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Fang Y, Li Z, Song H, Zhang W, Li N, Yang Y. Does bilateral Wilms' tumor involving the collecting system in children have a worse prognosis? BMC Urol 2024; 24:141. [PMID: 38977987 PMCID: PMC11229180 DOI: 10.1186/s12894-024-01525-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 06/27/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND The literature on nephron-sparing surgery (NSS) in children with bilateral Wilms' tumors (BWT) involving the collection system is mostly comprised of case reports. The present study aimed to summarize the clinical characteristics, treatments, and prognosis of children with BWT involving the collecting system admitted to our pediatric surgery center compared with those whose tumors did not involve the collecting system. A secondary aim was to discuss how to preserve more kidney parenchyma and prevent long-term renal failure under the premise of preventing tumor recurrence. METHODS Patients with BWT admitted to our pediatric surgery center between January 2008 and June 2022 were reviewed. All included patients were grouped according to the relationship between the tumor and collecting system according to the intraoperative findings. Group I included children with tumor infiltrating the collecting system, group II included children with tumor growing into the collecting system, and group III included children whose tumor did not involve the collecting system. The clinical features, treatments and prognosis of the patients were analyzed. RESULTS Seventy patients were enrolled, including 20 patients with 25 sides of tumors infiltrating the collecting system in group I,10 patients with 13 sides of tumors growing into the collecting system in group II, and 40 patients in group III. There was no significant difference in patients age and gender between group I and group II. In total, 20 patients in group I and 9 patients in group II had partial response (PR) after neoadjuvant chemotherapy. In group I, 22 of 25 sides of tumors underwent NSS; in group II, 11 of 13 sides of tumors underwent NSS. During an average follow-up of 47 months, in group I, 6/20 patients relapsed and 2/20 patients died; in group II, 3/10 patients relapsed and 1/10 patient died. There was no significant difference in 4-year overall survival (OS) rate among groups I, II and III (86.36% vs. 85.71%vs. 91.40%, P = 0.902). CONCLUSIONS To preserve renal parenchyma, NSS is feasible for children with BWT involving the collecting system. There was no significant difference in postoperative long-term OS between patients with BWT involving the collecting system and not involving the collecting system.
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Affiliation(s)
- YiWei Fang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - ZhenWu Li
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China.
| | - HongCheng Song
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China.
| | - WeiPing Zhang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - Ning Li
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - Yang Yang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China
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Romao RLP, Aldrink JH, Renfro LA, Mullen EA, Murphy AJ, Brzezinski J, Malek MM, Benedetti DJ, Cost NG, Smith E, Dome JS, Davidoff AM, Treece A, Parsons LN, Fernandez CV, Tornwall B, Shamberger RC, Paulino A, Kalapurakal JA, Geller JI, Ehrlich PF. Bilateral Wilms tumor with anaplasia: A report from the Children's Oncology Group Study AREN0534. Pediatr Blood Cancer 2024; 71:e30981. [PMID: 38637871 PMCID: PMC11116047 DOI: 10.1002/pbc.30981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/06/2024] [Accepted: 03/17/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION The purpose of this study is to examine the outcomes in children with anaplastic bilateral Wilms tumor (BWT) from study AREN0534 in order to define potential prognostic factors and areas to target in future clinical trials. METHODS Demographic and clinical data from AREN0534 study patients with anaplasia (focal anaplasia [FA], or diffuse anaplasia [DA]) were compared. Event-free survival (EFS) and overall survival (OS) were reported using Kaplan-Meier estimation with 95% confidence bands, and differences in outcomes between FA and DA compared using log-rank tests. The impact of margin status was analyzed. RESULTS Twenty-seven children who enrolled on AREN0534 had evidence of anaplasia (17 DA, 10 FA) in at least one kidney and were included in this analysis. Twenty-six (96%) had BWT. Nineteen percent had anaplastic histology in both kidneys (four of 17 DA, and one of 10 FA). Forty-six percent with BWT had bilateral nephron-sparing surgery (NSS); one child who went off protocol therapy, eventually required bilateral completion nephrectomies. Median follow-up for EFS and OS was 8.6 and 8.7 years from enrollment. Four- and 8-year EFS was 53% [95% confidence interval (CI): 34%-83%] for DA; 4-year EFS was 80% [95% CI: 59%-100%], and 8-year EFS 70% [95% CI: 47%-100%] for FA. Three out of 10 children with FA and eight out of 17 children with DA had events. EFS did not differ statistically by margin status (p = .79; HR = 0.88). Among the six children who died (five DA, one FA), all experienced prior relapse or progression within 18 months. CONCLUSION Events in children with DA/FA in the setting of BWT occurred early. Caution should be taken about interpreting the impact of margin status outcomes in the context of contemporary multimodal therapy. Future targeted investigations in children with BWT and DA/FA are needed.
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Affiliation(s)
- Rodrigo L P Romao
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer H Aldrink
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Lindsay A Renfro
- Division of Biostatistics, University of Southern California and Children's Oncology Group, Los Angeles, California, USA
| | - Elizabeth A Mullen
- Boston Children's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Andrew J Murphy
- St Jude's Children's Research Hospital, Memphis, Tennessee, USA
| | - Jack Brzezinski
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Marcus M Malek
- Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel J Benedetti
- Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nicholas G Cost
- The Surgical Oncology Program at the Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USA
| | - Ethan Smith
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey S Dome
- Children National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | | | - Amy Treece
- Children's Hospital of Alabama, Birmingham, Alabama, USA
| | | | | | - Brett Tornwall
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Robert C Shamberger
- Boston Children's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | - James I Geller
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Peter F Ehrlich
- Section of Pediatric Surgery, C.S. Mott Children's Hospital University of Michigan, Ann Arbor, Michigan, USA
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Fuchs J, Schunn MC, Schäfer JF, Ebinger M, Graf N, Furtwängler R, Warmann SW. Redo nephron-sparing surgery in stage V pediatric renal tumors - A report from the SIOP/GPOH study group for renal tumors. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107265. [PMID: 38035461 DOI: 10.1016/j.ejso.2023.107265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
PURPOSE Nephron-sparing Surgery (NSS) is the surgical treatment of choice in children with bilateral renal tumors or in syndromatic patients. With an increasing role of this surgical approach, there is also an increased number of tumor relapses after NSS. Aim of this study was to evaluate a second ("Redo-") NSS in children with relapsed renal tumors. MATERIALS AND METHODS We retrospectively analysed patients undergoing Redo-NSS for relapsed kidney tumors between 2009 and 2021 at our institution, which represents a national reference center of the SIOP/GPOH renal tumor study group. RESULTS Nine patients (5 girls, 4 boys) underwent Redo-NSS with resection of 15 lesions. Mean age at surgery was 58 months (12-137), mean operative time for Redo-NSS was 195 min (137-260). R0 resection status was achieved in all children. Two patients had second relapses, one of them was resected via NSS, the other child underwent tumor nephrectomy. Two patients with anaplastic relapses died from combined second relapses. Thus, 7/9 patients are alive without evidence of disease, an impaired renal function was observed in one child. Mean follow-up after Redo-NSS was 35 months (6-49). CONCLUSIONS In renal tumor relapses, Redo-NSS can be performed with satisfactory oncological and functional results. Occurrence of diffuse anaplasia should possibly refrain from this approach. Further evaluation in international multicenter analyses are necessary for a definitive determination of Redo-NSS.
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Affiliation(s)
- Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tuebingen, Germany.
| | - Matthias C Schunn
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tuebingen, Germany
| | - Jürgen F Schäfer
- Department of Diagnostic and Interventional Radiology, University Hospital Tuebingen, Germany
| | - Martin Ebinger
- Department of Pediatric Oncology, University Children's Hospital Tuebingen, Germany
| | - Norbert Graf
- Department of Pediatric Oncology & Haematology, Saarland University, Homburg, Germany
| | - Rhoikos Furtwängler
- Department of Pediatric Oncology & Haematology, Saarland University, Homburg, Germany
| | - Steven W Warmann
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tuebingen, Germany
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Chen SY, Lee WG, Laifman E, Mack SJ, Zhou S, Kim ES. A Single Center Experience With Bilateral Wilms Tumor. Am Surg 2023; 89:4101-4104. [PMID: 37208897 PMCID: PMC10756228 DOI: 10.1177/00031348231175446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
BACKGROUND Wilms tumor (WT) is the most common pediatric renal malignancy and bilateral disease (BWT) occurs in 5% of cases and is associated with poor outcomes. Management of BWT includes chemotherapy and oncologic resection while preserving renal function. Previous literature has demonstrated variable approaches in BWT treatment. The aim of this study was to examine a single institution experience and outcomes with BWT. METHODS A retrospective chart review was performed for all patients with WT treated at a free-standing tertiary children's hospital between 1998 and 2018. Patients with BWT were identified and treatment courses were compared. Outcomes of interest included need for dialysis post-operatively, need for renal transplantation post-operatively, disease recurrence, and overall survival. RESULTS Of 120 children with WT, 9 children (6F:3M) of median age 32 months (IQR: 24-50 months) and median weight 13.7 kg (IQR: 10.9-16.2 kg) were diagnosed with and treated for BWT. Pre-operative biopsies were obtained in 4/9 patients, 3 of whom received neoadjuvant chemotherapy and 1 who underwent radical nephrectomy. Of the 5 patients who did not undergo biopsy, 4/5 were treated with neoadjuvant chemotherapy, and 1/5 underwent upfront nephrectomy. Post-operatively, 4/9 children required dialysis, of whom 2 subsequently underwent renal transplantation. Two patients were lost to follow-up, and of the remaining 7 patients, disease recurrence occurred in 5/7 children and overall survival was 71% (n=5). CONCLUSION Management of BWT varies regarding the use of pre-operative biopsy, neoadjuvant chemotherapy, and extent of disease resection. Further guidelines on treatment protocols may optimize outcomes in children with BWT.
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Affiliation(s)
- Stephanie Y. Chen
- Division of Pediatric Surgcery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - William G.H. Lee
- Division of Pediatric Surgcery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric Laifman
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Shale J. Mack
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Shengmei Zhou
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Clinical Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Eugene S. Kim
- Division of Pediatric Surgcery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Geller JI, Hong AL, Vallance KL, Evageliou N, Aldrink JH, Cost NG, Treece AL, Renfro LA, Mullen EA. Children's Oncology Group's 2023 blueprint for research: Renal tumors. Pediatr Blood Cancer 2023; 70 Suppl 6:e30586. [PMID: 37477907 PMCID: PMC10529605 DOI: 10.1002/pbc.30586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/22/2023]
Abstract
Every year, approximately 600 infants, children, and adolescents are diagnosed with renal cancer in the United States. In addition to Wilms tumor (WT), which accounts for about 80% of all pediatric renal cancers, clear cell sarcoma of the kidney, renal cell carcinoma, malignant rhabdoid tumor, as well as more rare cancers (other sarcomas, rare carcinomas, lymphoma) and benign tumors can originate within the kidney. WT itself can be divided into favorable histology (FHWT), with a 5-year overall survival (OS) exceeding 90%, and anaplastic histology, with 4-year OS of 73.7%. Outcomes of the other pediatric renal cancers include clear cell sarcoma (5-year OS: 90%), malignant rhabdoid tumor (5-year OS: 10% for stages 3 and 4), and renal cell carcinoma (4-year OS: 84.8%). Recent clinical trials have identified novel biological prognostic markers for FHWT, and a series of Children's Oncology Group (COG) trials have demonstrated improving outcomes with therapy modification, and opportunities for further care refinement.
