Wilms' tumor--an interdisciplinary treatment program with and without dactinomycin

Solitary cerebral metastasis from Wilms' tumor without pulmonary involvement

A 6-year-old boy presented with a solitary cerebral metastasis 5 years after nephrectomy for stage I Wilms' tumor. Chest x-ray and computed tomography scan were normal. The occurrence of cerebral metastasis without pulmonary involvement in Wilms' tumor has not been described before.

The changing management of Wilms' tumor over a 30-year period. 1949-1978

Seventy-four patients with histologically confirmed diagnoses of Wilms' tumor were treated between 1949 and 1978 at the Mallinckrodt Institute of Radiology and St. Louis Children's Hospital. The results have been divided into two eras of therapy, i.e., before and after 1965, when chemotherapy became a major modality for Wilms' tumor therapy. Analysis at 5 years by era of therapy has shown similar disease-free survival results for Stage I ("prechemotherapy" era 67% versus "chemotherapy" era 75%), whereas the Stage II ("prechemotherapy" era 33% versus "chemotherapy" era 100%) and Stage III ("prechemotherapy" era 0% versus "chemotherapy" era 70%) are significantly different (P less than 0.001). This suggests that chemotherapy has substituted for postoperative irradiation in Stage I patients; whereas in Stage II and III, improved survival occurs as a result of the eradication of subclinical metastatic disease. The patterns of failure by era of treatment are presented and the literature is discussed.

The use of four-drug combination chemotherapy (D.A.V.E.) in the treatment of advanced Wilms' tumour

A study was begun in 1971 at St. Bartholomew's Hospital with a combination of 4 drugs, dactinomycin (actinomycin D), adriamycin, vincristine and Endoxan (cyclophosphamide) (D.A.V.E.), together with surgery and radiation, in the treatment of stage III and stage IV Wilms' tumour. Seventy-one percent of the children treated achieved complete response. The median survival from diagnosis was 19 months, and in those children achieving complete response the median disease-free survival has not yet been reached. Toxicity was not a serious problem. The study group is compared with a group of children treated at this hospital before 1971. There is an improved survival in the children treated with D.A.V.E. Children who have relapsed with stage I or stage II disease may also respond. This four-drug combination was well tolerated and effective, and confirms recent experience suggesting that intensive multiple-drug regimens may be curative even in advanced disease.

Rhabdomyosarcoma of the kidney in children

Among 227 consecutive renal tumors examined from the Hospital de Niños de Buenos Aires, seven examples of a distinctive clinicopathological entity occurred. These renal neoplasms were all unilateral, grossly infiltrative without a definitive capsule. Microscopically, the lesion was characterized by a sarcomatous pattern with a rhabdomyoblastic differentiation. Four of them had regional lymph node involvement at surgery. Four developed bone metastases and none had lung metastases. In three instances, the bone metastases were histologically similar to the original neoplasm. The age of the patients ranged from 11 months to 5 1/2 years. A male predominance was observed. Two patients died; one is alive 5 years after surgery; three are alive with metastases; one has been followed for less than a year. In this study, it is proposed that another group of tumors be removed from the Wilms' tumor classification. The neoplasm has been described previously in the literature under several names. It is not clearly related clinicopathologically to nephroblastoma. The term rhabdomyosarcoma is proposed in view of its entirely different biological behavior.

Wilms' tumor--model of a curable pediatric malignant solid tumor

Wilms' tumor is the model of the treatment of a pediatric solid tumor. Initially it appeared that multi-modality therapy, consisting of transabodominal nephrectomy, post-operative radiation therapy to the tumor bed and adjuvant, single agent chemotherapy provided the highest likelihood of disease-free survival. The identification of important prognostic factors, such as histology, tumor weight, lymph node involvement and age at diagnosis has led to a re-examination of the treatment of Wilms' tumor. Future therapeutic developments will include the administration of less therapy to some well defined groups of patients, and the exploration of new programs for patients who have been demonstrated to have a poor prognosis using currently accepted treatment techniques.

Prognosis and treatment of Wilms' tumor at Great Ormond Street Hospital for Sick Children--1960-1972

Eighty-one children with a diagnosis of Wilms' tumor who were treated at the Great Ormond Street Hospital for Sick Children between 1960 and 1972 are reviewed. The National Wilms' Tumor Study group staging system is used. Distribution by age and sex in each stage together with survival rate is given. Treatment and prognostic factors are discussed. Wilms' tumor is most common in children below the age of 3 years. There was a survival rate of 87% in Stage I, 36% in Stage II, 8% in Stage III, and 33% in Stage IV. The survival was worse in patients with locally advanced tumor than in patients who had pulmonary metastases in association with a locally resectable tumor. Whole abdominal irradiation is necessary in all patients in whom the tumor has breached the renal capsule. Single agent chemotherapy has not proved effective in preventing relapse in patients with advanced tumors. More intensive therapy is needed in this group to prevent both local recurrence and distant metastases. The addition of multiple drug chemotherapy to nephrectomy and whole abdominal irradiation is already improving the disease-free survival.

The incipient Wilms' tumor

The diagnosis of Wilms' tumor is usually made by excretory urography after the patient presents with an abdominal mass. A diagnosis prior to the appearance of an obvious mass might result in an improved cure rate and less morbid therapy. The three cases described illustrate the difficulty in making an earlier diagnosis since pyelograms were "normal" prior to detection of the abdominal mass.

Renal tumours in children

A ten-year series of renal tumours in children up to 14 years of age was collected from the files of the Finnish Cancer Register. After histological evaluation of the material, 74 cases were accepted as primary renal tumours. Fifty-eight of these were typical Wilms' tumours, three rhabdomyosarcomas, six foetal hamartomas and seven unclassified malignant tumours. Wilms' tumours were classified into three types on the basis of the histological differentiation. The total five year survival in the Wilms group was 50 per cent with no difference between patients over and under the age of one year. Of the subtypes of Wilms' tumours the sarcomatous type showed worse prognosis than average; only three out of 16 patients were alive after a five-year follow-up time. None of the patients with foetal hamartoma died of tumour, although two fatalities, connected with the surgery, were recorded. The value of histological classification of Wilms' tumours and the importance of the recognition of the foetal hamartoma is emphasized.