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Lorenzo A, Buchanan AF, Cost N, Kieran K, Romao R. Pediatric Urologic Oncology Series-Renal Tumors. Urology 2024:S0090-4295(24)00721-0. [PMID: 39214498 DOI: 10.1016/j.urology.2024.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Armando Lorenzo
- University of Toronto & Hospital for Sick Children, Toronto, ON
| | | | - Nicholas Cost
- University of Colorado School of Medicine, Department of Surgery, Division of Urology, Aurora, CO
| | - Kathleen Kieran
- Seattle Children's Hospital, Department of Urology, Seattle, WA
| | - Rodrigo Romao
- University of Toronto & Hospital for Sick Children, Toronto, ON
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Modi JB, deshmukh S, jha S, gupta A, kothari P, oak S. "Bilateral synchronous, NON syndromic wilms tumor". JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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3
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Aldrink JH, Cost NG, McLeod DJ, Bates DG, Stanek JR, Smith EA, Ehrlich PF. Technical Considerations for Nephron-Sparing Surgery in Children: What Is Needed to Preserve Renal Units? J Surg Res 2018; 232:614-620. [PMID: 30463781 DOI: 10.1016/j.jss.2018.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 06/19/2018] [Accepted: 07/10/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chemotherapy is used preoperatively for children with bilateral Wilms tumor (BWT) or unilateral high-risk Wilms tumor (UHRWT) to promote tumor regression to facilitate renal preservation with nephron-sparing surgery (NSS). In adults, various surgical techniques have been described to preserve renal tissue. Few studies have examined the use of surgical adjuncts in NSS in children with renal tumors. METHODS We performed a multi-institutional retrospective review of patients with BWT or UHRWT. Patient demographics, tumor size at diagnosis, following neoadjuvant chemotherapy, utilization of surgical adjuncts including intraoperative ultrasound (IOUS), margin status, complications, renal function, and follow-up were recorded. RESULTS The cohort comprised 23 patients: 18 BWT, 3 UHRWT, and 2 patients with solitary kidney. Twenty-two of the 23 patients had successful NSS. IOUS was used 19 times, and seven had positive margins after surgery. Cooling/vascular isolation was used six times. At a median follow-up of 18 mo, median estimated glomerular filtration rate Schwartz was 126 mL/min/1.73 m2 and median serum creatinine 0.39 mg/dL in the 22 patients who had successful NSS. There have been no tumor recurrences. CONCLUSIONS In patients with BWT and UHRWT, surgical adjuncts such as cooling/vascular isolation are uncommonly performed. IOUS may be helpful but does not guarantee negative microscopic margins. LEVEL OF EVIDENCE Level 4, Case series with no comparison group.
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Affiliation(s)
- Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.
| | - Nicholas G Cost
- Division of Pediatric Urology, Department of Surgery, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Daryl J McLeod
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Section of Pediatric Urology, Nationwide Children's Hospital, Columbus, Ohio
| | - David Gregory Bates
- Division of Pediatric Radiology, Department of Radiology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph R Stanek
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Biostatistics, Nationwide Children's Hospital, Columbus, Ohio
| | - Ethan A Smith
- Department of Radiology, Section of Pediatric Radiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Peter F Ehrlich
- Division of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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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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[Is nephron-sparing surgery relevant for unilateral Wilms tumors?]. Arch Pediatr 2017; 24:650-658. [PMID: 28576587 DOI: 10.1016/j.arcped.2017.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 02/05/2017] [Accepted: 04/10/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Wilms tumors (WTs) are the most frequent renal tumors in children. Radical nephrectomy (RN) remains the gold-standard surgical treatment for this type of cancer. Excellent results in overall survival (>90%) make it possible to consider nephronic preservation. The objective of this systematic review is to evaluate the relevance of nephron-sparing surgery (NSS) for the treatment of nonsyndromic unilateral Wilms tumor (UWT) in children. METHODS Articles in English related to "unilateral Wilms tumor, unilateral nephroblastoma, partial nephrectomy, nephron-sparing surgery, renal function" identified in the Medline library were screened and data were extracted to perform a qualitative systematic review. RESULTS We identified 377 articles, 14 of which were integrated into the analysis. Data on 4288 children were included, 3994 (93.1%) underwent RN, whereas 294 (6.8%) underwent NSS. Stage I anatomopathology resulted in 55.1% RN and 79% NSS. Overall survival and event-free survival were similar: respectively 95.7% and 92.8% after RN and 96 and 90.5% after NSS. Positive margin status was higher after NSS (8.5% vs 0.5%), but tumor rupture and local tumor recurrences were similar. The rate of mild to moderate renal function was higher after RN (42% vs 10% after NSS). DISCUSSION NSS is regularly performed for WT in case of bilateral or syndromic tumors, but the literature considering UWT does not show consensus. The superiority of NSS for renal outcomes has now been fully evaluated, but the main problem of this surgery in case of UWT is to ensure oncologic outcomes as good as outcomes after RN. WTs are usually massive tumors for which partial nephrectomy is contraindicated, but studies showed that chemotherapy before surgery could reduce tumor volume and make NSS possible. This review shows that NSS results seem to be as good as RN results and that preoperative chemotherapy should be highlighted for its participation in the reduction of the positive margin status. Although radiotherapy is used with caution because of its side effects, some studies showed that it gave excellent results for oncologic salvage after local recurrence. Constant progress in medical imaging and detection systems has led to the emergence of a new type of assistance for surgeons such as image reconstruction and vessel or urinary tract system segmentation. Virtual simulation of the operation based on a real case should help evaluate the feasibility of complex procedures in the near future. CONCLUSION NSS for UWT seems to be a credible therapeutic alternative. New technologies such as 3D reconstruction should help surgeons define the best parameters to select ideal tumors for this surgery in the near future. For the moment, small tumors (<4cm), distant from the renal hilum (ideally on the upper pole) that respect at least 50% of the renal parenchyma (ideally superficial with exophytic development) seem to be the perfect indication for NSS.