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Affiliation(s)
- James I Geller
- Division of Oncology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Andrew L Hong
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kelly L Vallance
- Hematology and Oncology, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Nick Evageliou
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Nicholas G Cost
- Department of Surgery, Division of Urology and the Surgical Oncology Program at Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amy L Treece
- Department of Pathology and Laboratory Medicine, Children's of Alabama, Birmingham, Alabama, USA
| | | | - Elizabeth A Mullen
- Dana-Farber/Boston Children's Blood Disorders and Cancer Center, Boston, Massachusetts, USA
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Saltzman AF, Cost NG, Romao RLP. Wilms Tumor. Urol Clin North Am 2023; 50:455-464. [PMID: 37385707 DOI: 10.1016/j.ucl.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Wilms tumor (WT), or nephroblastoma, is the most common primary malignant renal tumor of childhood. It is an embryonal tumor that develops from remnants of immature kidney. There are approximately 500 new WT cases diagnosed in the United States every year. Advances in multimodal therapy including surgery, chemotherapy, and radiation therapy given according to risk stratification have allowed most patients to achieve survival rates in excess of 90%.
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Affiliation(s)
| | - Nicholas G Cost
- Division of Urology, Department of Surgery, University of Colorado School of Medicine, 13123 East 16th Avenue, B 463, Aurora, CO 80045, USA; Surgical Oncology Program, Children's Hospital Colorado, 13123 East 16th Avenue, B 463, Aurora, CO 80045, USA.
| | - Rodrigo L P Romao
- Department of Surgery, IWK Health Centre, Dalhousie University, Halifax, Canada; Department of Urology, IWK Health Centre, Dalhousie University, Halifax, Canada
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7
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Ekuk E, Odongo CN, Tibaijuka L, Oyania F, Egesa WI, Bongomin F, Atwiine R, Acan M, Situma M. One year overall survival of wilms tumor cases and its predictors, among children diagnosed at a teaching hospital in South Western Uganda: a retrospective cohort study. BMC Cancer 2023; 23:196. [PMID: 36864435 PMCID: PMC9979450 DOI: 10.1186/s12885-023-10601-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 02/01/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Wilms tumor (WT) is the second most common solid tumor in Africa with both low overall survival (OS) and event-free survival (EFS) rates. However, no known factors are predicting this poor overall survival. OBJECTIVE The study was to determine the one-year overall survival of WT cases and its predictors among children diagnosed in the pediatric oncology and surgical units of Mbarara regional referral hospital (MRRH), western Uganda. METHODOLOGY Children's treatment charts and files diagnosed and managed for WT were retrospectively followed up for the period between January 2017 to January 2021. Charts of children with histologically confirmed diagnoses were reviewed for demographics, clinical and histological characteristics, as well as treatment modalities. RESULTS One-year overall survival was found to be 59.3% (95% CI: 40.7-73.3), with tumor size greater than 15 cm (p 0.021) and unfavorable WT type (p 0.012) being the predominant predictors. CONCLUSION Overall survival (OS) of WT at MRRH was found to be 59.3%, and predictive factors noted were unfavorable histology and tumor size greater than 115 cm.
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Affiliation(s)
- Eddymond Ekuk
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda.
| | - Charles Newton Odongo
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda.,Department of Anatomy, Faculty of Medicine Soroti University, Soroti, Uganda
| | - Leevan Tibaijuka
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Felix Oyania
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Walufu Ivan Egesa
- Department of Pediatrics, Faculty of Clinical Medicine and Dentistry, Kampala International, Kampala, Uganda
| | - Felix Bongomin
- Department of Microbiology, Mycology, and Immunology, Internal Medicine Gulu University, Gulu, Uganda
| | - Raymond Atwiine
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Moses Acan
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
| | - Martin Situma
- Department of Surgery, Mbarara University of Science and Technology, Faculty of Medicine, Mbarara, Uganda
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Fang Y, Li Z, Song H, Sun N, Zhang W. Treatment of bilateral Wilms' tumor in children: how to improve the application of nephron-sparing surgery. Pediatr Surg Int 2023; 39:145. [PMID: 36856873 DOI: 10.1007/s00383-023-05433-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE To summarize the experience of nephron-sparing surgery (NSS) for bilateral Wilms tumors (BWT) in children. METHODS This study included children with BWT admitted to our hospital between January 2008 and June 2022. The details of the treatments and outcomes were analyzed. RESULTS In all, 70 patients (39 males and 31 females) were enrolled, including 66 patients with synchronous tumors and 4 patients with metachronous tumors. The median age at diagnosis was 13 (3-75) months. Overall, 59 patients received preoperative chemotherapy and 45.8% (54/118) of the 118 sides of WT achieved a partial response (PR). Of the 70 patients, 48 (68.6%) underwent bilateral NSS and 22 (31.4%) underwent unilateral NSS and contralateral total nephrectomy. The proportion of bilateral NSS in the preoperative chemotherapy group was significantly higher than in the non-chemotherapy group (P = 0.031). Additionally, there were 26, 25, 14, and 5 cases of stage I, stage II, stage III, and stage IV, respectively. Among the 70 children, 16 had a recurrence, and 8 died. The 4 years EFS and OS were 67.9% and 89.3%, respectively. CONCLUSIONS The long-term survival rates of patients with BWT improved. Hence, preoperative chemotherapy should be administered to enhance the use of NSS in BWT.
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Affiliation(s)
- YiWei Fang
- Department of Urology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - ZhenWu Li
- Department of Urology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - HongCheng Song
- Department of Urology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China.
| | - Ning Sun
- Department of Urology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China.
| | - WeiPing Zhang
- Department of Urology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi St, Xicheng District, Beijing, 100045, China
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Gao P, Li J, Chen H, Wu W, Liu L, Jiang H, Xu L, Wu C, Fu Q, Liu J, Wang C. Bench surgery with autotransplantation for bilateral Wilms tumor-A feasible technique for renal sinus invasion. Front Surg 2022; 9:1047975. [PMID: 36582965 PMCID: PMC9793901 DOI: 10.3389/fsurg.2022.1047975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022] Open
Abstract
Purpose Bilateral Wilms tumor (BWT) with renal sinus invasion requires extremely difficult surgical care. This study presents an alternative strategy for tumor removal while at the same time preserving the renal parenchyma. Materials and methods In total, 9 cases of synchronous BWT were admitted to our hospital between May 2016 to Aug 2020. We retrospectively reviewed the clinical data, surgical technique, and functional and oncological outcomes of these cases. Results The 9 cases included 3 males and 6 females, with a median age of 12 months at surgery (range 7-40). A total of 14 kidney units had renal sinus invasion (77.8%), whereas multifocal neoplasms were observed in 7 units (38.9%). The local stage distribution revealed 1 kidney with stage I, 10 kidneys with stage II, and 7 kidneys with stage III. Nephron-sparing surgery was performed on 15 kidney units (83.3%), among which 13 (72.2%) underwent bench surgery with autotransplantation (BS-AT), whereas 2 (11.1%) were subjected to tumor enucleation in vivo. Urinary leakage was the most prevalent postoperative complication. We observed negative margins. During the mean follow-up of 28.4 months, 2 patients (22.2%) succumbed from sepsis and renal failure, respectively, whereas the other 7 (77.8%) survived without recurrence. Survivors experienced an estimated glomerular filtration rate of 81 ± 15.4 ml/(min × 1.73 m2). The endpoint renal volume of 9 renal units receiving BS-AT significantly increased (P = 0.02). Conclusions In summary, the surgical management of bilateral Wilms tumor requires meticulous operative approach and technique. Besides, BS-AT provides a viable alternative to nephron-sparing surgery for BWT patients with renal sinus invasion.
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Affiliation(s)
- Pengfei Gao
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Department of Pediatric Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun Li
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huadong Chen
- Department of Pediatric Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenrui Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Longshan Liu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hong Jiang
- Department of Pediatric Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Lingling Xu
- Pediatric Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chenglin Wu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qian Fu
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Juncheng Liu
- Department of Pediatric Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Correspondence: Juncheng Liu Changxi Wang
| | - Changxi Wang
- Organ Transplant Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Correspondence: Juncheng Liu Changxi Wang
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10
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Chintagumpala MM, Perlman EJ, Tornwall B, Chi YY, Kim Y, Hoffer FA, Kalapurakal JA, Warwick AB, Shamberger RC, Khanna G, Hamilton TE, Gow KW, Paulino AC, Gratias EJ, Mullen EA, Geller JI, Fernandez CV, Ritchey ML, Grundy PE, Dome JS, Ehrlich PF. Outcomes based on histopathologic response to preoperative chemotherapy in children with bilateral Wilms tumor: A prospective study (COG AREN0534). Cancer 2022; 128:2493-2503. [PMID: 35383900 DOI: 10.1002/cncr.34219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 02/03/2022] [Accepted: 03/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND An objective of the Children's Oncology Group AREN0534 Study was to improve the survival of patients with bilateral Wilms tumors (BWT) by using preoperative chemotherapy of limited duration and tailoring postoperative therapy based on histopathologic response. The authors report outcomes based on postoperative histopathologic responses. METHODS Patients with BWT received treatment with vincristine, dactinomycin, and doxorubicin for 6 or 12 weeks followed by surgery. Postoperative therapy was prescribed based on the highest risk tumor according to the International Society of Pediatric Oncology classification and the Children's Oncology Group staging system. RESULTS Analyses were performed on data from 180 evaluable children. The 4-year event-free survival (EFS) and overall survival (OS) rates were 81% (95% CI, 74%-87%) and 95% (95% CI, 91%-99%), respectively. Seven patients who had completely necrotic tumors had a 4-year EFS rate of 100%. Of 118 patients who had tumors with intermediate-risk histopathology, the 4-year EFS and OS rates were 82% (95% CI, 74%-90%) and 97% (95% CI, 94%-100%), respectively. Fourteen patients who had blastemal-type tumors had 4-year EFS and OS rates of 79% (95% CI, 56%-100%) and 93% (95% CI, 79%-100%), respectively. Eighteen patients who had diffuse anaplasia had 4-year EFS and OS rates of 61% (95% CI, 35%-88%) and 72% (95% CI, 47%-97%), respectively; and the 4-year EFS and OS rates of 7 patients who had focal anaplasia were 71% (95% CI, 38%-100%) and 100%, respectively. There was no difference in the outcomes of patients who had different histopathologic subtypes within the intermediate-risk group (P = .54). CONCLUSIONS A risk-adapted treatment approach for BWT results in excellent outcomes. This approach was not successful in improving the outcome of patients who had diffuse anaplasia.
