Predictors of treatment outcome of Wilms Tumour in low-income country; single centre experience from Pakistan

Advances in the clinical management of high-risk Wilms tumors

Outcomes are excellent for the majority of patients with Wilms tumors (WT). However, there remain WT subgroups for which the survival rate is approximately 50% or lower. Acknowledging that the composition of this high-risk group has changed over time reflecting improvements in therapy, we introduce the authors' view of the historical and current approach to the classification and treatment of high-risk WT. For this review, we consider high-risk WT to include patients with newly diagnosed metastatic blastemal-type or diffuse anaplastic histology, those who relapse after having been initially treated with three or more different chemotherapeutics, or those who relapse more than once. In certain low- or low middle-income settings, socio-economic factors expand the definition of what constitutes a high-risk WT. As conventional therapies are inadequate to cure the majority of high-risk WT patients, advancement of laboratory and early-phase clinical investigations to identify active agents is urgently needed.

Wilms Tumor in India: A Systematic Review

Shyam SrinivasanBackground  Cure rates of childhood malignancies are inferior in India compared with upper-middle-income countries. There is paucity of quality data addressing outcome of childhood Wilms tumor (WT) from India. This systematic review was conducted to assess the disease trends, treatment strategies, and outcome indicators in WT across India. Materials and Methods  We conducted a systematic search of MEDLINE, Google Scholar, and SCOPUS database, and additionally screened International Society of Pediatric Oncology conference abstracts. Data concerning WT or nephroblastoma published from India were extracted. Results  A total of 17 studies containing 1,170 patients were included in this review. Ninety-four percent of the studies were published after the year 2010. Advanced stage (III and IV) disease was seen in 46% of included patients. In seven studies, patients underwent a pretreatment biopsy before commencement of therapy. A hybrid approach consisting of "surgery first" in a selected subset and "neo-adjuvant chemotherapy" in all others was the most common treatment strategy adopted in half of the studies. The overall survival ranged between 48 and 89%. Key prognostic factors influencing survival across studies included increased tumor volume, metastatic disease, and unfavorable histology. Nonrelapse mortality (2.7-8.5%) was noted to be high. Conclusion  Substantial proportion of children with WT from India present with advanced stages of the disease. Despite several limitations, the current systematic review showed a modest survival among Indian children with WT. Adopting strategies through collaboration to ensure early access to expert care along with involvement of social support team to improve compliance may further improve survival of WT in India.

Advances in the clinical management of high-risk Wilms tumors

Outcomes are excellent for the majority of patients with Wilms tumors (WT). However, there remain WT subgroups for which the survival rate is approximately 50% or lower. Acknowledging that the composition of this high-risk group has changed over time reflecting improvements in therapy, we introduce the authors' view of the historical and current approach to the classification and treatment of high-risk WT. For this review, we consider high-risk WT to include patients with newly diagnosed metastatic blastemal-type or diffuse anaplastic histology, those who relapse after having been initially treated with three or more different chemotherapeutics, or those who relapse more than once. In certain low- or low middle-income settings, socio-economic factors expand the definition of what constitutes a high-risk WT. As conventional therapies are inadequate to cure the majority of high-risk WT patients, advancement of laboratory and early-phase clinical investigations to identify active agents is urgently needed.

Harmonica consensus, controversies, and future directions in radiotherapy for pediatric Wilms tumors

Radiotherapy (RT) is essential for multimodality treatment of pediatric renal tumors, particularly in higher-risk and metastatic disease. Despite decades of use, particularly for Wilms tumor, there remain controversies regarding RT indications, timing, dose, and targets. To align global management, we address these issues in this international HARMONIsation and CollAboration (HARMONICA) project. There are multiple knowledge gaps and opportunities for future research including: (1) utilization of advanced RT technologies, including intensity-modulated RT, proton beam therapy, combined with image-guided RT to reduce target volumes; (2) impact of molecular biomarkers including loss of heterozygosity at 1p, 16q, and 1q gain on RT indications; (3) mitigation of reproductive toxicity following RT; (4) promotion of RT late effects research; and (5) support to overcome challenges in RT utilization in low- and middle-income countries where 90% of the world's children reside. Here, we outline current status and future directions for RT in pediatric renal tumors.

Challenges in the Management of Wilms Tumor in a Developing Country: A Twenty Years' Experience From a Single Center in Pakistan

BACKGROUND

Wilms Tumor (WT) is one of the most curable childhood cancers. High cure rates seen in the developed countries are not reproduced in developing countries. Lack of access to cancer treatment facilities, financial constraints, late presentation, and abandonment have previously been described. We reviewed our data over the last 20 years to highlight some of these challenges.

