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Response to Neoadjuvant Chemotherapy and Outcomes in Children With Wilms Tumor With Caval Thrombus: A Single Center
Vishesh Jain1, Nellai Krishnan1, Sandeep Agarwala1
1Department of Pediatric Surgey.
Insights
Wilms tumor management is challenging with intracaval thrombus. Complete resolution of the thrombus with neoadjuvant chemotherapy significantly improves overall survival in pediatric patients.
Area of Science:
- Pediatric Oncology
- Nephrology
- Surgical Oncology
Background:
- Wilms tumor, a common pediatric kidney cancer, can present with complex cases involving intracaval thrombus.
- The presence of intracaval thrombus complicates surgical management and impacts patient outcomes.
Purpose of the Study:
- To review the management and outcomes of pediatric patients diagnosed with Wilms tumor and intracaval thrombus.
- To evaluate the efficacy of neoadjuvant chemotherapy in resolving intracaval thrombus and its effect on survival.
Main Methods:
- Retrospective review of 34 pediatric patients with Wilms tumor and intracaval thrombus from July 2000 to December 2017.
- Evaluation of tumor stage, treatment strategies including neoadjuvant chemotherapy, surgical intervention, and patient outcomes.
Main Results:
- Neoadjuvant chemotherapy was administered to 94% of patients, with complete thrombus resolution in 26%.
- Overall survival was significantly lower in patients with distant metastases (29%) compared to those without (94%).
- Complete resolution of intracaval thrombus after neoadjuvant chemotherapy correlated with significantly higher overall survival (100% vs. 48%).
Conclusions:
- Intracaval thrombus is a significant complicating factor in Wilms tumor management.
- Neoadjuvant chemotherapy plays a crucial role in thrombus resolution and improving survival outcomes.
- Metastatic disease remains a primary determinant of poor prognosis in pediatric Wilms tumor patients.
Aim:
The aim of our study is to present our experience in the management and outcome of Wilms tumor with intracaval thrombus.
Materials And Methods:
All children with Wilms tumor with intracaval thrombus who presented to us from July 2000 to December 2017 were reviewed retrospectively. We evaluated the tumor stage, management, and outcomes in these patients.
Results:
Thirty-four patients were included in the study. The median age of presentation was 48 months (11 to 84 mo). Preoperative chemotherapy was given in 32 (94%), with a median duration of 8 weeks. Intracaval thrombus completely resolved in 9 (26%) children after neoadjuvant chemotherapy. Surgical intervention for residual inferior vena cava (IVC) thrombus was performed in 32 patients. The median follow-up was 30 months (5 to 150 mo). At the last follow-up, 24 patients (70%) were alive and disease free. The 5-year overall survival (OS) and event-free survival were 67% (95% confidence interval, 50% to 84%) and 59% (95% confidence interval, 42% to 76%). The OS in children with nonmetastatic disease (94%) was significantly higher than those with metastases (29%; P <0.01). The OS in children with complete resolution of IVC thrombus (100%) was significantly higher than those with persistent thrombus (48%; P =0.025). Analysis of survival outcomes in children with nonmetastatic disease (stage III) revealed no significant difference on comparison with cohort with stage III disease with absence of IVC thrombus. The P -value was 0.224 and 0.53 for 5-year OS and event-free survival, respectively.
Conclusion:
The management of Wilms tumor can be complicated by the presence of caval thrombus. Patients with metastasis have a significantly poor outcome. Patients in whom, there is complete resolution of intracaval thrombus on neoadjuvant chemotherapy have a significantly higher OS.
