Patient selection and technical aspects for laparoscopic nephrectomy in Wilms tumor

Screening of potential hub genes involved in Kidney Wilms tumor via bioinformatics analysis and experimental validation

BACKGROUND

Wilms tumor (WT) is the most common pediatric embryonal tumor. Improving patient outcomes requires advances in understanding and targeting the multiple genes and cellular control pathways, but its pathogenesis is currently not well-researched. We aimed to identify the potential molecular biological mechanism of WT and develop new prognostic markers and molecular targets by comparing gene expression profiles of Wilms tumors and fetal normal kidneys.

METHODS

Differential gene expression analysis was performed on Wilms tumor transcriptomic data from the GEO and TARGET databases. For biological functional analysis, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment were utilized. Out of 24 hub genes identified, nine were found to be prognostic-related through univariate Cox regression analysis. These nine genes underwent LASSO regression analysis to enhance the predictive capability of the model. The key hub genes were validated in the GSE73209 datasets, and cell function experiments were conducted to identify the genes' functions in WiT-49 cells.

RESULTS

The enrichment analysis revealed that DEGs were significantly involved in the regulation of angiogenesis and regulation of cell differentiation. 24 DEGs were identified through PPI networks and the MCODE algorithm, and 9 of 24 genes were related to WT patients' prognosis. EMCN and CCNA1 were identified as key hub genes, and related to the progression of WT. Functionally, over-expression of EMCN and CCNA1 knockdown inhibited cell viability, proliferation, migration, and invasion of Wilms tumor cells.

CONCLUSIONS

EMCN and CCNA1 were identified as key prognostic markers in Wilms tumor, suggesting their potential as therapeutic targets. Differential gene expression and enrichment analyses indicate significant roles in angiogenesis and cell differentiation.

Systematic Review and Meta-analysis of Laparoscopic Versus Open Radical Nephrectomy for Paediatric Renal Tumors With Focus on Wilms' Tumor

OBJECTIVE

To summarize and evaluate the outcomes of laparoscopic radical nephrectomy (LRN) and compare its safety and efficacy with open radical nephrectomy (ORN) in pediatric renal tumors (RT) and Wilms' tumors (WT).

BACKGROUND

ORN is the gold standard treatment for pediatric RT, consisting predominantly of WT. LRN is gaining popularity but remains controversial in pediatric surgical oncology.

METHODS

A systematic search was performed for all eligible studies on LRN and comparative studies between LRN and ORN in pediatric RT and WT. Meta-analysis, subgroup analysis, and sensitivity analysis were conducted. The main endpoints were cancer-related outcomes and surgical morbidity. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed.

RESULTS

No levels I to II studies were identified. LRN was feasible in nearly 1 in 5 pediatric RT and WT after neoadjuvant chemotherapy, with pooled mid-term oncological outcomes (<7% local recurrence, >90% event-free survival) comparable with those of ORN. There was no strong evidence of an increased risk of intraoperative tumor spillage, but lymph node harvest was inadequate in LRN. Large tumors crossing the ipsilateral spinal border were associated with a trend for intraoperative complications and positive margins. Pooled complications rate and hospital stay duration were similar between LRN and ORN. Long-term (>3 years) outcomes are unknown.

CONCLUSIONS

Available level III evidence indicates that LRN is a safe alternative to ORN for carefully selected cases, with similar spillage rates and mid-term oncological outcomes. However, there was no advantage in surgical morbidity and lymph node harvest was inadequate with LRN. Tumor-matched-group studies with long-term follow-up are required.

LEVEL OF EVIDENCE

Level III.

Surgery in Bilateral Wilms Tumor-A Single-Center Experience

The treatment of bilateral Wilms tumors (BWT) involves curing the cancer, preserving long-term renal function, and maintaining a good quality of life. Established methods for achieving these goals include preoperative chemotherapy and nephron-sparing surgery (NSS). This study aimed to evaluate the experience of a single institution in treating patients with BWT. We analyzed cases of BWT treated at the Pediatric Oncology Institute-GRAACC-Federal University of São Paulo over a period of 35 years. Bleeding control was performed with manual compression of the renal parenchyma. Thirty-three patients were included in the study. Thirty cases were synchronous tumors. The mean age at diagnosis was 30.4 months (±22 m) and 66.7% were girls. The median follow-up period was 83 months. Neoadjuvant chemotherapy was the primary approach in most patients (87.9%), with a simultaneous upfront surgical approach performed in 84.8%. Most patients underwent bilateral NSS (70.4%). There were no early complications in this series, but 39.4% had clinical complications. The five-year survival rate was 76%. Therefore, it is clear that the surgical approach to BWT plays a crucial role in achieving good outcomes. However, it is difficult to standardize surgical techniques and technology may have the potential to enhance safety.