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Raghunath BV, Jadhav V, Shankar G, Narendrababu M, Ramesh S. Management of Bilateral Wilms' Tumor: Our Experience. Indian J Surg Oncol 2017; 8:4-8. [PMID: 28127175 PMCID: PMC5236017 DOI: 10.1007/s13193-016-0552-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 08/16/2016] [Indexed: 10/21/2022] Open
Abstract
Management of bilateral Wilms' tumor is particularly challenging, considering the chances of recurrence and long-term renal function for affected patients. Aggressive surgical resection to prevent recurrence must be balanced with the desire to preserve renal function. We evaluated our experience in the management of bilateral Wilms' tumor stressing the challenges encountered in decision making and the role of nephron sparing surgery. We had four children presenting with bilateral Wilms' tumor. All of them were appropriately staged and given standard chemotherapy as per NWTS-5 guidelines. Tumors were considered to have a 'good' response to chemotherapy if sufficient tumor shrinkage was observed so that renal hilum was seen free of tumor and vice versa. Nephron-sparing surgery was considered in all and was performed when feasible, followed by completion adjuvant chemotherapy. All patients were followed up with serial ultrasound scans (3-6 monthly) and CECT abdomen (yearly once). Blood urea and serum creatinine, hypertension, and proteinuria were assessed during follow-up visits. All four children received neo-adjuvant chemotherapy as per NWTS-5 guidelines. The first child had poor response to chemotherapy and was considered for left radical and right partial nephrectomy. However, patient attenders refused any surgical intervention and the child was taken home. The second child had a 'good' response on left side and was planned for left partial and right radical nephroureterectomy based on pre-operative imaging analysis. However, intra-operatively, bilateral partial nephrectomy with good margins was feasible. The third child though, showed 'poor' response to pre-op chemotherapy and warranted bilateral nephroureterectomy, right partial and left radical nephroureterectomy was feasible. However, in the fourth child, we were not able to perform nephron sparing surgery and left nephroureterectomy with right tumor biopsy was done. Following this, child was started on 2nd-line chemotherapy, now awaiting right partial nephrectomy. The second child is on follow up for 1.5 years, doing well. However, the third child expired 1.5 years following surgery due to recurrence (lung metastasis). Management of bilateral Wilm's tumor is challenging and nephron-sparing surgery should be considered in all patients having bilateral Wilm's tumor with favorable histology, even if pre-operative imaging studies suggest that the lesions are unresectable.
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Affiliation(s)
- Raghunath BV
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, India
- Rajarajeswari Medical College, Bengaluru, India
| | - Vinay Jadhav
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Gowri Shankar
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Narendrababu M
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Ramesh S
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, India
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Arora S, Kudchadkar S, Yadav P, Ansari MS. Nephron-sparing surgery in bilateral Wilms' tumor: A report of two cases. Urol Ann 2017; 8:486-489. [PMID: 28057999 PMCID: PMC5100160 DOI: 10.4103/0974-7796.192102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Nephron-sparing surgery (NSS) has been proposed by many as an alternative to bilateral nephrectomies and renal replacement therapy in bilateral Wilms’ tumor (BWT). NSS is not without significant recurrence, morbidity, and mortality. Long-term follow-up, especially with regard to the renal function, remains lacking. Preoperative computed tomography angiogram can help prepare a roadmap for NSS but can underestimate the salvageable parenchyma due to compression of normal adjacent parenchyma. Intraoperative ultrasound can delineate the boundary of surgical margin and help achieve negative margins. We present two cases of BWT, aged 7 and 13 months, managed with neoadjuvant chemotherapy followed by bilateral NSS and adjuvant chemotherapy and report the follow-up of the same. We also explore the role of preoperative imaging and intraoperative ultrasound in the management. Both patients are alive without recurrence at a follow-up of 12 and 8 months.
