What is the risk of local recurrence after laparoscopic transperitoneal radical nephrectomy in children with Wilms tumours? Analysis of a local series and review of the literature

Laparoscopic Treatment of Wilms' Tumor: Criteria of SIOP-UMBRELLA Protocol may be Updated

INTRODUCTION

Total nephrectomies for the treatment of Wilms' tumor (WT) are more and more performed by laparoscopy, although indications for this approach following the UMBRELLA guidelines are currently very restrictive. The purpose of this study was to assess the compliance to the criteria of the UMBRELLA protocol for minimally invasive approach of WT.

METHODS

This retrospective multicenter study included children operated on by laparoscopic total nephrectomy for suspected WT before 2020. Imaging was reviewed centrally.

RESULTS

Fifty-six patients (50 WT and 6 nephrogenic rests) were operated on at a median age of 3.3 ± 2.6 years. Thirteen (23%) patients had metastasis at diagnosis. The mean operative time was 213 ± 84 min. There were eight (14.3%) conversions and five peroperative complications. A local stage III was confirmed in seven (12.5%) cases, including two for tumor rupture. Only one (1.8%) of the procedures followed the SIOP-UMBRELLA indications for laparoscopy. The criterion "ring of normal parenchyma" was met only once. Conservative surgery seemed possible in ten (17.9%) cases. The extension of the tumor beyond the ipsilateral edge of the vertebra after chemotherapy and a volume over 200 mL were associated with an increased risk of conversion (p = 0.0004 and p = 0.001 respectively). After a mean follow-up of 5.2 ± 4.0 years, although there was no local recurrence, one death occurred due to metastatic progression at 15 months postoperatively.

CONCLUSIONS

The laparoscopic approach of WT beyond the UMBRELLA recommendations was feasible with low risk of local recurrence. Its indications may be updated and validated.

Robotic-assisted laparoscopic surgery for the treatment of Wilms' tumor in children: single-center experience and medium-term outcomes

To report our institutional experience and the medium-term outcomes of utilizing robotic-assisted laparoscopic surgery (RALS) in patients with Wilms' tumor (WT). The robotic surgical interventions include nephron-sparing surgery (RAL-NSS), radical nephrectomy (RAL-RN), and nephrectomy with inferior vena cava thrombectomy (RAL-N-IVCT). We retrospectively collected medical records of WT patients who underwent RALS in our center between August 2019 and February 2022. Patients' baseline demographics, preoperative parameters, and perioperative/postoperative data were recorded and analyzed. Follow-up results were collected to evaluate the oncological outcomes. A total of 12 patients (13 sides) with a median age of 30 (IQR: 19.5-45.5) months were included. All operations were successfully completed without conversion. Seven patients received preoperative chemotherapy. Distribution of surgical interventions was as follows: five patients underwent RAL-RN, five received RAL-NSS, one with bilateral WT underwent concurrent RAL-RN and RAL-NSS, and one received RAL-RN-IVCT post preoperative chemotherapy. Postoperative chemotherapy was conducted in ten patients. The estimated intraoperative blood loss was 27 ± 4.0 ml for the RAL-NSS group, 41.67 ± 12.13 ml for the RAL-RN group, and 350 ml for the RAL-RN-IVCT groups, respectively. The median perioperative serum creatinine levels were 32.5 (IQR: 30.75-39.5) μmol/l preoperatively and 35 (IQR: 31.75-38.5) μmol/l postoperatively, which showed no significant difference. No positive lymph nodes were detected. Postoperative chemotherapy was performed according to the tumor volume and pathological findings. The median follow-up time was 17.5 (15.8-22.3) months. During this interval, neither distant metastasis nor recurrence was identified. Based on our medium-term follow-up observations, RAL-NSS, RAL-RN, and RAL-RN-IVCT exhibit promising feasibility and safety profiles in the therapeutic landscape of WT.

Robotic approach with neoadjuvant chemotherapy in adult Wilms' tumor: A feasibility study report and a systematic review of the literature

Objective

The incidence of Wilms' tumor (WT) among adult individuals accounts for less than 1% of kidney cancer cases, with a prognosis usually less favorable when compared to younger individuals and an overall survival rate of 70% for the adult patients versus 90% for the pediatric cases. The diagnosis and treatment of WT are complex in the preoperative setting; neoadjuvant chemotherapy (NAC) or robotic surgery has rarely been described. This study aimed to review the literature of robotic surgery in WT and report the first adult WT management using both NAC and robotic strategy.