Technical advances in the surgical management of Wilms tumors in children

Surgery is one of the cornerstones of Wilms tumor treatment. In this article, we present technical advancements that are finding their way into the armamentarium of pediatric cancer surgeons. We discuss the current approaches, challenges, opportunities, and future directions of minimally invasive surgery (laparoscopic and robotics), image-guided surgery, and fluorescence-guided surgery. Furthermore, we discuss the use of intraoperative ultrasonography, as well as the use of new techniques to improve the quality of lymph node sampling.

Identification of a 12-Gene Signature and Hub Genes Involved in Kidney Wilms Tumor via Integrated Bioinformatics Analysis

Wilms tumor (WT), also known as nephroblastoma, is a rare primary malignancy in all kinds of tumor. With the development of second-generation sequencing, the discovery of new tumor markers and potential therapeutic targets has become easier. This study aimed to explore new WT prognostic biomarkers. In this study, WT-miRNA datasets GSE57370 and GSE73209 were selected for expression profiling to identify differentially expressed genes. The key gene miRNA, namely hsa-miR-30c-5p, was identified by overlapping, and the target gene of candidate hsa-miR-30c-5p was predicted using an online database. Furthermore, 384 genes were obtained by intersecting them with differentially expressed genes in the TARGET-WT database, and the genes were analyzed for pathway and functional enrichment. Kaplan–Meier survival analysis of the 384 genes yielded a total of 25 key genes associated with WT prognosis. Subsequently, a prediction model with 12 gene signatures (BCL6, CCNA1, CTHRC1, DGKD, EPB41L4B, ERRFI1, LRRC40, NCEH1, NEBL, PDSS1, ROR1, and RTKN2) was developed. The model had good predictive power for the WT prognosis at 1, 3, and 5 years (AUC: 0.684, 0.762, and 0.774). Finally, ERRFI1 (hazard ratios [HR] = 1.858, 95% confidence intervals [CI]: 1.298–2.660) and ROR1 (HR = 0.780, 95% CI: 0.609–0.998) were obtained as independent predictors of prognosis in WT patients by single, multifactorial Cox analysis.

MF, Dueñas-Ramírez JC, Idrobo AA. Abordaje mínimamente invasivo del tumor de Wilms unilateral: un reporte de caso y revisión de la literatura

Introducción. El tumor de Wilms es la neoplasia abdominal más común en pacientes pediátricos. En la mayoría de los casos se presenta como una masa unilateral indolora en el abdomen. El objetivo de este artículo fue presentar el caso de una paciente de 4 años con tumor de Wilms unilateral derecho manejado con cirugía mínimamente invasiva en el Hospital Universitario del Valle. Métodos. Revisión de la historia clínica e imágenes de la paciente, descripción de la técnica quirúrgica y revisión de la literatura del manejo de tumor de Wilms unilateral. Caso clínico. Paciente femenina de 4 años quien consultó en abril de 2019 por un cuadro clínico de dolor abdominal y sensación de masa en flanco derecho. Se realizó ecografía abdominal donde se encontró imagen nodular heterogénea de contornos definidos en riñón derecho, con riñón izquierdo normal. Se hizo diagnóstico de tumor de Wilms unilateral y se llevó a cirugía mediante abordaje mínimamente invasivo, con buena evolución postoperatoria. Conclusión. La cirugía es el pilar del manejo, y la nefrectomía mediante abordaje laparoscópico para casos seleccionados, en manos entrenadas, tiene la suficiente eficacia, seguridad y cumplimiento de los principios quirúrgicos y oncológicos que provee la cirugía abierta.

Multidisciplinary Treatment Strategies for Wilms Tumor: Recent Advances, Technical Innovations and Future Directions

