Evidence-based surgical guidelines for treating children with Wilms tumor in low-resource settings
Abdelhafeez H Abdelhafeez1,2, Tea Reljic3, Ambuj Kumar4
1Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee.
Insights
Wilms tumor (WT) survival is poor in low-resource settings. This study provides resource-sensitive surgical recommendations to improve outcomes for WT patients, focusing on neoadjuvant chemotherapy and surgical techniques.
Area of Science:
- Pediatric Oncology
- Surgical Oncology
- Global Health
Background:
- Wilms tumor (WT) survival rates are significantly lower in low-resource settings (<30%) compared to high-resource settings (>90%).
- Standardized surgical approaches for WT are challenging to implement in resource-limited environments.
- Improving surgical outcomes in low-resource settings requires tailored, resource-sensitive strategies for WT management.
Approach:
- A systematic review of PubMed and EMBASE databases was conducted up to July 7, 2020.
- The GRADE approach was utilized to assess the quality of evidence and formulate recommendations.
- Recommendations focus on resource-sensitive surgical management of Wilms tumor.
Key Points:
- Expedite treatment initiation and perform surgery in high-volume centers. Utilize cross-sectional imaging for preoperative planning.
- For typical WT, avoid pre-chemotherapy biopsy; administer neoadjuvant chemotherapy before resection, including lymph node sampling.
- Manage WT with inferior vena cava thrombus and bilateral WT with specific neoadjuvant chemotherapy protocols. Reserve nephron-sparing surgery for specific indications.
Conclusions:
- Evidence-based recommendations are provided for the surgical management of Wilms tumor, considering resource limitations.
- The recommendations aim to bridge the survival gap in Wilms tumor treatment between high- and low-resource settings.
- Optimizing surgical strategies is crucial for improving Wilms tumor outcomes globally.
Background:
Survival of Wilms tumor (WT) is > 90% in high-resource settings but < 30% in low-resource settings. Adapting a standardized surgical approach to WT is challenging in low-resource settings, but a local control strategy is crucial to improving outcomes.
Objective:
Provide resource-sensitive recommendations for the surgical management of WT.
Methods:
We performed a systematic review of PubMed and EMBASE through July 7, 2020, and used the GRADE approach to assess evidence and recommendations.
Recommendations:
Initiation of treatment should be expedited, and surgery should be done in a high-volume setting. Cross-sectional imaging should be done to optimize preoperative planning. For patients with typical clinical features of WT, biopsy should not be done before chemotherapy, and neoadjuvant chemotherapy should precede surgical resection. Also, resection should include a large transperitoneal laparotomy, adequate lymph node sampling, and documentation of staging findings. For WT with tumor thrombus in the inferior vena cava, neoadjuvant chemotherapy should be given before en bloc resection of the tumor and thrombus and evaluation for viable tumor thrombus. For those with bilateral WT, neoadjuvant chemotherapy should be given for 6-12 weeks. Neither routine use of complex hilar control techniques during nephron-sparing surgery nor nephron-sparing resection for unilateral WT with a normal contralateral kidney is recommended. When indicated, postoperative radiotherapy should be administered within 14 days of surgery. Post-chemotherapy pulmonary oligometastasis should be resected when feasible, if local protocols allow omission of whole-lung irradiation in patients with nonanaplastic histology stage IV WT with pulmonary metastasis without evidence of extrapulmonary metastasis.
Conclusion:
We provide evidence-based recommendations for the surgical management of WT, considering the benefits/risks associated with limited-resource settings.
