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Wilms tumor: preoperative risk factors identified for intraoperative tumor spill. - F1000Prime
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Wilms tumor: preoperative risk factors identified for intraoperative tumor spill.
Barber TD, Derinkuyu BE, Wickiser J, Joglar J, Koral K, Baker LA J Urol. 2011 Apr; 185(4):1414-8

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Chris Cooper
F1000 Urology University of Iow a Hospitals and Clinics, Iow a City, IA, USA.

Kathleen Kieran
F1000 Urology University of Iow a Hospitals and Clinics, Iow a City, IA, USA.

Follow Controversial DOI: 10.3410/f.9709956.10392054

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We found this article interesting because it seeks to identify preoperative risk factors for intraoperative tumor spill in the treatment of Wilms tumor. Intraoperative tumor spill is associated with increased risk of recurrence and poorer event-free survival, and also necessitates adjuvant radiotherapy as well as additional chemotherapy (both of which carry additional risks). Barber et al. performed a retrospective review of the Texas pediatric Wilms tumor registry at their home institution. Patients undergoing unilateral nephrectomy between January 2000 and August 2008 for stage I-IV disease were included; patients in whom preoperative cross-sectional imaging and/or surgical pathology reports were unavailable for review were excluded. Data abstracted included patient demographics, radiographic and histopathologic tumor characteristics, and whether or not neoadjuvant chemotherapy had been administered. Volumetric calculations were performed by a single radiologist on all computed tomography (CT) images. Of the 67 patients undergoing unilateral nephrectomy over the study period, 26 were excluded because either CT images or pathology reports were not available. None of the excluded patients had tumor spill. Of the remaining 41 patients, six patients (15%) had intraoperative tumor spill; patients with and without spill appeared demographically similar (Table 1). Half of the patients with spill were Stage III and half were Stage IV, with two-thirds of the Stage III patients being upgraded to Stage III based on intraoperative spill alone. Of the remaining 35 patients, nine were Stage I, 16 Stage II, four Stage III, and six Stage IV. The majority of patients (85%) had favorable histology tumors; of the patients with intraoperative spill, one (16.7%) had anaplasia. Preoperative tumor volume was significantly greater (802cc versus 403cc, p<0.01) in patients with tumor spill. Risk of tumor spill was significantly greater in patients with tumors >1000g (100% versus 12%, p=0.03). There were no radiographic findings which predicted an increased likelihood of tumor spill. No patient who had undergone neoadjuvant chemotherapy had tumor spill, although this was not statistically significant when stratified by stage. Preoperative tumor biopsy, which has been shown in prior studies to be a significant risk factor for intraoperative spillage, was not found to be significant in this study. The authors conclude that larger tumors likely present a technical challenge to the surgeon given the small operative field in young children, and this factor may account for the increased risk of spill with larger tumors. They also recommend consideration of neoadjuvant chemotherapy for selected Wilms tumors; neoadjuvant chemotherapy is the standard of care for the International Society of Pediatric Oncology (primarily Europe), but is not routinely endorsed by the Children's Oncology Group (North America). This study suggests that large tumors (>1000g) may be at increased risk for intraoperative spillage, and that neoadjuvant chemotherapy may be associated with a lower risk of spill. No radiographic risk factors could be identified on preoperative imaging. However, the small number of patients treated as well as the short duration of the study period make definitive conclusions difficult. The authors did not differentiate between local and diffuse spill, nor did they comment on the presence or absence of tumor in the renal vein and/or collecting system; these factors have previously been identified in a larger-scale study (National Wilms Tumor Study 5) to be associated with avoidable intraoperative tumor spills. In addition, margin status was not described in this study; positive margins are possible even in the absence of obvious tumor spill and confer an adverse prognosis. Despite its limitations, this study underscores the need for further investigation into the factors contributing to intraoperative tumor spill, and the need for a prospective analysis and larger-scale study to better delineate the relative influence of tumor characteristics, neoadjuvant treatment, and intraoperative variables on the ability to achieve complete resection. For further reading, please see {1-6}. References 1. Surgery-related factors and local recurrence of Wilms tumor in National Wilms Tumor Study 4. Shamberger RC, Guthrie KA, Ritchey ML, Haase GM, ..., Beckwith JB, D'Angio GJ, Green DM, Breslow NE. PMID: 10024113 2. Quality assessment for Wilms' tumor: a report from the National Wilms' Tumor Study-5. Ehrlich PF, Ritchey ML, Hamilton TE, Haase GM, ..., Green D, Norkool P, Becker J, Shamberger RC. PMID: 15868587