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Affiliation(s)
| | - Elizabeth J Perlman
- Department of Pathology, Ann and Robert H. Lurie Children's Hospital, Chicago, Illinois
| | - Brett Tornwall
- Department of Biostatistics, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, Florida
| | - Yueh-Yun Chi
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Yeonil Kim
- Merck Research Laboratories, Merck & Company Inc, Rahway, New Jersey
| | - Fredric A Hoffer
- Department of Radiology, Fred Hutchison Cancer Center, University of Washington, Seattle, Washington
| | - John A Kalapurakal
- Department of Radiation Oncology, Northwestern Memorial Hospital, Northwestern University, Chicago, Illinois
| | - Anne B Warwick
- Department of Pediatrics, Uniformed Services University, Walter Reed National Military Medical Center, Washington, DC
| | - Robert C Shamberger
- Department of Surgery, Boston Children's Hospital and Dana Farber Cancer Center, Boston, Massachusetts
| | - Geetika Khanna
- School of Medicine, Washington University of St Louis, St Louis, Missouri
| | - Thomas E Hamilton
- Department of Surgery, Boston Children's Hospital and Dana Farber Cancer Center, Boston, Massachusetts
| | - Kenneth W Gow
- Department of Surgery, University of Washington, Seattle, Washington
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Elizabeth A Mullen
- Department of Surgery, Boston Children's Hospital and Dana Farber Cancer Center, Boston, Massachusetts
| | - James I Geller
- Division of Hematology/Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Conrad V Fernandez
- Pediatrics and Bioethics, IWK Health Center, Halifax, Nova Scotia, Canada
| | - Michael L Ritchey
- Department of Urology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Paul E Grundy
- Department of Pediatrics and Oncology, University of Alberta Children's Hospital, Edmonton, Alberta, Canada
| | - Jeffrey S Dome
- Pediatric Surgery, Children's National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Peter F Ehrlich
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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11
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Ehrlich PF, Tornwall B, Chintagumpala MM, Chi YY, Hoffer FA, Perlman EJ, Kalapurakal JA, Warwick A, Shamberger RC, Khanna G, Hamilton TE, Gow KW, Paulino AC, Gratias EJ, Mullen EA, Geller JI, Fernandez CV, Dome JS. Kidney Preservation and Wilms Tumor Development in Children with Diffuse Hyperplastic Perilobar Nephroblastomatosis: A Report from the Children’s Oncology Group Study AREN0534. Ann Surg Oncol 2022; 29:3252-3261. [PMID: 35072864 PMCID: PMC9254258 DOI: 10.1245/s10434-021-11266-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 12/03/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Diffuse hyperplastic perilobar nephroblastomatosis (DHPLN) represents a unique category of nephroblastomatosis. Treatment has ranged from observation to multiple regimens of chemotherapy. Wilms tumors (WTs) develop in 100% of untreated patients and between 32 and 52% of treated patients. Renal preservation rates have not been previously reported. An aim of the Children's Oncology Group (COG) study AREN0534 was to prospectively evaluate the efficacy of chemotherapy in preserving renal units and preventing WT development in children with DHPLN. METHODS Patients were enrolled through the COG protocol AREN03B2 with central radiological review. DHPLN was defined as the cortical surface of the kidney being composed of hyperplastic rests, with the entire nephrogenic zone involved, and with a thick rind capping all of one or both kidneys. Treatment was with vincristine and dactinomycin (regimen EE4A), with cross-sectional imaging at weeks 6 and 12. If the patient's disease was stable or decreasing, treatment was continued for 19 weeks. Renal preservation, WT development rates at 1 year, and overall survival (OS) are reported. RESULTS Nine patients were enrolled (five females and four males), with a median age at enrollment of 10.22 months (range 2.92-29.11). One patient who was enrolled was deemed unevaluable because they did not meet the radiological criteria for DHPLN, resulting in eight evaluable patients. These eight patients had DHPLN confirmed via radiological criteria (all bilateral). Initial chemotherapy was EE4A for all eight patients, with seven of eight patients starting chemotherapy without tissue diagnosis.One patient who had an upfront partial nephrectomy was found to have DHPLN in the specimen and was subsequently treated with EE4A. All patients remained alive, with a median follow-up of 6.6 years (range 4.5-9.1). No patients were anephric; 14 of 16 kidneys were functioning (87.5%). Six of eight patients (75%) did not have WT on therapy, but two of these patients relapsed within 6 months of stopping therapy; both had favorable histology WT. One patient who was diagnosed with WT on therapy relapsed at 12 months (one of eight [12.5%]) and developed anaplastic histology. CONCLUSIONS Chemotherapy for patients with DHPLN was effective in preserving kidney function. Five-year OS is excellent, however the ideal type and duration of chemotherapy to prevent WT development remains elusive.
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Affiliation(s)
- Peter F Ehrlich
- Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
| | - Brett Tornwall
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | | | - Yueh-Yun Chi
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Fredric A Hoffer
- Fred Hutchison Cancer Center, University of Washington, Seattle, WA, USA
| | | | | | - Anne Warwick
- Walter Reed National Military Medical Center, Washington, DC, USA
| | - Robert C Shamberger
- Boston Children's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | | | - Thomas E Hamilton
- Boston Children's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | | | | | | | - Elizabeth A Mullen
- Boston Children's Hospital and Dana Farber Cancer Institute, Boston, MA, USA
| | | | | | - Jeffrey S Dome
- IWK Children's Hospital, Halifax, NS, Canada
- Children National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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12
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Balis F, Green DM, Anderson C, Cook S, Dhillon J, Gow K, Hiniker S, Jasty-Rao R, Lin C, Lovvorn H, MacEwan I, Martinez-Agosto J, Mullen E, Murphy ES, Ranalli M, Rhee D, Rokitka D, Tracy EL, Vern-Gross T, Walsh MF, Walz A, Wickiser J, Zapala M, Berardi RA, Hughes M. Wilms Tumor (Nephroblastoma), Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19:945-977. [PMID: 34416707 DOI: 10.6004/jnccn.2021.0037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The NCCN Guidelines for Wilms Tumor focus on the screening, diagnosis, staging, treatment, and management of Wilms tumor (WT, also known as nephroblastoma). WT is the most common primary renal tumor in children. Five-year survival is more than 90% for children with all stages of favorable histology WT who receive appropriate treatment. All patients with WT should be managed by a multidisciplinary team with experience in managing renal tumors; consulting a pediatric oncologist is strongly encouraged. Treatment of WT includes surgery, neoadjuvant or adjuvant chemotherapy, and radiation therapy (RT) if needed. Careful use of available therapies is necessary to maximize cure and minimize long-term toxicities. This article discusses the NCCN Guidelines recommendations for favorable histology WT.
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Affiliation(s)
- Frank Balis
- Abramson Cancer Center at the University of Pennsylvania
| | - Daniel M Green
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Shelly Cook
- University of Wisconsin Carbone Cancer Center
| | | | - Kenneth Gow
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | - Chi Lin
- Fred & Pamela Buffett Cancer Center
| | | | | | | | | | - Erin S Murphy
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Mark Ranalli
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Daniel Rhee
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - Amy Walz
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Matthew Zapala
- UCSF Helen Diller Family Comprehensive Cancer Center; and
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13
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Bhutani N, Kajal P, Sharma U. Many faces of Wilms Tumor: Recent advances and future directions. Ann Med Surg (Lond) 2021; 64:102202. [PMID: 33747498 PMCID: PMC7970064 DOI: 10.1016/j.amsu.2021.102202] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/28/2021] [Indexed: 01/08/2023] Open
Abstract
Background Wilms’ tumor (WT) is the most frequently occurring paediatric renal tumor and is one of the most treatment-responsive tumors. A tumor-suppressor gene and other genetic abnormalities have been implicated in its etiology. In addition, patients with many congenital anomalies, such as Beckwith-Wiedemann syndrome, WAGR syndrome and Denys-Drash syndrome, have an increased risk of WT. Methods and results Two large collaborative groups – National Wilms Tumor Study Group (NWTSG)/Children's Oncology Group (COG) and The International Society of Paediatric Oncology (SIOP) have laid down the guidelines for standardized treatment of WT, though differing in the diagnostic and therapeutic approach. The major difference in the two guidelines is the timing of surgery: SIOP recommends using preoperative chemotherapy and NWTSG/COG prefers primary surgery before any adjuvant treatments. Both these groups currently aim at intensifying treatment for patients with poor prognosticators while appropriating the therapy to reduce long-term complications for those with favourable prognostic features. As the survival rate has now reached 90%, the primary objectives of the physician are to perform nephron-sparing surgery in selected cases and to reduce the dosage and duration of chemotherapy and radiotherapy in appropriate cases. The purpose of this review is to present current standards of diagnosis and treatment of WT around the world. Conclusion Further studies in future should be done to highlight the use of chemotherapy and radiotherapy under risk-stratified strategies. Further improvement in survival of these children can only be achieved by increasing awareness, early recognition, appropriate referral, and a multidisciplinary approach. o Most of the patients with WT have good prognosis. o Multimodality treatment and multidisciplinary care are the major contributors for an improved prognosis. o Further studies should be done on usage of chemotherapy and radiotherapy under more accurate risk-stratified strategies and to decrease the late effects of surgery.
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Affiliation(s)
- Namita Bhutani
- Deptt. of Pathology, North DMC Medical College and Hindu Rao Hospital, New Delhi, India
| | - Pradeep Kajal
- Deptt. of Paediatric Surgery, PGIMS Rohtak, Haryana, India
| | - Urvashi Sharma
- Deptt. of Pathology, North DMC Medical College and Hindu Rao Hospital, New Delhi, India
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14
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Hol JA, Jongmans MCJ, Sudour‐Bonnange H, Ramírez‐Villar GL, Chowdhury T, Rechnitzer C, Pal N, Schleiermacher G, Karow A, Kuiper RP, de Camargo B, Avcin S, Redzic D, Wachtel A, Segers H, Vujanic GM, van Tinteren H, Bergeron C, Pritchard‐Jones K, Graf N, van den Heuvel‐Eibrink MM. Clinical characteristics and outcomes of children with WAGR syndrome and Wilms tumor and/or nephroblastomatosis: The 30-year SIOP-RTSG experience. Cancer 2021; 127:628-638. [PMID: 33146894 PMCID: PMC7894534 DOI: 10.1002/cncr.33304] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND WAGR syndrome (Wilms tumor, aniridia, genitourinary anomalies, and range of developmental delays) is a rare contiguous gene deletion syndrome with a 45% to 60% risk of developing Wilms tumor (WT). Currently, surveillance and treatment recommendations are based on limited evidence. METHODS Clinical characteristics, treatments, and outcomes were analyzed for patients with WAGR and WT/nephroblastomatosis who were identified through International Society of Pediatric Oncology Renal Tumor Study Group (SIOP-RTSG) registries and the SIOP-RTSG network (1989-2019). Events were defined as relapse, metachronous tumors, or death. RESULTS Forty-three patients were identified. The median age at WT/nephroblastomatosis diagnosis was 22 months (range, 6-44 months). The overall stage was available for 40 patients, including 15 (37.5%) with bilateral disease and none with metastatic disease. Histology was available for 42 patients; 6 nephroblastomatosis without further WT and 36 WT, including 19 stromal WT (52.8%), 12 mixed WT (33.3%), 1 regressive WT (2.8%) and 2 other/indeterminable WT (5.6%). Blastemal type WT occurred in 2 patients (5.6%) after prolonged treatment for nephroblastomatosis; anaplasia was not reported. Nephrogenic rests were present in 78.9%. Among patients with WT, the 5-year event-free survival rate was 84.3% (95% confidence interval, 72.4%-98.1%), and the overall survival rate was 91.2% (95% confidence interval, 82.1%-100%). Events (n = 6) did not include relapse, but contralateral tumor development (n = 3) occurred up to 7 years after the initial diagnosis, and 3 deaths were related to hepatotoxicity (n = 2) and obstructive ileus (n = 1). CONCLUSIONS Patients with WAGR have a high rate of bilateral disease and no metastatic or anaplastic tumors. Although they can be treated according to existing WT protocols, intensive monitoring of toxicity and surveillance of the remaining kidney(s) are advised. LAY SUMMARY WAGR syndrome (Wilms tumor, aniridia, genitourinary anomalies, and range of developmental delays) is a rare genetic condition with an increased risk of developing Wilms tumor. In this study, 43 patients with WAGR and Wilms tumor (or Wilms tumor precursor lesions/nephroblastomatosis) were identified through the international registry of the International Society of Pediatric Oncology Renal Tumor Study Group (SIOP-RTSG) and the SIOP-RTSG network. In many patients (37.5%), both kidneys were affected. Disease spread to other organs (metastases) did not occur. Overall, this study demonstrates that patients with WAGR syndrome and Wilms tumor can be treated according to existing protocols. However, intensive monitoring of treatment complications and surveillance of the remaining kidney(s) are advised.