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Affiliation(s)
- Sohrab Arora
- Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sharmad Kudchadkar
- Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Priyank Yadav
- Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - M S Ansari
- Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Interiano RB, McCarville MB, Santos ND, Mao S, Wu J, Dome JS, Kieran K, Williams MA, Brennan RC, Krasin MJ, Green DM, Davidoff AM. Comprehensive renal function evaluation in patients treated for synchronous bilateral Wilms tumor. J Pediatr Surg 2017; 52:98-103. [PMID: 27856008 PMCID: PMC5218869 DOI: 10.1016/j.jpedsurg.2016.10.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 10/20/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this study was to perform a comprehensive assessment of long-term renal function in patients treated at our institution for synchronous bilateral Wilms tumor (BWT) and to determine the optimal method for estimating glomerular filtration rate (eGFR). METHODS Surgical approach, adjuvant therapy, and pathology reports were reviewed for patients with at least six months follow-up from definitive surgery. eGFRs, as assessed by the Schwartz and Chronic Kidney Disease in Children (CKiD) formulas, were compared to measured GFR (mGFR) determined by 99mTc-DTPA scanning. Urine studies, including microalbumin, β-microglobulin, and FENa were also reviewed. RESULTS Forty-two patients were identified. Of 36 living patients, 28 (77.8%) had greater than 6months follow-up, with a median overall follow-up of 5.2years (range: 1.4-13.4). The median mGFR was 97mL/min/1.73m2, while the median eGFRSchwartz and eGFRCKiD were 103.3mL/min/1.73m2 and 79.7mL/min/1.73m2, respectively, (p=0.13 and p=0.75, compared to mGFR). Eleven (39.3%) patients had at least one abnormal urine study (microalbumin >30μg/g creatinine, n=3; β-2 microglobulin >133μg/g creatinine, n=9; FENa>1%, n=4). CONCLUSIONS In our series, few patients had an abnormally low GFR. Neither method for estimating GFR gave a significantly different result from measured GFR, suggesting that the Schwartz equation is adequate, although specific urine tests may be more sensitive for detecting subtle renal dysfunction. LEVEL OF EVIDENCE Level IV - retrospective case series with no comparison group.
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Affiliation(s)
- Rodrigo B. Interiano
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - M. Beth McCarville
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN
| | - Noel Delos Santos
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Shenghua Mao
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Jianrong Wu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Jeffrey S. Dome
- Department of Oncology, Children's National Medical Center, Washington, DC
| | - Kathleen Kieran
- Department of Urology, Seattle Children's Hospital, Seattle, WA
| | - Mark A. Williams
- Division of Pediatric Urology, Levine Children's Hospital, Charlotte, NC
| | - Rachel C. Brennan
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Matthew J. Krasin
- Department of Radiation Oncology, St. Jude Children's Hospital, Memphis, TN
| | - Daniel M. Green
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - Andrew M. Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
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Overall Survival and Renal Function of Patients With Synchronous Bilateral Wilms Tumor Undergoing Surgery at a Single Institution. Ann Surg 2015; 262:570-6. [PMID: 26366536 DOI: 10.1097/sla.0000000000001451] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Wilms tumor is the most common renal cancer in children. Approximately 5% of children with Wilms tumor present with disease in both kidneys. The treatment challenge is to achieve a high cure rate while maintaining long-term renal function. We retrospectively reviewed our institutional experience with nephron sparing surgery (NSS) in patients with synchronous bilateral Wilms tumor (BWT) operated on between 2001 and 2014. METHODS Imaging studies, surgical approach, adjuvant therapy, and pathology reports were reviewed. Outcomes evaluated included surgical complications, tumor recurrence, patient survival, and renal function, as assessed by estimated glomerular filtration rate. RESULTS A total of 42 patients with BWT were identified: 39 (92.9%) patients underwent bilateral NSS; only 3 patients (7.1%) underwent unilateral nephrectomy with contralateral NSS. Postoperative complications included prolonged urine leak (10), infection (6), intussusception (2), and transient renal insufficiency (1). Three patients required early (within 4 months) repeat of NSS for residual tumor. In the long-term, 7 (16.7%) patients had local tumor recurrence (managed with repeat NSS in 6 and completion nephrectomy in 1) and 3 had an episode of intestinal obstruction requiring surgical intervention. Overall survival was 85.7% (mean follow-up, 4.1 years). Of the 6 patients who died, 5 had diffuse anaplastic histology. All of the patients had an estimated glomerular filtration rate more than 60 mL/min/1.73 m at the last follow-up; no patient developed end-stage renal disease. CONCLUSIONS In patients with synchronous, BWT, bilateral NSS is safe and almost always feasible, thereby preserving maximal renal parenchyma. With this approach, survival was excellent, as was maintenance of the renal function.