Ann Surg 1999 Feb; 2(229):292-7

J Pediatr Surg 2005 Jan; 1(40):208-12; discussion 212-3

3. Effectiveness of preoperative chemotherapy in Wilms' tumor: results of an International Society of Paediatric Oncology (SIOP) clinical trial. The F1000.com cookies.MF, By continuing site, you areB, agreeing to our H, use of cookies. Find out more Oct; 10(1):604-9 Lemerle website J, Voute uses PA, Tournade Rodary C, to ..., browse Burgersthe JM, Sandstedt Mildenberger Carli M. J Clin Oncol 1983 PMID: 6321673 4. Prognostic factors in nonmetastatic, favorable histology Wilms' tumor. Results of the Third National Wilms' Tumor Study. Breslow N, Sharples K, Beckwith JB, Takashima J, Kelalis PP, Green DM, D'Angio GJ Cancer 1991 Dec 1; 11(68):2345-53 PMID: 1657352 5. Prognosis for Wilms' tumor patients with nonmetastatic disease at diagnosis--results of the second National Wilms' Tumor Study. Breslow N, Churchill G, Beckwith JB, Fernbach DJ, Otherson HB, Tefft M, D'Angio GJ J Clin Oncol 1985 Apr; 4(3):521-31 PMID: 2984345 6. The surgical treatment of Wilms' tumor: results of the National Wilms' Tumor Study. Leape LL, Breslow NE, Bishop HC Ann Surg 1978 Apr; 4(187):351-6 PMID: 206214 Disclosures None declared
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Wilms tumor: preoperative risk factors identified for intraoperative tumor spill. - F1000Prime
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Abstract:
We identified preoperative parameters associated with increased risk of intraoperative Wilms tumor spill.We retrospectively reviewed an institutional database of patients diagnosed with Wilms tumor between 2000 and 2008. Inclusion criteria consisted of available abdominal computerized tomogram and pathological stage I to IV disease. Patient characteristics and neoadjuvant chemotherapy use were noted. After blinding, a radiologist reviewed preoperative computerized tomogram parameters, calculating tumor volume and assigning a preoperative radiological stage.Of 67 patients diagnosed with Wilms tumor 41 (22 males, 19 females) met inclusion criteria, while 26 had incomplete imaging for analysis. Comparison of patients with and without intraoperative tumor spill demonstrated no significant differences in age (3.8 vs 3.6 years), sex (3 males and 3 females vs 19 males and 16 females), body weight or tumor capsule thickness. Preoperative radiological staging was unable to predict pathological stage I to III disease. Six intraoperative tumor spills (15%) were identified (left in 4, right in 2), of which 3 were stage III disease and 3 stage IV. Without neoadjuvant chemotherapy, patients with tumors greater than 1,000 cc had an increased risk of spill (2 of 2 [100%] vs 4 of 33 [12%], p = 0.03). Of 9 patients with stage IV disease 0% (0 of 4) receiving neoadjuvant chemotherapy experienced tumor spill, while lack of neoadjuvant chemotherapy was associated with a 60% (3 of 5 patients, 1 male and 2 females) risk of stage IV spill (p = 0.17).The sole significant tumor spill risk factor identifiable preoperatively was tumor volume greater than 1,000 cc. However, spill occurred at volumes less than 400 cc. Although not statistically significant, neoadjuvant chemotherapy for stage IV disease trended toward diminishing spill risk. Patients with Wilms tumors greater than 1,000 cc may benefit from neoadjuvant chemotherapy with less tumor spill, while stage IV tumors warrant further study in this regard. DOI: 10.1016/j.juro.2010.11.047 PMID: 21334640 Abstract courtesy of PubMed: A service of the National Library of Medicine and the National Institutes of Health.

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