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Affiliation(s)
- Janna A. Hol
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Marjolijn C. J. Jongmans
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
- Department of GeneticsUniversity Medical Center Utrecht/Wilhelmina Children's HospitalUtrechtthe Netherlands
| | | | | | - Tanzina Chowdhury
- Great Ormond Street Institute of Child HealthUniversity College LondonLondonUnited Kingdom
| | | | - Niklas Pal
- Department of Pediatric OncologyKarolinska University HospitalSolnaSweden
| | | | - Axel Karow
- Department of Pediatrics and Adolescent MedicineFriedrich‐Alexander University Erlangen‐NürnbergErlangenGermany
| | - Roland P. Kuiper
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Beatriz de Camargo
- Pediatric Hematology‐Oncology ProgramInstituto Nacional de CancerRio de JaneiroBrazil
| | - Simona Avcin
- Department of Pediatric OncologyUniversity Children's HospitalLjubljanaSlovenia
| | - Danka Redzic
- Department of Hemato‐OncologyMother and Child Health Care Institute of SerbiaBelgradeSerbia
| | - Antonio Wachtel
- Pediatric OncologyInstituto Nacional de Enfermedades NeoplásicasLimaPeru
| | - Heidi Segers
- Department of Pediatric Hemato‐OncologyUniversity Hospital LeuvenLeuvenBelgium
| | | | - Harm van Tinteren
- Department of BiometricsNetherlands Cancer InstituteAmsterdamthe Netherlands
| | - Christophe Bergeron
- Institut d'Hematologie et d'Oncologie PédiatriqueCentre Léon BérardLyonFrance
| | - Kathy Pritchard‐Jones
- Great Ormond Street Institute of Child HealthUniversity College LondonLondonUnited Kingdom
| | - Norbert Graf
- Department of Pediatric Oncology and HematologySaarland UniversityHomburgGermany
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15
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Ehrlich PF, Chi YY, Chintagumpala MM, Hoffer FA, Perlman EJ, Kalapurakal JA, Tornwall B, Warwick A, Shamberger RC, Khanna G, Hamilton TE, Gow KW, Paulino AC, Gratias EJ, Mullen EA, Geller JI, Grundy PE, Fernandez CV, Dome JS. Results of Treatment for Patients With Multicentric or Bilaterally Predisposed Unilateral Wilms Tumor (AREN0534): A report from the Children's Oncology Group. Cancer 2020; 126:3516-3525. [PMID: 32459384 DOI: 10.1002/cncr.32958] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/30/2020] [Accepted: 04/18/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND A primary objective of Children's Oncology Group study AREN0534 (Treatment for Patients With Multicentric or Bilaterally Predisposed, Unilateral Wilms Tumor) was to facilitate partial nephrectomy in 25% of children with bilaterally predisposed unilateral tumors (Wilms tumor/aniridia/genitourinary anomalies/range of developmental delays [WAGR] syndrome; and multifocal and overgrowth syndromes). The purpose of this prospective study was to achieve excellent event-free survival (EFS) and overall survival (OS) while preserving renal tissue through preoperative chemotherapy, completing definitive surgery by 12 weeks from diagnosis, and modifying postoperative chemotherapy based on histologic response. METHODS The treating institution identified whether a predisposition syndrome existed. Patients underwent a central review of imaging studies through the biology and classification study AREN03B2 and then were eligible to enroll on AREN0534. Patients were treated with induction chemotherapy determined by localized or metastatic disease on imaging (and histology if a biopsy had been undertaken). Surgery was based on radiographic response at 6 or 12 weeks. Further chemotherapy was determined by histology. Patients who had stage III or IV disease with favorable histology received radiotherapy as well as those who had stage I through IV anaplasia. RESULTS In total, 34 patients were evaluable, including 13 males and 21 females with a mean age at diagnosis of 2.79 years (range, 0.49-8.78 years). The median follow-up was 4.49 years (range, 1.67-8.01 years). The underlying diagnosis included Beckwith-Wiedemann syndrome in 9 patients, hemihypertrophy in 9 patients, multicentric tumors in 10 patients, WAGR syndrome in 2 patients, a solitary kidney in 2 patients, Denys-Drash syndrome in 1 patient, and Simpson-Golabi-Behmel syndrome in 1 patient. The 4-year EFS and OS rates were 94% (95% CI, 85.2%-100%) and 100%, respectively. Two patients relapsed (1 tumor bed, 1 abdomen), and none had disease progression during induction. According to Response Evaluation Criteria in Solid Tumor 1.1 criteria, radiographic responses included a complete response in 2 patients, a partial response in 21 patients, stable disease in 11 patients, and progressive disease in 0 patients. Posttherapy histologic classification was low-risk in 13 patients (including the 2 complete responders), intermediate-risk in 15 patients, and high-risk in 6 patients (1 focal anaplasia and 5 blastemal subtype). Prenephrectomy chemotherapy facilitated renal preservation in 22 of 34 patients (65%). CONCLUSIONS A standardized approach of preoperative chemotherapy, surgical resection within 12 weeks, and histology-based postoperative chemotherapy results in excellent EFS, OS, and preservation of renal parenchyma.
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Affiliation(s)
- Peter F Ehrlich
- Section of Pediatric Surgery, CS Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Yueh-Yun Chi
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Murali M Chintagumpala
- Department of Pediatrics and Oncology, Texas Children's Hospital Cancer Center at Baylor College of Medicine, Houston, Texas, USA
| | - Fredric A Hoffer
- Department of Radiology, Fred Hutchison Cancer Center, University of Washington, Seattle, Washington, USA
| | - Elizabeth J Perlman
- Division of Pediatrics and Oncology, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois, USA
| | - John A Kalapurakal
- Department of Radiation Oncology, Northwestern Memorial Hospital, Northwestern University, Chicago, Illinois, USA
| | - Brett Tornwall
- Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Anne Warwick
- Department of Oncology, Walter Reed National Military Medical Center, Washington, District of Columbia, USA
| | - Robert C Shamberger
- Department of Pediatric Surgery, Boston Children's Hospital and Dana Farber Cancer Center, Boston, Massachusetts, USA
| | - Geetika Khanna
- Department of Pediatric Radiology, Washington University of St Louis, St Louis, Missouri, USA
| | - Thomas E Hamilton
- Department of Pediatric Surgery, Boston Children's Hospital and Dana Farber Cancer Center, Boston, Massachusetts, USA
| | - Kenneth W Gow
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eric J Gratias
- Children's Oncology Group, Philadelphia, Pennsylvania, USA
| | - Elizabeth A Mullen
- Department of Pediatric Surgery, Boston Children's Hospital and Dana Farber Cancer Center, Boston, Massachusetts, USA
| | - James I Geller
- Division of Hematology/Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Paul E Grundy
- Department of Pediatrics, University of Alberta Children's Hospital, Edmonton, Alberta, Canada
| | - Conrad V Fernandez
- Department of Pediatrics, IWK Children's Hospital, Halifax, Nova Scotia, Canada.,Department of Bioethics, IWK Children's Hospital, Halifax, Nova Scotia, Canada
| | - Jeffrey S Dome
- Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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16
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Aldrink JH, Heaton TE, Dasgupta R, Lautz TB, Malek MM, Abdessalam SF, Weil BR, Rhee DS, Baertschiger R, Ehrlich PF. Update on Wilms tumor. J Pediatr Surg 2019; 54:390-397. [PMID: 30270120 PMCID: PMC7542630 DOI: 10.1016/j.jpedsurg.2018.09.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/28/2018] [Accepted: 09/14/2018] [Indexed: 02/07/2023]
Abstract
This article reviews of the current evidence-based treatment standards for children with Wilms tumor. In this article, a summary of recently completed clinical trials by the Children's Oncology Group is provided, the current diagnostic evaluation and surgical standards are discussed, and the surgical impact on current risk stratification for patients with Wilms tumor is highlighted. LEVEL OF EVIDENCE: This is a review article of previously published and referenced LEVEL 1 studies, but also includes expert opinion LEVEL V, represented by the American Pediatric Surgical Association Cancer Committee.
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Affiliation(s)
- Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH.
| | - Todd E Heaton
- Department of Surgery, Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Timothy B Lautz
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Marcus M Malek
- Department of Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shahab F Abdessalam
- Department of Surgery, Division of Pediatric Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Brent R Weil
- Department of Surgery, Division of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Daniel S Rhee
- Depatment of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Reto Baertschiger
- Department of Surgery, Children's Hospital at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Peter F Ehrlich
- Department of Surgery, Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
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17
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Murphy AJ, Davidoff AM. Bilateral Wilms Tumor: A Surgical Perspective. CHILDREN-BASEL 2018; 5:children5100134. [PMID: 30250006 PMCID: PMC6210093 DOI: 10.3390/children5100134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/13/2018] [Accepted: 09/21/2018] [Indexed: 12/27/2022]
Abstract
Historically, the management of bilateral Wilms tumor (BWT) was non-standardized and suffered from instances of prolonged chemotherapy and inconsistent surgical management which resulted in suboptimal renal and oncologic outcomes. Because of the risk of end-stage renal disease associated with the management of BWT, neoadjuvant chemotherapy and nephron-sparing surgery have been adopted as the guiding management principles. This management strategy balances acceptable oncologic outcomes against the risk of end-stage renal disease. A recent multi-institutional Children’s Oncology Group study (AREN0534) has confirmed the benefits of standardized 3-drug neoadjuvant chemotherapy and the utilization of nephron-sparing surgery in BWT patients; however, less than 50% of patients underwent bilateral nephron-sparing surgery. The coordination of neoadjuvant chemotherapy and the timing and implementation of bilateral nephron-sparing surgery are features of BWT management that require collaboration between oncologists and surgeons. This review discusses the surgical management strategy in the context of BWT disease biology, with an emphasis on timepoints during therapy at which surgical decision making can greatly impact this disease and minimize long-term toxicities.
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Affiliation(s)
- Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38105, USA.
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38105, USA.
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Royer‐Pokora B, Beier M, Brandt A, Duhme C, Busch M, de Torres C, Royer H, Mora J. Chemotherapy and terminal skeletal muscle differentiation in WT1-mutant Wilms tumors. Cancer Med 2018; 7:1359-1368. [PMID: 29542868 PMCID: PMC5911586 DOI: 10.1002/cam4.1379] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/13/2017] [Accepted: 01/13/2018] [Indexed: 12/26/2022] Open
Abstract
Wilms tumors (WT) with WT1 mutations do not respond well to preoperative chemotherapy by volume reduction, suggesting resistance to chemotherapy. The histologic pattern of this tumor subtype indicates an intrinsic mesenchymal differentiation potential. Currently, it is unknown whether cytotoxic treatments can induce a terminal differentiation state as a direct comparison of untreated and chemotherapy-treated tumor samples has not been reported so far. We conducted gene expression profiling of 11 chemotherapy and seven untreated WT1-mutant Wilms tumors and analyzed up- and down-regulated genes with bioinformatic methods. Cell culture experiments were performed from primary Wilms tumors and genetic alterations in WT1 and CTNNB1 analyzed. Chemotherapy induced MYF6 165-fold and several MYL and MYH genes more than 20-fold and repressed many genes from cell cycle process networks. Viable tumor cells could be cultivated when patients received less than 8 weeks of chemotherapy but not in two cases with longer treatments. In one case, viable cells could be extracted from a lung metastasis occurring after 6 months of intensive chemotherapy and radiation. Comparison of primary tumor and metastasis cells from the same patient revealed up-regulation of RELN and TBX2, TBX4 and TBX5 genes and down-regulation of several HOXD genes. Our analyses demonstrate that >8 weeks of chemotherapy can induce terminal myogenic differentiation in WT1-mutant tumors, but this is not associated with volume reduction. The time needed for all tumor cells to achieve the terminal differentiation state needs to be evaluated. In contrast, prolonged treatments can result in genetic alterations leading to resistance.
