeon does	When
Diagnosis	Biopsy by needle, keyhole or open surgery	Before any treatment
Access	Port or central line for chemotherapy	First week
Local control	Removal of the tumor	At diagnosis or after chemotherapy
Metastases	Removal of lung or other deposits	When the protocol calls for it

Children's tumors differ from adult cancers. They grow fast, respond well to chemotherapy and arise in growing organs.

Who works with the surgeon
Specialist	Role	Note
Pediatric oncologist	Chemotherapy and protocol	Leads overall treatment
Pediatric radiologist	Staging scans, image-guided biopsy	Reads risk factors
Pathologist	Diagnosis, margins, molecular tests	Decides the next step
Radiation oncologist	Radiotherapy when needed	Planned before surgery

One tumor board

Every child is discussed at the weekly pediatric tumor board, before the biopsy and again before surgery.

International protocols

Treatment follows the international protocols of SIOP Europe and the Children's Oncology Group, the same standards used in large children's cancer centers worldwide.

Tumors we operate on

Solid tumors make up around half of childhood cancers outside the brain and blood. Each type has its own surgical rules, and the surgeon's experience with that type matters as much as general skill.

Does every child with a solid tumor need surgery?

No. Some tumors, such as certain lymphomas, are treated with chemotherapy alone after a biopsy, and some low risk neuroblastomas in infants shrink without treatment. The tumor board decides who needs an operation and when.

Common solid tumors of childhood
Tumor	Usual age	Main surgery
Neuroblastoma	Under five years	Resection after chemotherapy for most
Wilms tumor	Two to five years	Nephrectomy
Hepatoblastoma	Under three years	Liver resection or transplant
Rhabdomyosarcoma and other sarcomas	Any age	Wide excision
Germ cell tumors and teratomas	Newborns and teenagers	Excision with organ sparing
Thyroid and adrenal tumors	Teenagers	Thyroidectomy, adrenalectomy

Surgery at the right moment

Timing is part of the treatment.

A tumor removed too early may take healthy organs with it, while chemotherapy given first can shrink it away from vessels and nerves and make a safe complete operation possible, and in other tumors an early operation spares the child chemotherapy altogether, so the decision rests on the tumor type, the scan findings and the international protocol for that tumor, discussed openly with the family before the first treatment. Our surgeons attend the tumor board from the first day, so the surgical plan is part of the treatment plan from the start.

No surprises, no rushed operations.

Biopsy first

A biopsy confirms the tumor type and provides tissue for the molecular tests that decide risk and treatment. Most biopsies use a needle under ultrasound or CT guidance, through a skin opening of a few millimeters. Keyhole or open biopsy is chosen when more tissue is needed.

Biopsy methods
Method	When	Anesthesia
Image-guided needle biopsy	Most abdominal and chest tumors	General anesthesia, day case
Keyhole biopsy	Deep tumors, lymph nodes	General anesthesia, one night
Open biopsy	Large tissue needs, some sarcomas	General anesthesia

Same anesthetic

We combine biopsy, port placement, bone marrow tests and scans in one anesthetic whenever possible.

Some tumors should not be biopsied. A typical Wilms tumor treated by the SIOP approach, and some germ cell tumors with clear blood markers, start treatment without a biopsy.

Neuroblastoma and risk factors

Neuroblastoma arises from nerve tissue, most often in the adrenal gland, and can wrap around major blood vessels and the airway or grow into the spinal canal.

Image-defined risk factors

Twenty findings on MRI or CT, such as encasement of the aorta, renal vessels or superior mesenteric artery, that make surgery at diagnosis risky.

L1 and L2

In the international staging system, a localized tumor without risk factors is stage L1 and one with risk factors is L2. Among 661 European children, five-year event-free survival was 90 percent for L1 and 78 percent for L2 (Monclair and colleagues, Journal of Clinical Oncology, 2009).

How staging guides surgery
Stage	First step	Surgery
L1, no risk factors	Surgery alone for most	Resection at diagnosis
L2, risk factors present	Chemotherapy or observation	Resection when risk factors resolve
M, metastatic	Intensive chemotherapy	Resection of the primary after induction
MS, infants	Observation for most	Rarely needed

The neuroblastoma operation

The aim

Remove as much tumor as possible while keeping the kidneys, vessels and nerves intact. A small piece left on a vessel is safer than losing an organ.

After chemotherapy

Scans after chemotherapy show whether risk factors have resolved. The surgeon peels the tumor away from the vessels it surrounds, working along each artery, a technique that takes hours and rewards experience.