Methods

We reported a case of WT managed in a multidisciplinary setting. Furthermore, according to Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations, a systematic review of the literature until August 2020 of WT treated with a robotic approach was carried out.

Results

A 33-year-old female had a diagnosis of WT. She was scheduled to NAC, and according to the clinical and radiological response to a robotic radical nephrectomy with aortic lymph nodes dissection, she was managed with no intraoperative rupture, a favorable surgical outcome, and a follow-up of 25 months, which did not show any recurrence. The systematic review identified a total number of 230 cases of minimally invasive surgery reported in the literature for WT. Of these, approximately 15 patients were carried out using robotic surgery in adolescents while none in adults. Moreover, NAC has not been administered before minimally invasive surgery in adults up until now.

Conclusion

WT is a rare condition in adults with only a few cases treated with either NAC or minimally invasive approach so far. The advantage of NAC followed by the robotic approach could lead to favorable outcomes in this complex scenario. Notwithstanding, additional cases of adult WT need to be identified and investigated to improve the oncological outcome.

Evidence-based surgical guidelines for treating children with Wilms tumor in low-resource settings

BACKGROUND

Survival of Wilms tumor (WT) is > 90% in high-resource settings but < 30% in low-resource settings. Adapting a standardized surgical approach to WT is challenging in low-resource settings, but a local control strategy is crucial to improving outcomes.

OBJECTIVE

Provide resource-sensitive recommendations for the surgical management of WT.

METHODS

We performed a systematic review of PubMed and EMBASE through July 7, 2020, and used the GRADE approach to assess evidence and recommendations.

RECOMMENDATIONS

Initiation of treatment should be expedited, and surgery should be done in a high-volume setting. Cross-sectional imaging should be done to optimize preoperative planning. For patients with typical clinical features of WT, biopsy should not be done before chemotherapy, and neoadjuvant chemotherapy should precede surgical resection. Also, resection should include a large transperitoneal laparotomy, adequate lymph node sampling, and documentation of staging findings. For WT with tumor thrombus in the inferior vena cava, neoadjuvant chemotherapy should be given before en bloc resection of the tumor and thrombus and evaluation for viable tumor thrombus. For those with bilateral WT, neoadjuvant chemotherapy should be given for 6-12 weeks. Neither routine use of complex hilar control techniques during nephron-sparing surgery nor nephron-sparing resection for unilateral WT with a normal contralateral kidney is recommended. When indicated, postoperative radiotherapy should be administered within 14 days of surgery. Post-chemotherapy pulmonary oligometastasis should be resected when feasible, if local protocols allow omission of whole-lung irradiation in patients with nonanaplastic histology stage IV WT with pulmonary metastasis without evidence of extrapulmonary metastasis.

CONCLUSION

We provide evidence-based recommendations for the surgical management of WT, considering the benefits/risks associated with limited-resource settings.

Oncologic Fidelity of Minimally Invasive Surgery to Resect Neoadjuvant-Treated Wilms Tumors

Background

The Children's Oncology Group recommends upfront resection of Wilms tumor (WT), however, unique scenarios warrant neoadjuvant chemotherapy and delayed resection. We hypothesized that in the context of neoadjuvant chemotherapy, minimally invasive surgery (MIS) to resect WT achieves equivalent oncologic fidelity and better maintains therapy schedules.

Methods

A retrospective analysis of WT treated between 2010-2021 at a free-standing children's hospital was performed. Patient and disease specific characteristics were collected, and pre-resection tumor volumes (TV) were calculated. Impact of MIS or open resection on oncologic fidelity and time to resume chemotherapy was analyzed.

Results

For the study period, 62 patients were treated for 65 WT, and 14 patients (22.6%) received neoadjuvant chemotherapy to treat 17 WT (26.2%): 7 Stage I (all predisposition syndromes), 2 stage III, 7 stage IV, and 1 stage V (bilateral). MIS was utilized to resect 6 WT from 5 patients. For partial nephrectomy, pre-resection TV was 0.38 ml if MIS and 10.38 ml if open ( P = .025). For radical nephrectomy, pre-resection TV was 31.58 ml if MIS and 175.00 ml if open ( P = .101). No significant differences between surgical approach were detected regarding pathologic variables or survival. Epidural use was significantly greater with open procedures ( P = .001). Length of stay was 2.00 days after MIS compared to 6.00 for open resection ( P = .004). Time to resume chemotherapy was 7.00 days after MIS versus 27.00 for open ( P = .004).

