Biopsy-Only Versus Debulking Surgical Approaches for Pediatric Orbital Rhabdomyosarcoma: Impact on Eye Preservation and Oncologic Outcomes.
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PURPOSE: To compare eye preservation and survival outcomes between biopsy-only and debulking surgical approaches in pediatric orbital rhabdomyosarcoma treated with contemporary multimodal therapy. METHODS: Retrospective chart review of 27 patients with primary orbital rhabdomyosarcoma treated at Children's Hospital of Philadelphia between 2006 and 2025. Patients were categorized by initial surgical approach: biopsy-only (n = 18, 67%) or debulking (n = 9, 33%). All patients received multimodal therapy including chemotherapy and radiation. Primary outcome was eye preservation. Secondary outcomes included local recurrence, overall survival, and treatment complications. RESULTS: Median follow-up was 2.32 years (range: 0.4-16.5 years). Baseline characteristics including age, tumor size, tumor location, and histology were well-balanced between groups. Eye preservation was achieved in 89% (16/18) of biopsy-only patients versus 78% (7/9) of debulking patients (OR 2.29, 95% CI 0.28-18.8, P = .58). Local recurrence occurred in 11% (2/18) of biopsy-only patients versus 33% (3/9) of debulking patients (P = .30). Overall survival was 94% (17/18) in the biopsy-only group versus 78% (7/9) in the debulking group (OR 4.86, 95% CI 0.36-65.6, P = .25). Post-treatment complications including ptosis (70%) and cataracts (44%) did not differ significantly between groups. CONCLUSIONS: Biopsy-only surgical approaches were noninferior and potentially superior to debulking, achieving comparable or better eye preservation, lower recurrence rates, and improved survival in pediatric orbital rhabdomyosarcoma, despite well-balanced baseline tumor characteristics. The consistent advantage of biopsy-only across multiple independent outcomes supports conservative surgical management that minimizes tissue disruption while maintaining excellent oncologic control. These findings validate current protocols advocating diagnostic biopsy as the primary surgical procedure, with chemotherapy and radiation providing definitive treatment.