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Romao RLP, Lorenzo AJ. Renal function in patients with Wilms tumor. Urol Oncol 2015; 34:33-41. [PMID: 26278364 DOI: 10.1016/j.urolonc.2015.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/07/2015] [Accepted: 07/07/2015] [Indexed: 12/18/2022]
Abstract
Survival in patients with Wilms tumor (WT) is excellent compared with other pediatric malignancies and adult renal tumors. Treatment-related long-term morbidity and mortality in WT survivors is an area of increasing concern. Renal dysfunction is an example of one of the most feared long-term issues observed in these survivors. Direct toxicity from chemotherapy and radiation as well as direct nephron ablation from surgical treatment (nephrectomy) renders the kidney susceptible to a multitude of problems over time in patients with WT. In this article, we review the existing literature pertaining to renal function in these patients. Incidence rates, causes, and methods to mitigate renal dysfunction are presented in 3 distinct clinical situations: sporadic unilateral WT, syndromic unilateral WT, and bilateral WT. We also offer a critical lens on the current role of nephron-sparing surgery as a means to preserve renal function in these patients. Finally, we discuss potential avenues for refining renal function preservation in patients with WT in the future. We conclude that: (1) renal function in pediatric cancer survivors must be carefully ascertained prospectively using methods that allow diagnosis of mild cases (rather than focus solely on extreme cases represented by the development of end-stage renal disease), (2) every effort should be made to recognize subtle features of predisposition syndromes to avoid syndromic cases from being misclassified and treated as sporadic, (3) molecular stratification for disease aggressiveness as well as multifocality and renal dysfunction will be very important to tailor treatment and balance survival with preservation of renal function, and (4) the role and potential benefits of nephron-sparing surgery deserves careful exploration under well-designed protocols.
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Affiliation(s)
- Rodrigo L P Romao
- Division of Urology, Division of Pediatric General Surgery, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Armando J Lorenzo
- Division of Urology, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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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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Abstract
Synchronous bilateral disease occurs in approximately 5 % of children with Wilms tumor (WT), and is independently associated with an increased risk of renal insufficiency. Nephron-sparing surgery (NSS) allows preservation of renal mass and improved renal function. Published oncologic and functional outcomes with NSS to date are generally good, likely reflecting proper patient selection and excellent surgical technique during tumor excision, as well as appropriate use of upfront and adjuvant therapies. Here we highlight important issues regarding the use of NSS in children with bilateral Wilms tumor (BWT).
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Affiliation(s)
- Kathleen Kieran
- Department of Urology, Division of Pediatric Urology, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Andrew M. Davidoff
- Department of Surgery, St Jude Children’s Research Hospital, Memphis, TN
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Hubertus J, Günther B, Becker K, Graf N, Furtwängler R, Ferrari R, Gruhn B, Stahl R, von Schweinitz D, Stehr M. Development of Hypertension is Less Frequent after Bilateral Nephron Sparing Surgery for Bilateral Wilms Tumor in a Long-Term Survey. J Urol 2015; 193:262-6. [DOI: 10.1016/j.juro.2014.07.116] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Jochen Hubertus
- Department of Pediatric Surgery, Research Laboratories, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Brigitte Günther
- Department of Pediatric Surgery, Research Laboratories, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Kristina Becker
- Department of Pediatric Surgery, Research Laboratories, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Norbert Graf
- Department of Pediatric Oncology and Hematology, University of Saarland, Homburg/Saar, Germany
| | - Rhoikos Furtwängler
- Department of Pediatric Oncology and Hematology, University of Saarland, Homburg/Saar, Germany
| | - Rudolf Ferrari
- Department of Pediatric Oncology and Hematology, Gemeinschaftsklinikum Koblenz-Mayen, Koblenz, Germany
| | - Bernd Gruhn
- Department of Pediatrics, Jena University Hospital, Jena, Germany
| | - Robert Stahl
- Department of Clinical Radiology, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Dietrich von Schweinitz
- Department of Pediatric Surgery, Research Laboratories, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Maximilian Stehr
- Department of Pediatric Surgery, Research Laboratories, Ludwig-Maximilians-University of Munich, Munich, Germany
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Cost NG, DeFoor WR, Crotty EJ, Geller JI. The initial experience with RENAL Nephrometry in children, adolescents, and young adults with renal tumors. Pediatr Blood Cancer 2014; 61:1434-9. [PMID: 24610879 DOI: 10.1002/pbc.25027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 02/17/2014] [Indexed: 01/20/2023]
Abstract
BACKGROUND No standardized manner exits to objectively compare renal tumor complexity in children and adolescents. However, the RENAL Nephrometry scoring system has been recently developed in adults and shown to predict tumor complexity and correlate with clinical outcomes. Thus, the study objective was to evaluate RENAL Nephrometry tumor score in a population of children, adolescents, and young adults and correlate it with tumor features and pathology. METHODS Patients at the study institution who underwent attempted renal tumor resection from 2002 to 2012, and had pre-operative imaging available for scoring were retrospectively reviewed. A Nephrometry score for each affected kidney was calculated separately by two blinded reviewers and the final score was based on consensus review. Tumor characteristics and oncologic outcomes were compared between the low-, moderate-, and high-complexity masses. RESULTS Sixty-five patients and 67 kidneys met study criteria. This included: 5 (7.5%) low-complexity, 11 (16.4%) moderate-complexity, and 51 (76.1%) high-complexity lesions. In comparing the clinical and pathologic features between groups, it was observed that less complex masses were observed in older patients, were more commonly managed with nephron-sparing surgery, and more often represented renal cell carcinoma (RCC) and other non-Wilms tumor pathology. No statistically significant correlation was observed between tumor complexity score and blood loss, operative time, transfusion requirement, positive margins or tumor rupture. CONCLUSION In general, renal lesions in this population are highly complex. In its current form, RENAL Nephrometry appears most useful in evaluating tumor complexity in RCC and masses in older children and adolescents.