When the tumor cannot be removed completely

In intermediate and high risk neuroblastoma, removing most of the tumor while protecting organs gives results close to complete removal. Radiotherapy, chemotherapy and immunotherapy treat what remains. We explain the expected extent of surgery before the operation.

Risks we watch for

Bleeding, kidney injury from vessel damage, diarrhea after nerve injury around the mesenteric artery, and chyle leak. Each has a plan, and most settle within weeks.

Kidney and liver tumors

Kidney tumors
Tumor	Treatment	Our page
Wilms tumor	Chemotherapy, then nephrectomy	Nephrectomy in children
Tumors in both kidneys	Partial nephrectomy on both sides	Same page
Other kidney tumors	Surgery by type	Tumor board

Wilms tumor and hepatoblastoma each have their own detailed page on this site, covering staging, operations and follow-up.

Liver tumors
Tumor	Treatment	Our page
Hepatoblastoma	Cisplatin, then resection	Hepatoblastoma surgery
Unresectable liver tumors	Living donor transplant	Pediatric liver transplant
Benign liver tumors	Observation or resection	Tumor board

Why links matter

A child whose liver tumor may need a transplant is referred to the transplant team at diagnosis, and a child with tumors in both kidneys is planned for kidney sparing surgery from the first scan.

Sarcomas and germ cell tumors

Rhabdomyosarcoma, the most common soft tissue sarcoma of childhood, arises in the head and neck, bladder and prostate, limbs or genital area. Surgery removes the tumor with a margin of normal tissue when this is possible without disabling loss of function, and radiotherapy controls what surgery cannot.

Sarcoma and germ cell tumor surgery
Tumor	Surgery	Note
Rhabdomyosarcoma	Wide excision, sentinel node biopsy for limbs	Organ sparing first
Non-rhabdomyosarcoma soft tissue sarcoma	Wide excision	Surgery is the main treatment
Ovarian germ cell tumor	Removal of the ovary, keeping the other	Fertility sparing
Testicular tumor	Inguinal orchiectomy	Through the groin
Sacrococcygeal teratoma	Removal with the coccyx	In the newborn period

Margins

The pathologist checks every edge of the specimen under the microscope, and a clear margin decides whether more surgery or radiotherapy follows.

Blood markers

Germ cell tumors release AFP and beta-hCG into the blood. Falling markers after surgery confirm removal, and a rise points to return.

Bone tumors

Shared care

Osteosarcoma and Ewing sarcoma of bone are operated on by orthopedic oncology surgeons, with the same tumor board and chemotherapy team.

Ports and central lines

Central venous devices in 40 studies of children with cancer
Finding	Rate	Note
Any complication	31.4 percent of devices	Infection, blockage, clot, dislodgement
Device failure before treatment ended	14.8 percent	Needed replacement
Fewest complications	Totally implanted ports	Against tunneled lines and PICC lines

A port sits under the skin of the chest and connects to a large vein. Nurses reach it with a fine needle for chemotherapy, blood tests and transfusions, and between treatments nothing shows outside, so children bathe and swim. A review of 40 studies found fewer complications with ports than with tunneled lines or PICC lines (Nunn and colleagues, Supportive Care in Cancer, 2024).

Which device for which child

When is a tunneled line better than a port?

Intensive treatments that need several infusions at once, stem cell collection and transplant use a tunneled line with two or three channels. For most solid tumor protocols, a single port is enough, and we decide with the oncologist before placement.

Caring for the port at home
Item	What to do	When to call
Skin over the port	Keep clean, no special care	Redness or swelling
Fever	Never ignore during chemotherapy	At once, any temperature over 38 degrees
Arm or neck swelling	Possible clot	The same day

Keyhole and image-guided surgery

Keyhole surgery for selected tumors

Small, well defined tumors without risk factors, such as some adrenal neuroblastomas, ovarian tumors and lung nodules, can be removed by laparoscopy or thoracoscopy, with smaller scars and a faster return to chemotherapy.

Indocyanine green, a fluorescent dye given before surgery, lights up liver tumor deposits and lymph nodes under a special camera.
Radioguided surgery with MIBG helps find neuroblastoma deposits.
Three-dimensional models built from MRI or CT plan complex resections.

Evidence

A 2025 review by international pediatric surgical oncologists described fluorescence, radioguided techniques and three-dimensional planning as promising aids for finding small deposits and defining margins (Fusco and colleagues, Pediatric Blood and Cancer, 2025).

Our rule

The approach never changes the cancer operation. Keyhole surgery is used only when the same complete, intact removal and lymph node sampling are possible.