Conclusion

After neoadjuvant chemotherapy for WT, MIS partial and radical nephrectomies achieved equivalent oncologic fidelity, reduced epidural use and post-operative stays, and better maintained adjuvant therapy timelines when compared to open resections.

Robotics-Assisted Pediatric Oncology Surgery-A Preliminary Single-Center Report and a Systematic Review of Published Studies

AIM

The use of robotics-assisted surgery in oncology has been proved effective and safe in adults. Despite these results, the use of robotics has been rarely reported for pediatric oncology. Our review aims to evaluate the safety and feasibility of robotics-assisted surgery in this field, analyzing our experience and performing a systematic review of the most recent studies.

METHODS

We reviewed all patients affected by an oncological disease who underwent a robotics-assisted procedure at our institute. We performed a systematic review of the literature from 2012 to 2021 on the subjects.

FINDINGS

A total of 14 patients underwent robotics-assisted tumor resection. Eleven procedures (median age 13.2-years old) were carried out in children with adnexal lesions (seven tumor excision and four ovariectomies). Histological diagnosis was mature teratoma (six), serous papillary cystadenofibromas of the fallopian tube (two), ovarian serous cystadenoma (one), ovarian mucinous cystadenoma (one), and ovarian seromucinous cystadenoma. The median length of stay was 2 days. No recurrences or complications at a median follow-up of 2.1-years were observed. A 5-year-old girl underwent a complete posterior resection of a type 3 sacrococcygeal tumor with a robotics-assisted approach for the dissection of a possible intraabdominal residual component of the lesion. No intra- and postoperative complications were recorded. Complete excision of a recurrent differentiating neuroblastoma of the left para-renal region was performed on a 9-year-old girl. An idiopathic anaphylactic shock occurred 1 day after the procedure. At 9 months' follow-up, no local recurrences of the lesion were observed. Overall, we reported no conversion to open surgery. Lastly, a robotic excision of a growing left superior mediastinal intermixed ganglioneuroblastoma was performed on an 8-year-old girl with no postoperative complications. Follow-up was uneventful (7 months). In the literature, the rate of complications ranges from 0 to 28%, mainly related to difficult dissection and impaired anatomy. Conversion is reported in 5% of all oncological procedures, due to more invading tumors and altered anatomical features. No robotics-related complications were reported.

CONCLUSION

Robotics-assisted surgery in pediatric oncology has proven to be feasible. Nevertheless, its use should be limited to selected cases and performed by highly trained oncological surgeons. Preparation and patient positioning, alongside a correct port placement, are crucial to carrying out these procedures. Further innovations in robotics may allow a wider application of this technology in pediatric oncology.

Minimally Invasive Approach for Wilms Tumor Treatment in a Small Child - A Case Report

Wilms tumor is the most common malignant primary tumor in children. Open traditional approach is often aggressive and offers a burden on the patient's life, imposing longer hospital stays, scarring, and higher levels of complications. Here, we present a case of a small child with Wilms tumor on the right kidney that was successfully treated with minimally invasive surgery, with no tumor spillage or rupture, hospital discharge in the next day, and good oncological outcome, with 1-year recurrence-free follow-up. We also show a comprehensive literature review of similar cases, expecting to push forward medical awareness about this approach.

A single centre matched pair series comparing minimally invasive and open surgery for the resection of pediatric renal tumours

INTRODUCTION

Minimally invasive nephrectomy (MIN)for the resection of pediatric renal tumors is controversial. We compared patients who underwent laparoscopic MIN according to our unit protocol with matched patients who underwent open surgery (ON).

METHOD

A single centre retrospective analysis of prospectively collected data for MIN. Tumor volume was calculated from pre-operative imaging and volume matched ON patients were identified from the regional tumor database. Demographics, complications, operative time, length of stay, number of nodes resected, status of margins, radiotherapy (RT)requirement, length of follow-up and outcomes were analysed.

RESULTS

Fourteen MINs performed between September 2016 and 11/2019 (M:F 5:9; median age 37 (range 2-73)months) were matched with ON controls (7:7 M:F, median age 42 (1-74)months). Diagnoses in the MIN group were Wilms Tumour (WT)in11 and one each of mesoblastic nephroma (MN), malignant rhabdoid tumour of the kidney (MRTK), nephroblastomatosis and in the ON group were 13 WT and 1 MN. Median operating time for MIN was 180 (125-300)minutes, with 4 conversions and 155 (1-3-480)minutes in ON. There were no intra-operative ruptures. Three tumors in each group had positive margins. A median of 4 (0-6) nodes were removed during MIN and 4 (2-22) during ON. Median length of stay (LoS)was 4 (2-15)days following MIN and 4 (2-9) following MIN. Six ON and 3 MIN patients required radiotherapy. Differences were not significant. Median follow up of 30 (6-44)months for MIN and 73 (34-109)months for ON patients was significantly different. There have been no local recurrences but the child with MRTK died following brain tumor recurrence.