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Affiliation(s)
- Nicholas G Cost
- Division of Urology, University of Colorado School of Medicine, Aurora, Colorado; Division of Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Variation in use of nephron-sparing surgery among children with renal tumors. J Pediatr Urol 2014; 10:724-9. [PMID: 24517904 PMCID: PMC4107205 DOI: 10.1016/j.jpurol.2013.12.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 12/23/2013] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Given the negative long-term effects of renal insufficiency, nephron-sparing surgery (NSS) is increasingly discussed for the treatment of pediatric renal tumors. We sought to examine variation in practice patterns of NSS among children with renal tumors. MATERIALS AND METHODS We performed a retrospective cohort analysis of claims data for pediatric inpatient admissions captured by the Kids Inpatient Database (1997-2009). We identified children with renal tumors who underwent surgery, including radical nephrectomy (RN) and NSS. We used multivariable logistic regression to assess the relationship between use of NSS and various clinical, demographic, and geographic predictors of interest. RESULTS We identified 10,108 pediatric inpatient admissions for renal tumors. Of these, 1657 were surgical admissions, with 1501 patients (90.5%) undergoing RN and 156 (9.5%) undergoing NSS. On multivariable analysis, NSS was associated only with a concomitant diagnosis of renal insufficiency (relative ratio [RR] 3.37, p = 0.01) and surgery in the Northeastern USA (RR 3.07, p = 0.03). Race/ethnicity, age, payer type, procedure year, and other non-clinical factors were not significantly associated with NSS. CONCLUSION In a large, nationwide pediatric cohort, RN remains the most common surgical intervention for renal tumors. NSS is significantly associated with a diagnosis of renal insufficiency, but not non-clinical factors such as patient gender or race. © 2014 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
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Kieran K, Williams MA, McGregor LM, Dome JS, Krasin MJ, Davidoff AM. Repeat nephron-sparing surgery for children with bilateral Wilms tumor. J Pediatr Surg 2014; 49:149-53. [PMID: 24439600 DOI: 10.1016/j.jpedsurg.2013.09.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 09/30/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Renal insufficiency is a significant complication of Wilms tumor treatment in the 5% with bilateral disease. Nephron-sparing surgery (NSS) is recommended after neoadjuvant chemotherapy initially. However, the role of NSS in recurrent disease is unknown. We reviewed our experience to assess the feasibility and oncologic and functional outcomes of repeat NSS for children with recurrent disease. METHODS A retrospective review was performed of all children treated at our institution for bilateral, favorable histology (FH) Wilms tumor. Patients undergoing repeat NSS for locally recurrent disease were identified. The outcomes evaluated included tumor recurrence, renal function, and patient survival. RESULTS Since 2001, 36 children with bilateral FH Wilms tumor have been treated at our institution. Eight patients (22%) underwent repeat NSS for locally recurrent disease. Two patients had a second local recurrence and underwent a third NSS. Six patients are alive without disease (75%) with an average follow-up of 4.5years. Two patients have died, each with blastemal-predominant histology at repeat NSS. The surviving patients have normal renal function, although two patients require medical management of hypertension. CONCLUSIONS Our experience suggests that repeat NSS for local recurrence of FH bilateral Wilms tumor is feasible and affords acceptable oncologic outcome with preservation of renal function. However, more aggressive therapy may be required for patients whose recurrence has blastemal-predominant histology, given the poor outcome for these patients in our series.