Protecting fertility

Before treatment starts

Fertility protection options
Patient	Option	Timing
Girls before puberty	Ovarian tissue freezing	Before chemotherapy, by keyhole surgery
Girls after puberty	Egg freezing or ovarian tissue freezing	Before treatment, when time allows
Boys after puberty	Sperm banking	Before chemotherapy
Pelvic radiotherapy	Moving an ovary out of the field	During surgery

Some chemotherapy and pelvic radiotherapy can damage fertility. The discussion belongs before the first treatment.

Combined with other procedures

Ovarian tissue can be removed by keyhole surgery under the same anesthetic as port placement or biopsy.

Our reproductive medicine team stores tissue and cells for the future, and the family receives written information on each option.

After the operation

A typical recovery
Stage	Timing	Note
Intensive care	One to two days after major surgery	Pediatric intensive care unit
Ward	Five to ten days	Parent in the room
Return to chemotherapy	Two to three weeks after surgery	Once the wound has healed

Pain relief starts in the operating room with epidural or regional blocks, and play specialists and physiotherapists help children move and eat early. Pathology results arrive within one to two weeks and go back to the tumor board for the next step.

Nutrition

Dietitians support children who lose weight during treatment, with high calorie feeds and, when needed, a feeding tube.

Growing up after cancer

Survivors deserve long-term care.

Children treated for solid tumors return to school and sport, and most grow into healthy adults, but chemotherapy, radiotherapy and surgery leave marks that can appear years later, in hearing, kidney function, the heart, growth, puberty and fertility, so our long-term follow-up clinic checks each of these on a schedule set by the treatment the child received and passes a written summary to the family doctor at the transition to adult care. Psychologists support children and their brothers and sisters throughout.

Scars fade, follow-up stays.

For families from abroad

Length of stay

A biopsy and port placement take one to two weeks, and a major tumor operation two to three weeks before fitness to fly. Full treatment in Istanbul lasts months.

Families can choose full treatment in Istanbul, or chemotherapy at home with surgery at Biruni Hospital following the same protocol.

What to send

MRI, CT or PET images with reports, pathology reports and slides, blood markers and a summary of chemotherapy given so far.

One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number after you return. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages, and it arranges the visa invitation letter, airport transfers, daily transport and accommodation near the hospital. Halal, vegetarian and diabetic meals, a prayer room on site, and a female physician on request wherever the rota allows.

Our pathologists can review slides and tissue blocks before travel. Sometimes this changes the diagnosis or the plan.

After you return home, scans and blood tests continue with your local oncologist, and our tumor board reviews results by video and message.

Cost

The quote follows the plan the tumor board proposes, and lists surgery, chemotherapy, radiotherapy and hospital stay separately.

We send a written quote after reviewing scans and pathology, before you travel.

What a quote for pediatric cancer surgery covers
Item	Included	Priced separately
Surgery	Surgeon, anesthesia, operating room, pathology	Second operations
Hospital	Intensive care and ward stay as planned	Extra days
Aftercare	Medicines at discharge, video follow-up	Chemotherapy, radiotherapy

Factors that change the quote
Factor	Effect	Example
Tumor type and stage	Extent of surgery	Neuroblastoma with risk factors
Approach	Keyhole or open	Small adrenal tumor
Extra procedures	Port, fertility protection	Same anesthetic when possible

Compare quotes for the same plan, and check that tumor board review, pathology and follow-up are part of it.

References

Monclair T, Brodeur GM, Ambros PF, et al. The International Neuroblastoma Risk Group (INRG) staging system, an INRG Task Force report. J Clin Oncol. 2009;27(2):298-303.
Parhar D, Joharifard S, Lo AC, Schlosser MP, Daodu OO. How well do image-defined risk factors (IDRFs) predict surgical outcomes and survival in patients with neuroblastoma? A systematic review and meta-analysis. Pediatr Surg Int. 2020;36(8):897-907.
Nunn JL, Takashima MD, Wray-Jones EM, et al. Central venous access device adverse events in pediatric patients with cancer, a systematic review and meta-analysis. Support Care Cancer. 2024;32(10):662.
Fusco JC, Abdelhafeez AH, Krauel L, et al. Imaging adjuvants in pediatric surgical oncology. Pediatr Blood Cancer. 2025;72(Suppl 2):e31241.

Editor's note

Written by the Biruni Hospital medical editorial team. Reviewed by Assistant Professor Kamil Değer DEVECİOĞLU, Pediatric Surgery.

Medically reviewed by

Assistant Professor Kamil Değer DEVECİOĞLU

Pediatric Surgery

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