CONCLUSION

MIN for pediatric renal tumors has similar short term outcomes to ON in carefully selected patients.

Standard of care for adult Wilms tumor? From adult urologist to pediatric oncologist. A retrospective review

Nephroblastoma or Wilms tumor, a common embryonal tumor in children, can occasionally occur in adults. The survival of patients older than 18 years is reported to be significantly inferior to that of pediatric patients. Establishing a diagnosis for these rare tumors can be challenging for both clinicians and pathologists, who are not accustomed to considering Wilms tumor as a potential differential in adults. This leads to misdiagnosis and a subsequent delay in the initiation of appropriate therapy. The standard of care is not well established for Wilms tumors in adults. We provide here a comprehensive review of the international literature on the subject with the current management protocols in France. We also propose the need of strong inter-disciplinary collaboration between surgeons, pathologists, and medical and pediatric oncologists for increasing knowledge and formulating treatment strategies for these rare tumors. Homogenous guidelines for treating adults with Wilms tumors have been proposed for all patients in France.

Wilms tumor: a review of current surgical controversies

Overall survival (OS) for children with Wilms tumor (WT) currently stands at around 90%. This is markedly improved from the survival rates of around 30% reported in the middle of the last century. This improvement is due to the development of multimodal treatment for this disease, based on the evidence yielded through international collaboration on trials conducted by the Société Internationale d'Oncologie Pédiatrique (SIOP) and the Children’s Oncology Group (COG). In this article, we review some of the current surgical controversies surrounding the management of WT.

Minimally invasive surgery for unilateral Wilms tumors: Multicenter retrospective analysis of 50 transperitoneal laparoscopic total nephrectomies

PURPOSE

To evaluate feasibility and outcomes of minimally invasive surgery (MIS) in Wilms tumor (WT).

METHODS

International multicenter review of MIS total nephrectomies for WT between 2006 and 2018. Medical records of confirmed WT were retrospectively assessed for demographic, imaging, treatment, pathology, and oncological outcome data.

RESULTS

Fifty patients, with a median age of 38 months (6-181), were included in 10 centers. All patients received neoadjuvant chemotherapy, as per SIOP protocol. Median tumor volume post-chemotherapy was 673 mL (18-3331), 16 tumors crossed the lateral border of the spine, and three crossed the midline. Six patients with tumors that crossed the lateral border of the spine (tumor volumes 1560 mL [299-2480]) were converted to an open approach. There was no intraoperative tumor rupture. Overall, MIS was completed in 19% of the 195 nephrectomies for WT presenting during the study period. Tumor was stage I in 29, II in 16, and III in 5, and histology was reported as low in three, intermediate in 42, and high risk in five. Three patients had positive tumor margins. After a median follow-up of 34 months (2-138), there were two local recurrences (both stage I, intermediate risk, 7 and 9 months after surgery) and one metastatic relapse (stage III, high risk, four months after surgery). The three-year event-free survival was 94%.

CONCLUSION

MIS is feasible in 20% of WT, with oncological outcomes comparable with open surgery, no intraoperative rupture, and a low rate of local relapse. Ongoing surveillance is, however, needed to evaluate this technique as it becomes widespread.

International Publication Patterns on Operative Management of Wilms Tumor: A Review by Surgeon Specialty and Surgical Modality

OBJECTIVE

To review the temporal trends in the published literature of the surgical management of Wilms tumor (WT) relative to surgical modality and authorship by surgeon specialty (pediatric urology [PU] vs pediatric surgery [PS]).

METHODS

The MEDLINE/PubMed database was queried for manuscripts published by PU or PS including operative management of WT from 1993-2017. After manuscript review, 187 of 2420 studies were included. Studies were compared by author specialty, country of origin, and represented patients.