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Affiliation(s)
- Kathleen Kieran
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | - Mark A Williams
- Division of Urology, University of Tennessee Health Science Center, Memphis, TN
| | - Lisa M McGregor
- Division of Pediatric Hematology/Oncology, Penn State Hershey Children's Hospital, Hershey, PA
| | - Jeffrey S Dome
- Division of Oncology, Children's National Medical Center, Washington, DC
| | - Matthew J Krasin
- Department of Radiological Sciences, St Jude Children's Research Hospital, Memphis, TN
| | - Andrew M Davidoff
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN
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Kieran K, Williams MA, Dome JS, McGregor LM, Krasin MJ, Davidoff AM. Margin status and tumor recurrence after nephron-sparing surgery for bilateral Wilms tumor. J Pediatr Surg 2013; 48:1481-5. [PMID: 23895958 DOI: 10.1016/j.jpedsurg.2013.02.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 01/31/2013] [Accepted: 02/02/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Nephron-sparing surgery (NSS) has been advocated for patients with bilateral Wilms tumor (BWT). We sought to determine whether margin status impacted local tumor recurrence. METHODS A retrospective review of patients undergoing NSS for BWT from November 1999 to March 2009 at our institution in which local recurrence rates based on margin status were compared. RESULTS Of 21 patients, five (23.8%) had positive margins. These and 2 (9.5%) with focal anaplasia received flank XRT. Seven (33%) patients developed recurrent disease, a mean of 18.0 (range 1.3-39.9) months after NSS. Recurrence rates were similar in patients with positive and negative margins (1/5 [20%] vs 6/16 [37.5%]; p = 0.47). Hypertension occurred more frequently in patients who received XRT (57.1% vs 28.6%). At a median follow-up of 28.6 months (range 5.2-142.3), 19 patients are alive, without evidence of disease; one patient (with a positive margin at initial NSS) died of metastatic anaplastic WT and another died of a brain tumor. One patient, with multiple risk factors, developed renal failure. CONCLUSIONS In our experience, local recurrence rates after NSS were not affected by surgical margin status although all patients with positive margins received XRT. These results support the aggressive use of NSS for patients with BWT.
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Affiliation(s)
- Kathleen Kieran
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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Abstract
Wilms tumor represents the most common pediatric renal malignancy and the fourth most common childhood cancer overall. Overall survival from Wilms tumor has increased to over 90 % secondary to multidisciplinary therapy and multi-institutional cooperative group trials. Recent therapeutic focus has shifted to reduction in treatment morbidity and renal preservation while maintaining the high survival rates. Partial nephrectomy is an integral component of the multimodal treatment protocols for Wilms tumor patients with bilateral disease, solitary kidney, or predisposing syndromes. Recent consideration has been given to utilization of nephron sparing surgery (NSS) in carefully selected patients with nonsyndromic unilateral Wilms tumor. While long-term, prospective data in this subgroup of patients is not yet available, case series demonstrate comparable oncologic outcomes after partial versus radical nephrectomy. The relative rarity of Wilms tumor, especially those amenable to upfront partial nephrectomy, presents a challenge to conducting controlled trials.
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Affiliation(s)
- Miriam Harel
- Connecticut Children's Medical Center, Hartford, CT, USA.
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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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Carmichael SP, Pulliam JF, D'Orazio JA. Delayed tumor resection in a 5-year-old child with bilateral Wilms tumor. J Surg Case Rep 2013; 2013:rjt012. [PMID: 24964423 PMCID: PMC3635223 DOI: 10.1093/jscr/rjt012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We describe the case of a 5-year-old girl whose abdominal pain and distension were caused by Wilms tumor of the kidney. Because of the bilateral nature of her disease, she was spared biopsy or initial nephrectomy as part of her treatment course. Rather, she was treated presumptively for Wilms tumor based primarily on radiologic findings. Neoadjuvant chemotherapy consisting of vincristine, dactinomycin and doxorubicin was given to facilitate nephron-sparing surgery for tumor resection. Her initial chemotherapeutic course was complicated by tumor lysis syndrome manifested by elevated serum uric acid and was treated effectively with hyperhydration and alkalization of intravenous fluids. The patient's disease responded well to chemotherapy, and she underwent successful tumor excision after 12 weeks of chemotherapy. The resected tumor was identified as anaplastic Wilms tumor, illustrating that pathologic identification of Wilms tumor is possible even after multiple cycles of neoadjuvant chemotherapy and marked tumor shrinkage.
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Affiliation(s)
| | - Joseph F Pulliam
- Department of Pathology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - John A D'Orazio
- Department of Pediatrics (Hematology-Oncology) and the Markey Cancer Center, University of Kentucky College of Medicine, Lexington, KY, USA
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Elashry R. Bilateral Wilms' tumor: Mansoura multi-centers 15 years experience. J Oncol Pharm Pract 2012; 18:115-21. [DOI: 10.1177/1078155210396575] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose. Bilateral Wilms' tumor (WT) is a challenge. Aggressive surgical resection is needed to prevent recurrence. We revised the clinico-epidemiological criteria of bilateral WT patients in our locality and relation to outcome. Subjects and methods. 462 WT patients were registered in three medical centers at Mansoura, Egypt. Twenty five patients had bilateral WT whose medical records were revised for all clinico-epidemiologic data plus treatment details, toxicity, and outcome. Results. The mean age was 34.5 months; 64% of cases were female. Abdominal mass was the commonest presentation (72%). Congenital anomalies were reported in two cases (one case showed hemihypertrophy and the other showed aniridia). About 60% had favorable pathology. Nineteen cases had synchronous bilateral WT (76%) and the remaining (six cases) had metachronous tumors. For the synchronous cases, the response rate to preoperative chemotherapy was 79% and nephron sparing surgery for the least involved kidney was possible in all. Survival rate was 74%. Metachronous tumor management included nephrectomy followed by chemotherapy for the initially diagnosed tumors. However, nephron sparing surgery of the contralateral tumors following preoperative chemotherapy was possible in two cases and the survival rate was 33%. No renal failure or any therapy-related complications were reported. Conclusions. Bilateral WT is predominantly synchronous with favorable histology, with female predilection and possibly congenital anomalies. Preoperative chemotherapy followed by nephron sparing surgery has a favorable outcome with preserved renal function especially in patients with synchronous WT. Response to preoperative chemotherapy had a statistically significant prognostic impact.