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Affiliation(s)
| | - Manfred Beier
- Institute of Human GeneticsHeinrich‐Heine UniversityDüsseldorfD‐40225Germany
| | - Artur Brandt
- Institute of Human GeneticsHeinrich‐Heine UniversityDüsseldorfD‐40225Germany
| | - Constanze Duhme
- Institute of Human GeneticsHeinrich‐Heine UniversityDüsseldorfD‐40225Germany
| | - Maike Busch
- Institute of Human GeneticsHeinrich‐Heine UniversityDüsseldorfD‐40225Germany
| | - Carmen de Torres
- Department of OncologyHospital Sant Joan de DeuBarcelona08950Spain
| | - Hans‐Dieter Royer
- Institute of Human GeneticsHeinrich‐Heine UniversityDüsseldorfD‐40225Germany
| | - Jaume Mora
- Department of OncologyHospital Sant Joan de DeuBarcelona08950Spain
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Ehrlich P, Chi YY, Chintagumpala MM, Hoffer FA, Perlman EJ, Kalapurakal JA, Warwick A, Shamberger RC, Khanna G, Hamilton TE, Gow KW, Paulino AC, Gratias EJ, Mullen EA, Geller JI, Grundy PE, Fernandez CV, Ritchey ML, Dome JS. Results of the First Prospective Multi-institutional Treatment Study in Children With Bilateral Wilms Tumor (AREN0534): A Report From the Children's Oncology Group. Ann Surg 2017; 266:470-478. [PMID: 28795993 PMCID: PMC5629006 DOI: 10.1097/sla.0000000000002356] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The Children's Oncology Group study AREN0534 aimed to improve event-free survival (EFS) and overall survival (OS) while preserving renal tissue by intensifying preoperative chemotherapy, completing definitive surgery by 12 weeks from diagnosis, and modifying postoperative chemotherapy based on histologic response. BACKGROUND No prospective therapeutic clinic trials in children with bilateral Wilms tumors (BWT) exist. Historical outcomes for this group were poor and often involved prolonged chemotherapy; on NWTS-5, 4-year EFS for all children with BWT was 56%. METHODS Patients were enrolled and imaging studies were centrally reviewed to assess for bilateral renal lesions. They were treated with 3-drug induction chemotherapy (vincristine, dactinomycin, and doxorubicin) for 6 or 12 weeks based on radiographic response followed by surgery and further chemotherapy determined by histology. Radiation therapy was provided for postchemotherapy stage III and IV disease. RESULTS One hundred eighty-nine of 208 patients were evaluable. Four-year EFS and OS were 82.1% (95% CI: 73.5%-90.8%) and 94.9% (95% CI: 90.1%-99.7%. Twenty-three patients relapsed and 7 had disease progression. After induction chemotherapy 163 of 189 (84.0%) underwent definitive surgical treatment in at least 1 kidney by 12 weeks and 39% retained parts of both kidneys. Surgical approaches included: unilateral total nephrectomy with contralateral partial nephrectomy (48%), bilateral partial nephrectomy (35%), unilateral total nephrectomy (10.5%), unilateral partial nephrectomy (4%), and bilateral total nephrectomies (2.5%). CONCLUSION This treatment approach including standardized 3-drug preoperative chemotherapy, surgical resection within 12 weeks of diagnosis and response and histology-based postoperative therapy improved EFS and OS and preservation of renal parenchyma compared with historical outcomes for children with BWT.
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Affiliation(s)
- Peter Ehrlich
- *Section of Pediatric Surgery CS Mott Children's Hospital, University of Michigan, Ann Arbor MI †COG Data Center, University of Florida, Gainesville, FL ‡Texas Children's Cancer Center at Baylor College of Medicine, Houston, TX §Fred Hutchison Cancer Center, University of Washington, Seattle, WA ¶Ann and Robert H Lurie Children's Hospital, Chicago, IL ||Northwestern University, Chicago, IL **Walter Reed National Military Medical Center, Washington DC ††Boston Children's Hospital and Dana Farber Cancer Center, Boston, MA ‡‡Washington University of St Louis, St Louis, MO §§University of Washington, Seattle, WA ¶¶MD Anderson Cancer Center, Houston, TX ||||Children's Oncology Group, Philadelphia, PA ***Cincinnati Children's Hospital, Cincinnati, OH †††University of Alberta Children's Hospital, Edmonton, Alberta, Canada ‡‡‡IWK Children's Hospital, Halifax, Nova Scotia, Canada §§§Phoenix Children's Hospital, Phoenix, AZ ¶¶¶Children National Medical Center, Washington, DC
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Charlton J, Irtan S, Bergeron C, Pritchard-Jones K. Bilateral Wilms tumour: a review of clinical and molecular features. Expert Rev Mol Med 2017; 19:e8. [PMID: 28716159 PMCID: PMC5687181 DOI: 10.1017/erm.2017.8] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Wilms tumour (WT) is the most common paediatric kidney cancer and affects approximately one in 10 000 children. The tumour is associated with undifferentiated embryonic lesions called nephrogenic rests (NRs) or, when diffuse, nephroblastomatosis. WT or NRs can occur in both kidneys, termed bilateral disease, found in only 5-8% of cases. Management of bilateral WT presents a major clinical challenge in terms of maximising survival, preserving renal function and understanding underlying genetic risk. In this review, we compile clinical data from 545 published cases of bilateral WT and discuss recent progress in understanding the molecular basis of bilateral WT and its associated precursor NRs in the context of the latest radiological, surgical and epidemiological features.
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Affiliation(s)
- Jocelyn Charlton
- UCL Institute of Child Health, University College London, London, UK
| | - Sabine Irtan
- UCL Institute of Child Health, University College London, London, UK
- Paediatric Surgery Department, Trousseau Hospital, Paris, France
| | - Christophe Bergeron
- Centre Léon Bérard, Institut d'Hématologie et d'Oncologie Pédiatrie, Lyon, France
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21
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Outcome and renal function following salvage surgery for bilateral Wilms tumor. ANNALS OF PEDIATRIC SURGERY 2017. [DOI: 10.1097/01.xps.0000516079.54951.ec] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Wilms tumour is named after Max Wilms. It is an embryonal tumour derived from the metanephros. It is the commonest childhood renal tumour and the third commonest paediatric malignancy. Synchronous bilateral Wilms tumours (BWT) represent 4-7% of all Wilms tumours (WT) and present at a younger age than unilateral Wilms tumours. At least 10% of synchronous BWTs have unfavourable histology, and up to 22% are associated with genitourinary abnormalities, aniridia, WAGR syndrome, Denys-Drash syndrome, hemihypertrophy, or one of the other overgrowth syndromes. The long-term disease-free survival rate for patients with unilateral WT is approaching 90%, and is around 70% for those with metastatic disease. For both synchronous and metachronous Wilms tumours the prognosis is less favourable with reported cure rates approaching 80% in the best centres and lower in resource poor settings. There is potential for a reduced quality of life due to renal insufficiency and the possible need for renal transplantation. The major clinical challenge in BWTs is preservation of functioning renal tissue using nephron-sparing surgical techniques, while achieving cure with minimum therapy-related morbidity. Mortality is generally associated with progressive disease of anaplastic tumours. Chemotherapy followed by nephron-sparing surgery has been able, in most cases, to eradicate the tumour while preserving renal function. Radiotherapy has largely been avoided because of fears of long-term radiation injury to the residual functioning renal mass. Patient selection, appropriate pre- and post-operative chemotherapy and skilled surgical techniques all contribute to excellent outcomes where these are achievable.
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Affiliation(s)
- Alastair J W Millar
- Emeritus Professor of Paediatric Surgery, Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa.
| | - Sharon Cox
- Associate Professor and Head of Clinical Unit, Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Alan Davidson
- Associate Professor and Head of Division of Haematology and Oncology, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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Abstract
Wilms tumour is named after Max Wilms. It is an embryonal tumour derived from the metanephros. It is the commonest childhood renal tumour and the third commonest paediatric malignancy. Synchronous bilateral Wilms tumours (BWT) represent 4-7% of all Wilms tumours (WT) and present at a younger age than unilateral Wilms tumours. At least 10% of synchronous BWTs have unfavourable histology, and up to 22% are associated with genitourinary abnormalities, aniridia, WAGR syndrome, Denys-Drash Syndrome, hemihypertrophy, or one of the other overgrowth syndromes. The long-term disease-free survival (DFS) rate for patients with unilateral Wilms' tumours is approaching 90%, and is around 70% for those with metastatic disease. For both synchronous and metachronous Wilms tumours the prognosis is less favourable with reported cure rates approaching 80% in the best centres and lower in resource poor settings. There is potential for a reduced quality of life due to renal insufficiency and the possible need for renal transplantation. The major clinical challenge in BWTs is preservation of functioning renal tissue using nephron sparing surgical techniques, while achieving cure with minimum therapy-related morbidity. Mortality is generally associated with progressive disease of anaplastic tumours. Chemotherapy followed by nephron sparing surgery has been able, in most cases, to eradicate the tumour while preserving renal function. Radiotherapy has largely been avoided because of fears of long term radiation injury to the residual functioning renal mass. Patient selection, appropriate pre- and post-operative chemotherapy and skilled surgical techniques all contribute to excellent outcomes where these are achievable.
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Lockwood G, Ferrer F, Makari J. Bilateral Wilms Tumor With Ureteral Extension. Urology 2017; 102:219-221. [PMID: 28063884 DOI: 10.1016/j.urology.2016.12.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
Abstract
Wilms tumor is the most common renal tumor in children. However, tumor extension into the ureter is exceedingly rare. We present a case of bilateral Wilms tumor with unilateral ureteral extension into the bladder. This case illustrates the importance of thoughtful diagnostic evaluation and surgical planning to obtain a good oncologic outcome while preserving renal function.
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Affiliation(s)
- Gina Lockwood
- Department of Surgery, Division of Pediatric Urology, Connecticut Children's Medical Center, Hartford, CT; School of Medicine, University of Connecticut, Farmington, CT.
| | - Fernando Ferrer
- School of Medicine, University of Connecticut, Farmington, CT
| | - John Makari
- Department of Surgery, Division of Pediatric Urology, Connecticut Children's Medical Center, Hartford, CT; School of Medicine, University of Connecticut, Farmington, CT
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Abstract
BACKGROUND Treatment results of Wilms tumors have been impressively improved over the past 50 years resulting in a stage-independent overall survival of greater than 90%. However, unsatisfying treatment results still remain in children with high-risk tumors and tumor relapses. MATERIALS AND METHODS This review highlights the current concepts of Wilms tumor surgery as a cornerstone of the treatment strategy for this malignancy. A selective literature review focusing on the past 5 years served as the basis for this article. RESULTS Nephron-sparing surgery is associated with an analogue outcome compared to tumor nephrectomy in unilateral Wilms tumors. The surgical panel of the International Society of Pediatric Oncology (SIOP) group has recently introduced a novel nomenclature for organ-preserving resection procedures in order to facilitate a prospective comparison of data. The minimally invasive approach represents an alternative technique with adequate outcome. In bilateral disease, nephron-sparing procedures are gold standard. Complete resection of lung and liver metastases has a significant impact on patients' survival. CONCLUSIONS Surgical guidelines for nephron-sparing surgery and minimally invasive tumor nephrectomy need to be established and implemented within newly formulated treatment protocols of the different national and international treatment trials. Risk stratification of patients needs to be more individualized with the aim of reducing late effects while at least maintaining the same survival rates. The unsatisfying treatment results of tumor relapses-associated with low patient numbers within the different trials-emphasize the need for international collaboration.
