Selecting initial therapy for pediatric genitourinary cancers

A few decades ago, there were few choices in the initial management of children with genitourinary tumors. Radical surgical removal was the only line of attack that promised any chance of survival. Improvement in the results of multimodal therapy in the last 15 years have radically altered the outlook for these children, hence the choice of therapy. As with other childhood cancers, the choice of therapy is based on risk-benefit evaluations of the roles of surgery, irradiation, and chemotherapy, since all three modalities have their associated morbidities. Current emphases are on preservation of function without compromising cure. The large cooperative clinical trials have emphasized this aspect of pediatric oncology. They have demonstrated, for example, that radiation therapy can be omitted from primary management of early stage Wilms' tumor patients who are given adequate adjuvant chemotherapy as can both radiation therapy and ablative surgery in certain cases of early stage rhabdomyosarcoma. Routine retroperitoneal node dissections have been shown to be of dubious diagnostic or therapeutic value in boys with testicular cancers. The need for bilateral oophorectomy in girls with dysgerminoma can similarly be questioned. Choices of initial therapy, therefore, are not static. They are becoming wider with each advance in multimodal therapy. Clinicians must keep abreast of the results of clinical trials so they can offer their patients the combination of treatments that will preserve function, and produce the smallest number of late complications without jeopardizing survival chances.