7/28/2019 Wilms Tumor_ Preoperative Risk Factors Identified for Intraoperative Tumor Spill

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7/2/13 Wilms tumor : pr eoper ative risk factors identified for intr aoper ative tumor spill. - F1000Pr ime

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DOI: 10.3410/f.9709956.10392054

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 isassociated with increased risk of recurrence and poorer event-free survival, and also necessitates adjuvant radiotherapy as well as additional chemotherapy (both of which carryadditional risks).

Barber et al. performed a retrospective review of the Texas pediatric Wilms tumor registry at their home institution. Patients undergoing unilateral nephrectomy between January2000 and August 2008 for stage I-IV diseas e were included; patients in whom preoperative cross-s ectional imaging and/or s urgical pathology reports were unavailable for reviewwere exclud ed. Data abstracted included p atient d emographics, radiographic and histopathologic tumor characteristics, and whether or not neoadjuvant chemotherapy had beenadministere d. Volume tric calculations wer e performed by a single radiologis t on all com puted 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 theexcluded patients had tumor spill. Of the remaining 41 patients, s ix 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 withintraoperative s pill, one (16.7%) had anaplas ia.

Preoperative tumor volume was significantly greater (802cc versus 403cc, p1000g (100% versus 12%, p=0.03). There were no radiographic findings which predicted an increased l ikelihood of tumor s pill. No patient who had undergone neoadjuvantchemotherapy had tumor s pill, although this was n ot st atistically significant w hen stra tified b y stage. Preoperative tumor biops y, which has been shown in prior studies to be asi gnificant risk factor for intraoperative spi llage, was not found to be s ignificant 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 theincreased risk of spill with larger tumors. They also recommend consideration of neoadjuvant chemotherapy for selected Wilms tumors; neoadjuvant chemotherapy is thestandard 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 s tudy suggests that large tumors (>1000g) may be at increased ris k for intraoperative spillage, and that neoadjuvant chemotherapy may be ass ociated with a lower ris k of spill. No radiographic risk factors could be identified on preoperative imaging. However, the small num ber of patients treated as well as the short duration of the study periodmake definitive conclusions difficult. The authors did not differentiate between local and diffuse spill, nor did they comment on the presence or abs ence of tumor in the renal veinand/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 s pill 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 analysisand larger-scale study to better delineate the relative influence of tumor characteristics, neoadjuvant treatment, and intraoperative variables on the ability to achieve completeresection. For further reading, please see {1-6}.

References1. Surgery-related factors and local rec urrence of W ilms tumor in National Wilms Tumor Study 4.Shambe rger RC, Guthrie KA, Ritchey ML, Haase GM, ..., Beckwith JB, D'Angio GJ, Green DM, Breslow NE. Ann Surg 1999 Feb; 2(229):292-7PMID: 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. J Pediatr Surg 2005 Jan; 1(40):208-12; discuss ion 212-3PMID: 15868587

3. Effectiveness of preoperative chemotherapy in Wilms' tumor: results of an International Society of Paediatric Oncology (SIOP) clinical trial.Leme rle J, Voute PA, Tournade MF, Rodary C, ..., Burgers JM, Sandstedt B, Milden berger H, Carli M. J Clin Oncol 1983 Oct; 10(1):604-9PMID: 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):2345-53PMID: 1657352

5. Prognosis for Wilms' tumor patients with nonmetastatic disease at diagnosis--results of the second National Wilms' Tumor Study.Breslo w N, Churchil l G, Beckwith JB, Fernbach DJ, Otherson HB, Tefft M, D'Angio GJ J Cli n Oncol 1985 Apr; 4(3):521-31PMID: 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):351-6PMID: 206214

DisclosuresNone declared

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Wilms tumor: preoperative risk factors identified forintraoperative tumor spill.Barber TD , Derinkuyu BE , Wickiser J , Joglar J , Koral K , Baker LAJ U rol. 2011 Apr; 185(4):1414-8

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Chris Cooper F1000 UrologyUniversity of Iow a Hospitals and Clinics,Iowa City, IA, USA.

Kathleen Kieran F1000 UrologyUniversity of Iowa Hospitals and Clinics,Iowa City, IA, USA.

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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. Patientcharacteristics and neoadjuvant chemotherapy use were noted. After blinding, a radiologist reviewed preoperative computerized tomogram parameters, calculating tumor volumeand ass igning a preoperative radiological stage.Of 67 patients diagnos ed with Wilms tumor 41 (22 m ales, 19 females) m et inclusion criteria, while 26 had incomplete im aging for analysis. Comparison of patients wi th and without intraoperative tumor spi ll demons trated no s ignificant differences in age (3.8 vs 3.6 years), sex (3 males and 3 females vs 19males and 16 females), body weight or tumor capsule thickness. Preoperative radiological staging was unable to predict pathological stage I to III diseas e. Six intraoperativetumor 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 than1,000 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 experiencedtumor spill, while lack of neoadjuvant chemotherapy was as sociated with a 60% (3 of 5 patients, 1 male and 2 females ) risk of s tage 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 dimi nishing spill risk. Patients with Wilms tumors greater than 1,000 cc may benefit from neoadjuvantchemotherapy with less tumor spill, while s tage 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 o f Health.

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