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Affiliation(s)
- J Fuchs
- Abteilung für Kinderchirurgie und Kinderurologie, Universitätsklinikum Tübingen, Hoppe-Seyler-Straße 03, 72076, Tübingen, Deutschland.
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Vanden Berg RNW, Bierman EN, Noord MV, Rice HE, Routh JC. Nephron-sparing surgery for Wilms tumor: A systematic review. Urol Oncol 2015; 34:24-32. [PMID: 26254695 DOI: 10.1016/j.urolonc.2015.07.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 06/30/2015] [Accepted: 07/06/2015] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Radical nephrectomy (RN, or total nephrectomy) is the current gold-standard surgical treatment for children with Wilms tumors (WT). However, nephron-sparing surgery (NSS, or partial nephrectomy) has recently been gaining increasing attention. The objective of this systematic review is to compare the effectiveness of NSS as compared with RN for the treatment of children with WT. METHODS We searched the Cochrane Controlled Trials Register, clinicaltrials.gov, MEDLINE, EMBASE, Google Scholar, and recently presented meeting abstracts for reports in English. The bibliographies of included studies were then hand-searched for any missed articles. The protocol was prospectively registered. Manuscripts were assessed and data abstracted in duplicate with differences resolved by the senior author. Owing to high heterogeneity among the final included studies, only a qualitative systematic review was performed; no formal meta-analysis was undertaken. RESULTS We identified 694 articles, 118 of which were selected for full-text review and 66 of which were included in the final analysis. Most studies were single- or multi-institution retrospective case series (60, 91%), with a small number of prospective cohort studies (6, 9%) and 1 administrative database analysis. Most studies were from Europe (27, 41%) or North America (21, 32%). Nearly half (32, 48%) of studies those were included were dated from 2010 or later. In total, data on 4,002 patients were included, of whom 1,040 (26%) underwent NSS and 2,962 (74%) underwent NSS. Reported rupture rates were similar between RN and NSS (13% vs. 7%), as were recurrence rates (12% vs. 11%) and survival rates (85% vs. 88%). However, these comparisons are limited by inherent biases in the design and reporting of most included studies. CONCLUSIONS Most contemporary studies reporting the use of NSS in children with WT report similar long-term outcomes to RN. However, most existing studies are limited by their small numbers, inconsistent reporting, and methodological biases. There are significant opportunities for future research on the use of NSS in children with WT, including issues related to surgical quality, optimal technique, timing and duration of chemotherapy, and variation in the use of NSS among centers.
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Affiliation(s)
| | | | | | - Henry E Rice
- Duke University School of Medicine, Durham, NC; Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jonathan C Routh
- Duke University School of Medicine, Durham, NC; Division of Urologic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Kieran K, Ehrlich PF. Current surgical standards of care in Wilms tumor. Urol Oncol 2015; 34:13-23. [PMID: 26122713 DOI: 10.1016/j.urolonc.2015.05.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Wilms tumor (WT) is the second most common abdominal tumor in children. METHODS This chapter discusses surgical considerations for the management of unilateral and bilateral WT. RESULTS Currently, survival exceeds 90%, owing to multicenter studies under the auspices of the Children's Oncology Group and Société Internationale d'Oncologie Pédiatrique. Surgical excision remains the mainstay of oncologic control and is also crucial for proper staging of disease in order to direct adjuvant therapy and limit treatment-related morbidity. CONCLUSIONS Careful attention must be paid to proper disease staging, upfront and adjuvant therapy, and surgical technique in order to optimize oncologic outcomes while minimizing short- and long-term morbidity.
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Affiliation(s)
- Kathleen Kieran
- Division of Urology, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98109.
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28
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User IR, Ekinci S, Kale G, Akyüz C, Büyükpamukçu M, Karnak I, Çiftçi AÖ, Tanyel FC, Şenocak ME. Management of bilateral Wilms tumor over three decades: The perspective of a single center. J Pediatr Urol 2015; 11:118.e1-6. [PMID: 25842994 DOI: 10.1016/j.jpurol.2014.11.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 11/19/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Outcomes of Wilms tumor improved in last 50 years and excellent survival rates can be achieved especially in case of non-metastatic disease and favorable histology. Nevertheless, bilateral cases still stand as a therapeutic challenge. Prognosis of bilateral Wilms tumor (BWT) is not as good as the unilateral tumors of similar stage and histology in terms of survival and renal function. OBJECTIVE Management of BWT is constantly evolving and still stands as a therapeutic challenge. This study is designed to review and share our experiences on this topic from a surgical standpoint. STUDY DESIGN The records of patients treated in our clinic between 1980 and 2013 according to Turkish Pediatric Group of Oncology protocol were analyzed retrospectively and clinical data, surgical details, pathology results, long term outcomes were analyzed. RESULTS Thirteen girls and 7 boys with a mean age of 2,5 years were treated. There were 2 patients with Wilms tumor-Aniridia-Growth Retardation complex and one with isolated hemihypertrophy. Metastasis were detected in lungs of 4 patients; liver of 2 and in the cranium of one. All patients except one with the presumptive diagnosis of unilateral Wilms tumor were given preoperative chemotherapy. To sum up; 19 nephroureterectomies, 8 partial nephrectomies and 13 enucleations were performed to 36 kidneys without any major early or late postoperative complications. Pathologic results revealed positive surgical margins in 2 lesions with enucleation and in 2 with partial nephrectomies and anaplasia in 4 patients. Two patients were not operated due to parental disapproval. Two patients had the need of dialysis; one was anephric and the others' renal functions recovered over a year. Seven patients received radiotherapy for pulmonary metastasis, positive surgical margins or local recurrences. Overall, 13 patients survived and 7 died due to metastasis, recurrences, and complication of dialysis and refusal of surgical treatment. Survival among all patients was 65% and 72.2% among operated ones. Of the 7 patients with the partial nephrectomy, 2 died and 5 survived. Among enucleation group, 8 out of 10 survived and 2 died. Survival was slightly higher among enucleation group (80% vs 71.4%). Median time of follow-up for survivors of disease is 5.8 years (min: 6 months and max: 14 years). DISCUSSION Outcomes of BWT management have changed dramatically during the last few decades from only survival, to a long life expectancy without the need of renal replacement therapy owing to improvements in treatment options. We argue that positive surgical margins do not necessarily lead to local recurrence. For this reason it may be wiser to favor on more nephron sparing surgery than to achieve negative surgical margins. Adjuvant chemotherapy and radiotherapy may be adequate to prevent local recurrence. Also, survival did not differ significantly between different ways of nephron sparing surgeries, so it may be wiser to choose enucleation over partial nephrectomy which preserves more nephrons. Nephron-sparing surgery should have utmost importance despite the risk of positive margins. On the other hand, there is not enough data to interpret if positive surgical margins have role on distant metastases or not. Presence of metastasis and recurrence seems to be an important determinant of prognosis given the fact that none of the survivors had any metastasis or recurrence. CONCLUSION Nephron preservation should be the aim while taking positive surgical margin risk on nephron sparing surgery side relying on postoperative chemotherapy and carefully planned radiotherapy to avoid recurrence. However, there is significant diversity on the management BWT in different centers and a certain validated guideline or protocol to provide the optimal treatment is still lacking.
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Affiliation(s)
- I R User
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - S Ekinci
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - G Kale
- Pediatric Pathology Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - C Akyüz
- Pediatric Oncology Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - M Büyükpamukçu
- Pediatric Oncology Unit, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - I Karnak
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - A Ö Çiftçi
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - F C Tanyel
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - M E Şenocak
- Department of Pediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Agarwala S, Mittal D, Bhatnagar V, Srinivas M, Bakhshi S, Bajpai M, Gupta DK, Iyer VK, Mohanti BK, Thulkar S. Management and outcomes in massive bilateral Wilms' tumors. J Indian Assoc Pediatr Surg 2014; 19:208-12. [PMID: 25336802 PMCID: PMC4204245 DOI: 10.4103/0971-9261.142005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose: To evaluate the outcome of children with bilateral Wilms’ tumor (BWT) treated on All India Institute of Medical Sciences-Wilms Tumor-99 (AIIMS-WT-99) protocol. Materials and Methods: All children with BWT, registered in our solid tumor clinic from August 1999 through December 2010 were included. Results: Of the 178 fresh cases of Wilms Tumor (WT) treated during this period, 11 (6.2%) had bilateral involvement. All patients except one (12 and 3 cm), had massive bilateral tumors of more than 10 cm on each side. There were eight boys and three girls in the age range 6–30 months. One patient had Denys-Drash syndrome. Twenty renal units were operated upon (12 tumorectomy, five partial nephrectomy, and three nephrectomies), while one patient with inferior vena cava (IVC) thrombus died of renal failure. Tumor spill occurred in three units, lymphnode was positive in two patients. Local recurrence occurred in four patients (six of 18 renal units (33%)—two bilateral and two unilateral). There was one recurrence in the liver that was treated with radio-frequency ablation. The 5-year overall survival (OS) was 90% (95% confidence interval (CI) = 50.8–98.6) and the relapse free survival (RFS) was 38% (95% CI = 6.1–71.6). Conclusion: Massive BWT respond poorly to preoperative chemotherapy, are often not amenable to partial nephrectomy/tumorectomy and have a higher local recurrence rate, giving a poor RFS.
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Affiliation(s)
- Sandeep Agarwala
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Mittal
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Veereshwar Bhatnagar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - M Srinivas
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, BRAIRCH, AIIMS, New Delhi, India
| | - Minu Bajpai
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Devendra Kumar Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - V K Iyer
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
| | | | - Sanjay Thulkar
- Department of Radiodiagnosis, BRAIRCH, AIIMS, New Delhi, India
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Oue T, Koshinaga T, Okita H, Kaneko Y, Hinotsu S, Fukuzawa M. Bilateral Wilms tumors treated according to the Japan Wilms Tumor Study Group protocol. Pediatr Blood Cancer 2014; 61:1184-9. [PMID: 24623612 DOI: 10.1002/pbc.24979] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 01/17/2014] [Indexed: 01/25/2023]
Abstract
BACKGROUND The introduction of multimodal therapy has improved the survival rate of bilateral Wilms tumors (BWT); however, the results are still not satisfactory in terms of the renal preservation. To establish a new treatment strategy for BWT, we reviewed the results of the cases registered in the Japan Wilms Tumor Study Group (JWiTS). PROCEDURE This analysis concerned patients with synchronous BWT registered in the JWiTS between 1996 and 2011. In these patients, the management of BWT included initial tumor resection or biopsy followed by chemotherapy. The details of the treatments and outcomes were analyzed. RESULTS Among the 355 cases registered in the JWiTS database, 31 (8.7%) had BWT. They were 16 males and 15 females with a mean age of 15.5 months. Preoperative chemotherapy was performed in 24 cases. Bilateral nephron-sparing surgery (NSS) was achieved in 10 of 28 cases (36%). All of the cases were of favorable nephroblastoma without anaplasia, and a WT1 mutation was detected in 21 of the 27 cases (78%) examined. The 5-year overall survival was 92.6%; however, 10 children (40%) developed impaired renal function and three of them developed renal failure. CONCLUSIONS The long-term survival rates for patients with synchronous BWT have improved. However, more than half of patients receive nephrectomy. The protocol should be changed to improve the rate of preservation of the renal parenchyma. Preoperative chemotherapy should be performed to shrink the tumors in every case, and subsequent NSS should be carried out after a central imaging evaluation.