METHODS

This is a retrospective chart review of children with WT at our center up to the age of 18 years between 1 November 1997 and 30 November 2017. Demographic details, presentation characteristics and treatment details were recorded. Factors associated with poor outcome were analyzed.

RESULTS

Two hundred eleven children were registered; 117(55.5%) were males. Median age at presentation was 3 (range 0 to 18) years. Presentation data were available for 184/211 patients, staging details for 159/211 and metastatic status for 178/211. Of the available dataset, 60% presented without prior treatment, whereas 40% presented atleast after primary surgical excision. High-stage (stage III or above) disease was present in 79 (49.7%) patients; 61 (34.3%) was presented with metastases or recurrence; 63 (29.8%) abandoned or refused treatment; 99/172 (57.6%) patients finished treatment, 23 (13.4%) died during treatment, and 6 died before treatment. Of the 99 patients who finished treatment 83 (83.8%) are well off therapy; 15(15.2%) relapsed; 6 (40%) are alive after salvage therapy, while 9 (60%) died.

CONCLUSIONS

Our data highlights the challenges of managing WT in resource poor environments. Prior surgery, incomplete staging work-up and abandonment are some of the most frequently encountered barriers. A multipronged approach is required to overcome these challenges.

Profile and Clinical Outcome of Children with Wilms' Tumor treated at a Tertiary Care Centre, India

Pritanjali SinghBackground  Wilms' tumor (WT) is the most common kidney tumor of the pediatric age group. The outcome of WT has improved due to the evolution of the treatment approach. A prospective observational study was conducted at All India Institute of Medical Sciences (AIIMS), Patna, to analyze the clinical profile along with the response and outcome to neoadjuvant chemotherapy according to the International Society of Pediatric Oncology (SIOP) protocol. Materials and Methods  In total, 28 patients of WT visited the radiotherapy department from January 2015 to December 2019. Results  Gender distribution showed male preponderance with a median age at diagnosis was 31 months. The abdominal lump was the dominant clinical presentation. The median volume of tumor at diagnosis was 359.48 mL (52.67-1805.76). Radiological staging workup shows that stage I, II, III, IV, and V were 7.1%, 39.3%, 39.3%, 10.7%, and 3.6% respectively. Neoadjuvant chemotherapy (NACT) was received by all patients. Also, 71.4% of patients showed > 50% of tumor volume reduction, while 28.6% of patients showed < 50% of tumor mass reduction. There was a statistically significant decrease in the tumor volume reduction following neoadjuvant chemotherapy ( p  < 0.001). There was a statistically significant stage down ( p  = 0.018) of the disease. Bivariate correlation studies showed recurrence was correlating statistically significantly with age < 24 months ( p  = 0.049), locoregional lymph nodes ( p  = 0.008), histopathological subtypes ( p  < 0.001), stage of the disease ( p  = 0.003), and risk groups ( p  < 0.001). In addition, 25% of patients developed recurrence during the median follow-up of 25 months. The median disease-free survival (DFS) and overall survival (OS) were not reached. The mean DFS and OS were 48 and 59.13 months, respectively. One- and 3-year DFS were 100% and 64.1%, respectively. One- and 3-year OS were 100% and 75% respectively. Conclusion  Our study suggests that most of the patients presented at an advanced stage, thus rendering most of the cases difficult to undergo surgery at presentation. Neoadjuvant chemotherapy followed by surgery may be considered a well-balanced approach with a comparable response and survival outcomes.

Wilms tumor in Africa: A systematic review of management challenges and outcome in two decades (2000-2019)

We performed a systematic review to highlight trends in management and outcome of Wilms tumor (WT) in Africa in the past two decades (2000-2019). Twenty-seven studies involving 2250 patients were analyzed. Overall, barring regional variations, 57.7% of the cases presented with advanced disease, 57.3% completed planned treatment, and survival was 56.5%. The publications in the two decades did not show significant differences in proportions of cases with advanced disease, completion of treatment rate, and cases lost to follow up. However, significantly more cases received preoperative chemotherapy, and survival improved in the last decade (2010-2019) compared to the earlier decade (2000-2009). Survival of WT in Africa might have improved in the last decade, but challenges of delayed presentation and abandonment of treatment have persisted. Measures that will encourage early access to expert care as well as improve on treatment compliance may further improve survival of WT in Africa.