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Affiliation(s)
- Rasha Elashry
- Pediatric Oncology Department, Mansoura Faculty of Medicine, Mansoura, Egypt
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Routh JC, Graham DA, Estrada CR, Nelson CP. Contemporary use of nephron-sparing surgery for children with malignant renal tumors at freestanding children's hospitals. Urology 2011; 78:422-6. [PMID: 21689846 DOI: 10.1016/j.urology.2010.12.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 12/22/2010] [Accepted: 12/29/2010] [Indexed: 11/17/2022]
Abstract
OBJECTIVE It is widely accepted that, when feasible, nephron-sparing surgery (NSS) is preferable to radical nephrectomy (RN) for treatment of renal tumors in adults. However, RN is more frequently used in children. We sought to compare in-hospital outcomes after NSS and RN for malignant pediatric renal tumors. MATERIAL AND METHODS The pediatric health information system (PHIS) combines data from more than 40 North American pediatric hospitals. We queried PHIS to identify children with malignant renal tumors who underwent surgery from 2003 to 2009. We examined whether outcomes (complication rates, cost, and length of stay) differed by procedure type. Multivariate regression models were used to adjust for confounding, and generalized estimating equations were used to adjust for hospital clustering. RESULTS We identified 1235 children with renal tumors who underwent RN (91%) or NSS (9%). Patients undergoing RN and NSS had similar median comorbidity scores (P = .98), hospital lengths of stay (each 6.0 days, P = .54), in-hospital charges, ($25,700 vs $37,000, P = .11), and surgical complication rates (16.4 vs 20.5%, P = .24). These outcomes remained similar after adjusting for other patient and hospital factors. CONCLUSIONS Most children with malignant renal tumors treated at children's hospitals undergo RN. RN and NSS use were not significantly different in terms of their length of hospital stay, in-hospital charges, and complication rates. Although oncological outcomes are lacking, these data suggest that NSS may be performed in selected children with malignant renal tumors without significantly increasing their hospital charges, length of stay, or surgical complication rates.
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Affiliation(s)
- Jonathan C Routh
- Department of Urology, Children's Hospital Boston, Harvard Medical School, Boston, MA 02115, 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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Aronson DC, Slaar A, Heinen RC, de Kraker J, Heij HA. Long-term outcome of bilateral Wilms tumors (BWT). Pediatr Blood Cancer 2011; 56:1110-3. [PMID: 21370428 DOI: 10.1002/pbc.22881] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 09/27/2010] [Indexed: 11/10/2022]
Abstract
BACKGROUND Modern WT management consist of ample chemotherapy, nephron-sparing surgery, and, when indicated, radiotherapy. Survivors may develop renal failure or secondary tumors due to anticancer treatment. We analyzed long-term outcome (follow-up >5 years) after bilateral Wilms tumor (BWT) treatment with respect to survival, renal function, and secondary malignancies. METHODS From 41 patients (23 females, 28 synchronous tumors) diagnosed with BWT between 1967 and 2007, 25 (18 females, 14 synchronous) with a follow-up >5 years could be included. Of this subgroup, median age at diagnosis was 1.64 years (range 0.27-5.35), and at maximum follow-up 14.99 years (range 5.40-33.99). Data were retrospectively collected and analyzed. RESULTS One patient (4%) died 17.75 years after diagnosis, five (20%) had renal transplants: 3/5 after bilateral nephrectomy for Denys-Drash syndrome (DDS), and 2/5 for ESRD after an interval of 7 and 18 years, respectively. All transplanted patients remained in CR. Another three patients developed mild renal insufficiency (creatinine levels 1.3, 1.8, and 2.8 mg/100 ml, respectively; N = 0.5-1.2), combined with hypertension in 1; neither of them was transplanted. Sixteen (64%) had normal renal function and were in CR. Long-term renal function appeared significantly better after bilateral nephron sparing surgery (NSS) then after other surgical procedures (P < 0.0001). Seven secondary tumors were found in five (20%) patients, one of whom had a DDS. CONCLUSION Long-term 10-year overall survival was 78%. There was significant morbidity (13/25, 52%), in terms of renal failure (8/25, 32%) including renal transplantation (5/25, 20%), and secondary tumors (5/25). These findings necessitate long-term follow-up beyond childhood. Future work should be directed at reducing the harmful effects of treatment, including the increased use of NSS.