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Affiliation(s)
- Takaharu Oue
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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31
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Ehrlich PF. Bilateral Wilms’ tumor: the need to improve outcomes. Expert Rev Anticancer Ther 2014; 9:963-73. [DOI: 10.1586/era.09.50] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
PURPOSE To present our experience of 20 children with bilateral Wilms' tumour seen in a resource-challenged environment over a 10-year period. METHOD All patients with a diagnosis of bilateral synchronous Wilms' tumour were identified and recruited. RESULTS Study patients represented 11 % of a cohort of 177 new patients with Wilms' tumour seen over the same period. Three patients had a syndromic predisposition to Wilms' tumour. Metastatic disease was seen at presentation in four patients (20 %) and three children presented with unilateral tumour rupture. One patient presented with paraplegia and one with obstruction of the duodenum. All children received neoadjuvant chemotherapy. One HIV-infected child died of IRIS after neoadjuvant treatment, but before surgery. One child died of progressive disease after unilateral nephrectomy. Nephron-sparing surgery was performed in 22 kidneys and 15 kidneys were removed in toto. Following enucleation of tumours, three children had positive margins. Discordant histopathology was seen in 53 % of patients. Overall survival at 2 years is 85 %. CONCLUSION Despite significant co-morbidity and advanced disease, bilateral Wilms' tumour is a treatable disease in a resource-constrained environment.
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Popov SD, Vujanic GM, Sebire NJ, Chagtai T, Williams R, Vaidya S, Pritchard-Jones K. Bilateral wilms tumor with TP53-related anaplasia. Pediatr Dev Pathol 2013; 16:217-23. [PMID: 23387809 DOI: 10.2350/12-08-1245-cr.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Wilms tumor (WT) with diffuse anaplasia has an unfavorable prognosis and is often (>70%) associated with mutations in the TP53 gene. Although most WTs are unilateral, 5-10% are bilateral, and they are almost always present with nephrogenic rests. The latter are considered a precursor of WT. Two cases of bilateral WTs with nephroblastomatosis, in which anaplastic changes were detected over a period of time, were analyzed using clinical, radiological, histopathological, and molecular-genetic data. TP53 was analyzed by direct sequencing of its full coding sequence and intron-exon boundaries in 11 fragments. DNA was extracted from paraffin-embedded or frozen specimens. High-resolution genomic copy number profiling was carried out by UCL Genomics on the Affymetrix Human Mapping 250K Nsp or Genome-Wide Human SNP Array 6.0 platform. Both cases demonstrated a strong association between the appearance of anaplastic clones and TP53 mutations. Synchronous ganglioneuroma was diagnosed in one case. Our cases are unique as they represent a long disease history and demonstrate the difficulties in managing rare cases of bilateral WT with anaplasia. These cases also emphasize the practical importance of modern molecular-genetic techniques and their clinical application. Moreover, they highlight the issue of the adequate sampling needed in order to gather comprehensive, efficient, and sufficient information about genetic events in a single tumor.
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Affiliation(s)
- Sergey D Popov
- Divisions of Molecular Pathology and Cancer Therapeutics, Institute of Cancer Research, Sutton, Surrey, United Kingdom.
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Indolfi P, Jenkner A, Terenziani M, Crocoli A, Serra A, Collini P, Biasoni D, Gandola L, Bisogno G, Cecchetto G, Di Martino M, D'Angelo P, Bianchi M, Conte M, Inserra A, Pession A, Spreafico F. Synchronous bilateral Wilms tumor: a report from the Associazione Italiana Ematologia Oncologia Pediatrica (AIEOP). Cancer 2013; 119:1586-92. [PMID: 23310931 DOI: 10.1002/cncr.27897] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 09/20/2012] [Accepted: 09/21/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND The optimal management of bilateral Wilms tumor (BWT) is challenging, and their survival is lower than for unilateral tumors. This report discusses a large series of BWTs treated in Italy in the last 2 decades. METHODS This analysis concerns patients with synchronous BWT registered at Associazione Italiana Ematologia Oncologia Pediatrica (AIEOP) centers between 1990 and 2011; details on their treatment and outcome are presented and discussed. RESULTS Ninety BWTs were registered in the AIEOP Wilms tumor database. Preoperative chemotherapy was given for a median 12 weeks before definitive tumor resection was attempted. Forty-eight percent of the patients had preservation of bilateral renal parenchyma. The proportion of bilateral nephron-sparing surgeries was not higher in the 37 patients initially given doxorubicin/vincristine/actinomycin D (32%) than in the 43 children receiving vincristine/actinomycin D alone (58%). The 4-year disease-free survival rate was 66.5% ± 5% and overall survival was 80% ± 5% for the cohort as a whole. The 4-year disease-free survival (overall survival) for 18 children with diffuse anaplasia or postchemotherapy blastemal-type tumors was 51% ± 13% (62% ± 13%), as opposed to 72% ± 3% (88% ± 4%) for 68 children with a favorable histology (log-rank P = .04 [P = .007]). CONCLUSIONS These results provide further evidence that the optimal duration and choice of drugs for preoperative chemotherapy remain an open question. Outcome remained significantly worse for BWT than for unilateral Wilms tumor. To enable the conservative treatment of as many affected kidneys as possible, only centers with experience in BWT should manage such cases.
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Affiliation(s)
- Paolo Indolfi
- Pediatric Oncology Unit, Department of Pediatrics, II University, Naples, Italy
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Abstract
This article reviews common pediatric urologic cancers involving the genitourinary system. Rhabdomyosarcoma may occur in the bladder, prostate, paratesticular regions, vagina, or uterus. Some of these locations, such as the paratesticular region, have a more favorable outcome. Benign neoplasms account for the majority of pediatric testicular tumors and most are managed with testis-sparing surgery. Most genitourinary malignancies are expected to have a good outcome. One focus of treatment is organ preservation but not at the expense of a good oncologic outcome. Late sequelae of anticancer therapy are a concern and every attempt is made to decrease the intensity of tumor treatment.
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Sudour H, Audry G, Schleimacher G, Patte C, Dussart S, Bergeron C. Bilateral Wilms tumors (WT) treated with the SIOP 93 protocol in France: epidemiological survey and patient outcome. Pediatr Blood Cancer 2012; 59:57-61. [PMID: 22238153 DOI: 10.1002/pbc.24059] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 11/28/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND The treatment of bilateral Wilms tumors (WT) requires multimodality therapy with individualized decision to ensure cure while preserving as much renal parenchyma as possible. PROCEDURE We analyzed the clinical records of 49 children with bilateral WT treated in France between 1993 and 2001, according to the SIOP-93 guidelines (individual treatment program: Treatment was continued as long as there was imaging evidence of tumor regression). Pathology reports, duration of preoperative chemotherapy and surgical records were also reviewed. Overall Survival (OS) and Event-Free Survival (EFS) rates were studied and relationships between possible prognostic factors and survival were assessed. RESULTS Imaging studies revealed bilateral involvement in 98% of the cases. Whatever the response to preoperative chemotherapy, the mean duration of neoadjuvant chemotherapy was 80 days (Q1-Q3: 47-89 days). Forty-eight children underwent nephron sparing surgery (NSS) at least for one kidney and 19 for both. Five-year EFS and OS rates were, respectively, 83.4 and 89.5%. Only the most advanced stages were shown to affect OS (P = 0.03). At study endpoint, end-stage renal disease (ESRD) was reported in seven children, associated with a predisposing phenotype in three. CONCLUSIONS Results of this study demonstrate a favorable outcome of patients with bilateral WT receiving an individual treatment program. With a tailored approach to treatment according to the tumor response, 77% of our patients were operated before the third month of preoperative chemotherapy. In spite of good survival, 14% of our patients have ESRD.
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Affiliation(s)
- Hélène Sudour
- Department of Pediatrics, Centre Oscar Lambret, 59020 Lille Cedex, France.
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Abstract
The management of Wilms' tumor emerging of the outstanding clinical trials undertaken in the developed world in the last four decades has led to excellent longterm outcomes. The scenario in developing country like India is different; late presentation with massive tumors and advanced stage, lacunae in staging, nonavailability of pediatric medical oncologists and poor follow-ups are common. A comprehensive summary of available therapeutic modalities is provided here along with clear roadmaps of management of Wilms' tumor as per Société Internationale d'Oncologie Pédiatrique (SIOP) and National Wilms' Tumor Study Group/Children's Oncology Group (NWTSG/COG) protocols in simple tabulated form.
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Abstract
Significant improvement has been made in the treatment of children with Wilms tumor. New protocols are in place designed to maintain a high rate of cure for these patients while minimizing toxicity, based on refinement of the risk-stratification system.
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Affiliation(s)
- Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Fuchs J, Szavay P, Seitz G, Handgretinger R, Schäfer J, Warmann S. Nephron Sparing Surgery for Synchronous Bilateral Nephroblastoma Involving the Renal Hilus. J Urol 2011; 186:1430-6. [DOI: 10.1016/j.juro.2011.05.068] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Indexed: 10/17/2022]
Affiliation(s)
- J. Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Childrens Hospital Tuebingen, Tuebingen, Germany
| | - P. Szavay
- Department of Pediatric Surgery and Pediatric Urology, University Childrens Hospital Tuebingen, Tuebingen, Germany
| | - G. Seitz
- Department of Pediatric Surgery and Pediatric Urology, University Childrens Hospital Tuebingen, Tuebingen, Germany
| | - R. Handgretinger
- Department of Pediatric Oncology, University Childrens Hospital Tuebingen, Tuebingen, Germany
| | - J.F. Schäfer
- Institute of Radiology, University Hospital Tuebingen, Tuebingen, Germany
| | - S.W. Warmann
- Department of Pediatric Surgery and Pediatric Urology, University Childrens Hospital Tuebingen, Tuebingen, Germany
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Hamilton TE, Ritchey ML, Haase GM, Argani P, Peterson SM, Anderson JR, Green DM, Shamberger RC. The management of synchronous bilateral Wilms tumor: a report from the National Wilms Tumor Study Group. Ann Surg 2011; 253:1004-10. [PMID: 21394016 PMCID: PMC3701883 DOI: 10.1097/sla.0b013e31821266a0] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide guidelines for future trials, we reviewed the outcomes of children with synchronous bilateral Wilms tumors (BWT) treated on National Wilms Tumor Study-4 (NWTS-4). METHODS NWTS-4 enrolled 3335 patients including 188 patients with BWT (5.6%). Treatment and outcome data were collected. RESULTS Among 188 BWT patients registered with NWTS-4, 195 kidneys in 123 patients had initial open biopsy, 44 kidneys in 31 patients had needle biopsies. Although pre-resection chemotherapy was recommended, 87 kidneys in 83 patients were managed with primary resection: Complete nephrectomy 48 in 48 patients, 31 partial/wedge nephrectomies in 27 patients, enucleations 8 in 8 patients. No initial surgery was performed in 45 kidneys in 43 patients, 5 kidneys in 3 patients not coded. Anaplasia was diagnosed after completion of the initial course of chemotherapy in 14 patients (initial surgical procedure: 9 open biopsies, 4 needle biopsies, 1 partial nephrectomy). The average number of days from the start of chemotherapy to diagnosis of anaplasia was 390 (range 44-1925 days). Relapse or progression of disease occurred in 54 children. End stage renal failure occurred in 23 children, 6 of whom had bilateral nephrectomies. The 8 year event free survival for BWT with favorable histology was 74%, and overall survival was 89%; whereas the event free survival for BWT with unfavorable histology was 40%, overall survival was 45%. CONCLUSION The current analysis of patients with BWT treated on NWTS-4 shows that preservation of renal parenchyma is possible in many patients after initial preoperative chemotherapy. The incidence of end-stage renal disease remains significantly higher in children with BWT. Future studies are warranted to address the need for earlier biopsy in nonresponsive tumors and earlier definitive surgery to recognize unfavorable histology in these high-risk patients.