Significant progress has been made in the management of Wilms tumor (WT) in recent years, mostly as a result of collaborative efforts and the implementation of protocol-driven, multimodal therapy. This article offers a comprehensive overview of current multidisciplinary treatment strategies for WT, whilst also addressing recent technical innovations including nephron-sparing surgery (NSS) and minimally invasive approaches. In addition, surgical concepts for the treatment of metastatic disease, advances in tumor imaging technology and potentially prognostic biomarkers will be discussed. Current evidence suggests that, in experienced hands and selected cases, laparoscopic radical nephrectomy and laparoscopic-assisted partial nephrectomy for WT may offer the same outcome as the traditional open approach. While NSS is the standard procedure for bilateral WT, NSS has evolved as an alternative technique in patients with smaller unilateral WT and in cases with imminent renal failure. Metastatic disease of the lung or liver that is associated with WT is preferably treated with a three-drug chemotherapy and local radiation therapy. However, surgical sampling of lung nodules may be advisable in persistent nodules before whole lung irradiation is commenced. Several tumor markers such as loss of heterozygosity of chromosomes 1p/16q, 11p15 and gain of function at 1q are associated with an increased risk of recurrence or a decreased risk of overall survival in patients with WT. In summary, complete resection with tumor-free margins remains the primary surgical aim in WT, while NSS and minimally invasive approaches are only suitable in a subset of patients with smaller WT and low-risk disease. In the future, advances in tumor imaging technology may assist the surgeon in defining surgical resection margins and additional biomarkers may emerge as targets for development of new diagnostic tests and potential therapies.

New aspects and innovations in the local treatment of renal and urogenital pediatric tumors

Local treatment plays a key role for patients' outcome in tumors of the urogenital tract in children. Despite a great variety of different etiologies, the specific localization of pediatric urogenital tumors renders several characteristic demands to the treating personnel. Surgery and radiotherapy are the main elements of local treatment in this group of neoplasms. Numerous new guidelines and innovative technical developments of surgery and radiotherapy have recently been integrated into treatment concepts for pediatric urogenital tumors. Due to the broadness of the field it is not possible to give a full overview over all aspects. Therefore, this article highlights the most important innovations and new guidelines of surgery and radiotherapy of pediatric urogenital tumors.

Outcomes of event-free survival in patients with Wilms tumor undergoing preoperative chemotherapy. Analysis of lymph-node yield in a single-center cohort

INTRODUCTION

The clinical value of lymph node sampling in Wilms tumor (WT) lies in its ability to accurately determine lymph node (LN) involvement. LN yield (LNY) is used as a valuable tool to measure LN retrieval, and a minimum of 6 LNs is one of the current recommendations. In patients who are managed with the SIOP strategy, preoperative chemotherapy decreases the retrieval of LN during surgery resulting in lower LNY values.

PURPOSE

To determine the mean LNY and to analyze survival outcomes in patients with WT who underwent preoperative chemotherapy at a single center.

METHODS

We performed a retrospective chart review of all patients between 6 months and 12 years of age with unilateral WT who underwent preoperative chemotherapy between 2010 and 2018. Patients with bilateral WT or without preoperative chemotherapy were excluded. Collected data included: demographics, tumor volume, tumor histopathology, number of LNs collected (LNY), presence or absence of tumor in the retrieved LNs, and disease stage according to these results. Kaplan Meier curves were calculated to estimate 5-year event-free survival (EFS) and overall survival (OS).

RESULTS

95 patients with a median follow-up of 25 months were included in the study. A total of 19 patients underwent laparoscopic surgery. Mean LNY for the entire cohort was 3.26 (95% CI, 2.4-3.6; SD, 3.62). Six patients (6.3%) had at least one positive LN. The estimated 5-year OS was 89.3% (95% CI, 82.1%-96.5%). EFS was 79.8 (95% CI, 74.8%-84.8%). Recurrence rate was 20% (n: 19). Four patients (4.2%) developed local recurrence and 15 patients (15.7%) developed pulmonary recurrence. The initial mean LNY in patients that relapsed was 4.16 (95% CI, 2.2-5.8; SD: 4.18), which was higher than in patients who did not relapse (LNY: 3; 95% CI, 2.33-3.67; SD, 3.39). No recurrences or deaths occurred in the laparoscopic group.

DISCUSSION

The identification of a minimum LNY (i.e. threshold) to minimize the risk of harboring occult metastatic disease has been proposed to standardize the surgical procedure. Preliminary results in this study suggest that a limited LNY with acceptable survival outcomes is a possible scenario in patients treated according to the SIOP protocol. Systematic LN sampling to reduce the rate of false negatives is still strongly recommended.

CONCLUSION

Our cohort presented with a relatively low LNY compared to standard recommendations. Our EFS, however, remained acceptable. Multivariate analysis would be necessary to determine the actual role of LN sampling as an isolated prognostic factor in unilateral WT.

Minimally Invasive Techniques in Pediatric Surgical Oncology

Minimally invasive approaches to pediatric cancer surgery are increasingly used, not only for the benefits of smaller incisions, but also for better field visualization and precise dissection. Advances in technology and surgeon experience have facilitated this trend. However, the appropriate indications for its use remain to be determined, and oncologic principles should not be compromised. We discuss the current and potential future uses, and new technologies that are being developed and introduced to assist with and enhance the role of minimally invasive surgery in the management of children with cancer.

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.

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.