RESULTS

PU published 32% of included publications. The proportion of first author publications by PU increased over time (25% from 1993-2005 to 39% from 2006-2017, P = .029). While PU were first author on 44% of studies in North America, they were relatively underrepresented internationally. PU and PS were equally likely to be first author on cooperative group studies, which accounted for 19% of the overall publications. 14,958 patients underwent extirpative surgery for WT. There was a small increase in publications reporting the use of minimally-invasive surgery (MIS) and nephron-sparing surgery (NSS) over time (<1% and 4% from 1993-2005 to 2% and 7% from 2006-2017, respectively, P <.001). Compared to PS, PU were significantly more likely to publish on patients managed with MIS and NSS (P = .006 and P < 0.001 respectively).

CONCLUSION

Publications by PU on the surgical management of WT are increasing over time, but are still fewer than PS. PU appeared to be the drivers of the temporal trend towards the increasing use of MIS and NSS in the published literature.

3D Model Facilitated Zero-Ischemia Laparoscopic Nephron Sparing Resection in Nephroblastomatosis Following the Addition of Cis-Retinoic Acid

There are limited reports of laparoscopic nephron sparing surgery (LNSS) in children and none where a 3D model facilitated oncological resection. There are also limited reports discussing the use of cis-retinoic acid in bilateral diffuse hyperplastic perilobar nephrogenic rests (DHPLNR). We report the first case of a 3D model facilitated zero-ischemia LNSS in children and the first following treatment with cis-retinoic acid. The patient was a 3-year-old girl with bilateral DHPLNR who had recurrent disease following standard therapy. She had suspicious lesions in the upper pole of the left kidney. Both were completely excised and histologically described as hyperplastic nephrogenic rests.

Partial and radical nephrectomy in children, adolescents, and young adults: Equivalent readmissions and postoperative complications

OBJECTIVES

To compare and contrast the use of partial nephrectomy (PN) and radical nephrectomy (RN) in pediatric malignant renal tumors using a nationally representative database.

METHODS

The 2010-2014 Nationwide Readmissions Database (NRD) was used to obtain PN and RN select postoperative data. ICD-9-CM codes were used to identify children (<10 years), adolescents (10-19 years) and young adults (20-30 years) diagnosed with malignant renal tumors who were treated with a PN or RN. The presence of a 30-day readmission, occurrence of postoperative complications, cost, and length of stay (LOS) were studied and weighted logistic regression models were fit to test for associations.

RESULTS

There were 4330 weighted encounters (1289 PNs, 3041 RNs) that met inclusion criteria: 50.8% were children, 7.2% were adolescents, and 42% were young adults. Young adults had the highest rates of PN, whereas children had the highest rates of RN (p < 0.0001). Overall, no evidence was found to suggest a difference in odds between surgical modality and the presence of a 30-day readmission or postoperative complication. While PN was on average $9000 cheaper compared to RN overall, its cost was similar to that of RN for children. Similarly, PN patients had a shorter overall LOS compared to RN patients, but their LOS was similar to that of children who underwent RN.

CONCLUSION

There was no evidence of a difference in odds between RN and PN in terms of postoperative readmissions or in-hospital complication rates. Additionally, we observed descriptive differences in both cost and LOS between the surgical modalities across age groups.

TYPE OF STUDY

Retrospective comparative study (administrative database analysis).

LEVEL OF EVIDENCE

Level III.

Robotic-assisted laparoscopic management of renal tumors in children: Preliminary results

AIM

We present the preliminary results of robotic-assisted laparoscopic (RAL) total and partial nephrectomy for renal malignant tumors in children.

METHODS

This is a prospective study of patients operated with RAL between December 2016 and September 2018. Patients with Wilms tumors were treated according to the SIOP-2001 protocol. Patient and tumor characteristics, type of surgery, surgical-related morbidity, and oncologic outcomes were recorded. Results were compared with a series of patients with similar age- and tumor-related characteristics operated during the same period by an open surgical approach.

RESULTS

Ten children underwent RAL nephrectomy with a mean age of five years (3.2-14.1 years). Total nephrectomy was done in six cases for Wilms tumor and in one case for renal sarcoma; three cases were converted. Complete removal of tumor without rupture was achieved in all cases. Postoperative course was uneventful, and patients were discharged between days 2 and 7. Neither recurrence nor medium-term complications occurred. Nine patients are alive with a median follow-up of 16 months (6-27 months) and one female died from complications of central nervous system metastases one year after surgery. When compared with the open surgical approach group, median tumor volume was smaller (P = 0.005), hospital stay was shorter (P = 0.01), and operative time was similar (P = 0.20).

CONCLUSIONS

RAL total and partial nephrectomy procedure for renal tumor in children may be an option in carefully selected cases. Indication should be discussed at tumor boards and surgery performed while adhering strictly to oncological surgical rules.