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Affiliation(s)
- Daniel C Aronson
- Pediatric Surgical Center of Amsterdam (ECH-AMC/VUmc), Academic Medical Center, University of Amsterdam, Amsterdam.
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Rauth TP, Slone J, Crane G, Correa H, Friedman DL, Lovvorn HN. Laparoscopic nephron-sparing resection of synchronous Wilms tumors in a case of hyperplastic perilobar nephroblastomatosis. J Pediatr Surg 2011; 46:983-8. [PMID: 21616266 PMCID: PMC3105348 DOI: 10.1016/j.jpedsurg.2011.01.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 01/25/2011] [Accepted: 01/26/2011] [Indexed: 11/25/2022]
Abstract
Diffuse hyperplastic perilobar nephroblastomatosis (DHPLN) is a rare precursor lesion of Wilms tumor (WT). Because of the increased risk to develop WT in either kidney, current management algorithms of DHPLN merit nephron-sparing strategies, beginning with chemotherapy and close radiographic monitoring into late childhood. After resolution of DHPLN, subsequent detection of a renal nodule mandates resection to exclude WT. Here, we report the case of a 4-year-old girl who developed 2 synchronous nodules in the right kidney more than 2 years after completion of therapy for DHPLN. Because of the early detection and peripheral location of these 2 nodules, laparoscopic nephron-sparing resection of each was performed using ultrasonic dissection. Both nodules were determined on pathology to be favorable histology WT with negative surgical margins. The child was placed on vincristine and actinomycin D therapy for 18 weeks.
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Affiliation(s)
| | - Jeremy Slone
- Department of Pediatric Surgery, Division of Pediatric Hematology-Oncology, Vanderbilt University School of Medicine, Monroe Carrel, Jr. Children’s Hospital, Nashville, TN
| | - Gabriella Crane
- Division of Pediatric Radiology, Vanderbilt University School of Medicine, Monroe Carrel, Jr. Children’s Hospital, Nashville, TN
| | - Hernan Correa
- Division of Pediatric Pathology, Vanderbilt University School of Medicine, Monroe Carrel, Jr. Children’s Hospital, Nashville, TN
| | - Debra L. Friedman
- Department of Pediatric Surgery, Division of Pediatric Hematology-Oncology, Vanderbilt University School of Medicine, Monroe Carrel, Jr. Children’s Hospital, Nashville, TN
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Sarhan OM, El-Baz M, Sarhan MM, Ghali AM, Ghoneim MA. Bilateral Wilms' tumors: single-center experience with 22 cases and literature review. Urology 2010; 76:946-51. [PMID: 20708784 DOI: 10.1016/j.urology.2010.03.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 03/05/2010] [Accepted: 03/21/2010] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Bilateral Wilms' tumors represent a therapeutic challenge. The primary aim of management is eradication of the neoplasm and preservation of renal function. We present our experience in the management of such cases in a single-center experience. METHODS This was a retrospective study of 22 patients with histologically proven bilateral nephroblastoma who were treated from 1993 to 2008 at our center. Of the 22 patients, 12 were girls and 10 were boys, with a median age of 3 years (range 1-9); 19 had a synchronous presentation and 3 a metachronous presentation. Of the 22 patients, 6 underwent initial surgical resection followed by chemotherapy and 16 underwent initial biopsy and preoperative chemotherapy. The final oncologic and renal outcomes were assessed. RESULTS The median follow-up period was 3 years (range 1-11). Of the 22 patients, 8 died, for an overall survival rate of 63.5%. The survival for the initial chemotherapy and initial surgery groups was essentially similar. Of all the variables studied, unfavorable histologic findings had a significant negative effect on survival. Of the 5 patients with unfavorable histologic findings, 4 died during the follow-up period. The median volume of preserved renal parenchyma was 40%. All patients had good renal function during follow-up, except for 1 patient who had undergone bilateral nephrectomy. CONCLUSIONS Bilateral Wilms' tumors impose 2 conflicting issues: elimination of the pathology and preservation of the renal function. Currently, treatment regimens involving initial chemotherapy followed by conservative surgery can achieve these goals in an important proportion of patients.
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Affiliation(s)
- Osama M Sarhan
- Department of Urology, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
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Navai N, Ramos P, Zhao LC, Meeks JJ, Nadler RB, Smith ND. Why not partial nephrectomy? Urology 2008; 72:243-6. [PMID: 18584853 DOI: 10.1016/j.urology.2008.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 04/15/2008] [Accepted: 04/17/2008] [Indexed: 11/29/2022]
Affiliation(s)
- Neema Navai
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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