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Affiliation(s)
- Thomas E Hamilton
- *Department of Surgery, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA.
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Abstract
Wilms' tumor is the most common malignant renal tumor in children. Survival has improved dramatically over time as a result of prospective randomized clinical trials conducted by the pediatric cooperative cancer groups. Current research is directed toward identifying low-risk patients for whom a reduction in treatment intensity would decrease long-term morbidity. This article reviews the most recent advances in the biology and treatment of children with Wilms' tumor.
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Affiliation(s)
- Leah Nakamura
- Department of Urology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
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Makari JH, Ramachandra P, Ferrer FA. Pediatric urologic oncology: organ-sparing surgery in kidney and testis. Urol Clin North Am 2010; 37:287-98. [PMID: 20569806 DOI: 10.1016/j.ucl.2010.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Technological advances in imaging as well as increased knowledge of tumor-specific biology have promoted the role of organ-sparing approaches to pediatric renal and testicular tumors. Application of these techniques continues to evolve as data on long-term follow-up become available and as protocol-guided investigation provides answers to therapeutic outcomes of these approaches. Optimally, organ-sparing surgery will continue to provide increased potential for preservation of both renal function and fertility.
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Affiliation(s)
- John H Makari
- Department of Surgery, University of Connecticut School of Medicine, Farmington, CT 06030, USA
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Zhang DY, Lin T, Wei GH, He DW, Liu X, Liu JH, Li XL. A rare case of simultaneous occurrence of Wilms' tumor in the left kidney and the bladder. Pediatr Surg Int 2010; 26:319-22. [PMID: 20063003 DOI: 10.1007/s00383-009-2548-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2009] [Indexed: 11/30/2022]
Abstract
Wilms' tumor is the most common malignant solid tumor of the kidneys in children. Extrarenal Wilms' tumor is extremely rare. Herein, we report an 8-month-old boy with a chief complaint of frequent micturition and dysuria for 10 days. Physical examination and ultrasonography evaluation revealed simultaneous involvement of neoplasms in the left kidney and the bladder. Following excision of the masses, both were identified as Wilms' tumor by histopathology and immunohistochemistry. The two neoplasms are presumed to have developed independently because of the different pathological manifestation.
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Affiliation(s)
- De-ying Zhang
- Department of Urology, Children's Hospital of Chongqing Medical University, 400014 Chongqing, People's Republic of China
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Abstract
PURPOSE OF REVIEW Wilms' tumor accounts for nearly 6% of all pediatric cancers and more than 95% of all kidney tumors in children. Fortunately, survival for patients with Wilms' tumor is generally excellent. This review will outline the results of prior clinical trials that have led to this excellent outcome and how information gleaned from these trials has led to the development of the current series of clinical trials for the management of children with Wilms' tumor. RECENT FINDINGS Tumor stage and histologic subtype have long been recognized as important prognostic factors in Wilms' tumor. More recent evidence suggests that, in certain instances, patient age, tumor size, response to therapy, and genetic abnormalities, specifically the loss of genetic material on chromosomes 1p and 16q, provide additional prognostic information. These factors have, therefore, been incorporated into a new risk stratification system that is currently being used to assign patients with Wilms' tumor to specific protocol-based therapies. SUMMARY Survival for patients with Wilms' tumor when considered as a whole, once less than 30%, is currently greater than 90%, with this dramatic improvement being due, in part, to the systematic manner in which the approach to therapy has evolved. Further refinement in therapy is being undertaken, with the current trials aiming to maintain the excellent survival for children being treated for Wilms' tumor, while minimizing therapy-related toxicity.
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Hamilton TE, Ritchey ML, Argani P, Beckwith JB, Perlman EJ, Cotton CA, Shamberger RC. Synchronous bilateral Wilm's tumor with complete radiographic response managed without surgical resection: a report from the National Wilm's Tumor Study 4. J Pediatr Surg 2008; 43:1982-4. [PMID: 18970928 PMCID: PMC2801881 DOI: 10.1016/j.jpedsurg.2008.05.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Revised: 05/23/2008] [Accepted: 05/24/2008] [Indexed: 01/09/2023]
Abstract
PURPOSE We reviewed the long-term local tumor control in patients with bilateral Wilm's tumor (BWT) who received no definitive surgical therapy to one kidney after complete radiographic resolution after initial chemotherapy. METHODS National Wilm's Tumor Study 4 (NWTS-4) enrolled 3335 patients (pts) during the period August 1986 to August 1994. There were 188 pts with BWT or 5.6% of the total enrolled. The treatment records and imaging reports were reviewed to ascertain those children who had documented tumors without definitive surgical therapy after initial treatment. Patients who did not have renal surgery because of progression of tumor were excluded from this study. RESULTS Eleven children had no definitive surgical treatment of renal lesions in one kidney (right, 6; left, 5) after initial treatment with chemotherapy and/or radiation therapy. The pretreatment size of the lesions were less than 3 cm (4 pts), 3 to 6 cm (5 pts), more than 6 cm (1 pt), and unknown (1 pt). Prechemotherapy biopsy was performed in 6 of 11 patients. Lesions were less than 3 cm (1 pt), 3 to 6 cm (3 pts), more than 6 cm (1 pt), and unknown (1 pt). Four biopsy specimens showed favorable Wilm's histologic findings. One lesion (4 cm) showed an intralobar nephrogenic rest, another lesion of unknown size was read as favorable histologic findings vs perilobar nephrogenic rest. Biopsy was not performed on 5 lesions (4 pts, <1 cm; 1 pt, 3cm). Only 2 children in this study received radiation treatment. One child received 1050 cGy whole abdominal radiation, and 1 child received 1060 cGy to the left flank postnephrectomy. Radiation therapy was not given to any patient because of failure of the tumor to respond to chemotherapy. Five patients received treatment regimen EE-4A, dactinomycin, and vincristine. The duration of therapy ranged from 24 to 102 weeks for an average of 55.6 weeks. Three patients received treatment regimen DD-4A, dactinomycin, vincristine, and doxorubicin for 28, 52, and 52 weeks, respectively. Three patients received 2 separate regimens of chemotherapy. One child was treated with dactinomycin, vincristine, and cyclophosphamide for 60 weeks and then received regimen EE-4A for 24 weeks. Another patient received regimen EE-4A for 16 weeks and then regimen DD4-A for 36 weeks. One child received regimen EE-4-A for 12 weeks and then regimen DD4A for 40 weeks. Management of the contralateral kidney was complete nephrectomy in all 11 patients. There were no local relapses in the renal tumor bed. All patients were alive at a median follow-up of 9 years (range, 9 months to 15 years). CONCLUSION Children with synchronous BWT or Wilm's tumor and contralateral nephrogenic rests that have radiographic resolution, after initial treatment, have a low risk for local relapse. These children should be followed by serial imaging.
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Geller JI. Genetic stratification of Wilms tumor: is WT1 gene analysis ready for prime time? Cancer 2008; 113:893-6. [PMID: 18618514 DOI: 10.1002/cncr.23673] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Royer-Pokora B, Weirich A, Schumacher V, Uschkereit C, Beier M, Leuschner I, Graf N, Autschbach F, Schneider D, von Harrach M. Clinical relevance of mutations in the Wilms tumor suppressor 1 gene WT1 and the cadherin-associated protein beta1 gene CTNNB1 for patients with Wilms tumors: results of long-term surveillance of 71 patients from International Society of Pediatric Oncology Study 9/Society for Pediatric Oncology. Cancer 2008; 113:1080-9. [PMID: 18618575 DOI: 10.1002/cncr.23672] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Mutations in the Wilms tumor (WT) suppressor 1 gene (WT1) and the cadherin-associated protein beta1 gene (CTNNB1) are found predominantly in stromal type WT, defining a genetic subgroup. The clinical relevance of these mutations remains to be determined. METHODS A long-term follow-up study was performed for 71 patients (International Society of Pediatric Oncology Study 9/Society for Pediatric Oncology; n = 77 tumors) with known molecular genetic status. Eight patients had bilateral disease, including 2 patients with a WT in both kidneys and 5 patients with a WT in 1 kidney and nephrogenic rests (NRs) in the other kidney. The response to preoperative chemotherapy, relapses, metastases, metachronous tumor development, and deaths were evaluated with a median follow-up of 12 years and 4 months. RESULTS Nineteen patients (n = 24 tumors) had WT1 mutations, and 16 were constitutional mutations. Three patients with germline mutations had second tumor events: Two patients developed a WT in the kidney with NRs 3 years and 11 years after the first tumor; and 1 patient developed second tumors after 2 years, 1 in the kidney with a previous WT and 1 in the kidney with a previous NR. Eighteen of the WT1 mutant tumors were analyzed for CTNNB1 mutations, and all had mutations. A poor volumetric response (progression and <50% reduction) was observed in all patients who had tumors with a WT1 mutation and in 23 of 52 nonmutant tumors. CONCLUSIONS Patients with WT1 germline mutations had an increased risk for bilateral disease and second tumor events. Therefore, the authors concluded that tumor surveillance until adulthood should be considered. Although tumors with both WT1 and CTNNB1 mutations had a poor volumetric response, there was no significant difference in overall survival in this cohort of patients with and without WT1 mutations.
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Affiliation(s)
- Brigitte Royer-Pokora
- Institute of Human Genetics and Anthropology, Heinrich-Heine University of Duesseldorf, Duesseldorf, Germany.
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Davidoff AM, Giel DW, Jones DP, Jenkins JJ, Krasin MJ, Hoffer FA, Williams MA, Dome JS. The feasibility and outcome of nephron-sparing surgery for children with bilateral Wilms tumor. Cancer 2008; 112:2060-70. [DOI: 10.1002/cncr.23406] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Topotecan distribution in an anephric infant with therapy-resistant bilateral Wilms tumor with a novel germline WT1 gene mutation. Cancer Chemother Pharmacol 2008; 62:1039-44. [PMID: 18273617 DOI: 10.1007/s00280-008-0694-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 01/25/2008] [Indexed: 01/26/2023]
Abstract
The therapeutic strategy for bilateral Wilms tumor (WT) remains a challenge. Especially in cases with chemotherapy resistant disease, bilateral nephrectomy is sometimes inevitable. For optimal cure rates stage V WT patients benefit from adjuvant treatment; however, there are limited data available on chemotherapy pharmacokinetics in anephric children. In this report, we describe a 10-month old girl with bilateral Wilms tumor and a novel germline WT1 gene mutation. This patient hardly showed any response on preoperative chemotherapy, and ultimately, underwent sequential bilateral tumor-nephrectomy. Subsequently, during peritoneal dialysis, she received topotecan as adjuvant chemotherapy based on plasma levels, indicating that this is a reasonable option as adjuvant treatment in therapy-resistant Wilms tumor patients after bilateral nephrectomy. This case showed a novel germline WT1 gene mutation of which the correlation with resistant phenotype has to be confirmed in larger cohorts of WT patients.
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