Lymph node involvement in Wilms tumor: results from National Wilms Tumor Studies 4 and 5.
ABSTRACT The aim of the study was to determine the prognostic impact of lymph node (LN) involvement and sampling in patients with Wilms tumor (WT) and the minimum number of LNs needed for accurate staging.
We reviewed all patients with unilateral, nonmetastatic WT enrolled in the National Wilms Tumor Study 4 or 5. Data were abstracted on patient demographics, tumor histology, staging, number of LNs sampled, and disease-specific and overall patient outcomes.
A total of 3409 patients had complete information on LN sampling. Five-year event-free survival (EFS) was lower in patients with nodal disease (P < .001); the effect of LN positivity was greater for patients with anaplastic (P = .047) than with favorable histology (P = .02). The likelihood of obtaining a positive LN was higher when sampling at least 7 LNs. However, after controlling for tumor histology and stage, the number of LNs sampled did not predict EFS variations (P = .75). Among patients with stage II disease, patients with LN sampling (P = .055) had improved EFS, largely reflecting poorer EFS in patients with anaplastic tumors (P = .03).
Lymph node sampling is particularly important for patients with stage II anaplastic WT. Although the likelihood of finding a positive LN was greater when more than 7 LNs were sampled, EFS was not impacted by the number of LNs sampled.
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ABSTRACT: Nephron-Sparing Surgery (NSS) is the standard of care for many adults with renal tumors and has been described in some children with Wilms tumor (WT). Beyond case series, however, data concerning NSS utilization and outcomes in WT are scarce. We therefore examined NSS outcomes and factors associated with NSS use in WT. We retrospectively reviewed the 1998-2010 Surveillance, Epidemiology, and End Results (SEER) database. We identified WT patients aged ≤ 18 years. Clinical, demographic and socioeconomic data were abstracted, and statistical analysis was performed using multivariate logistic regression (predicting use of NSS, limited to unilateral tumors <15cm) and Cox regression (predicting Overall Survival, OS) models. We identified 876 boys and 956 girls with WT (mean age 3.3 ± 2.9 years). Of these, 114 (6.2%) underwent NSS (74 unilateral, 37 bilateral WT). Median follow up was 7.1 years. Regarding procedure choice, NSS was associated with unknown lymph node status (NX vs N0, p<0.001) and smaller tumor size (p<0.001). Regarding survival, only age (HR=1.09, p=0.002), race (HR=2.48, p=0.002), stage (HR=2.99, p<0.001), and LN status (HR=2.17, p=0.001) predicted reduced OS. Survival was not significantly different for children undergoing NSS vs. RN (HR=0.79, p=0.58). Among children with WT included in the SEER database, NSS is infrequently performed. NSS use is associated with smaller, bilateral tumors and with omission of lymphadenectomy; however, there are no evident differences in NSS use by demographic or socioeconomic factors. Despite lymph node under-staging, overall survival after NSS remains similar to radical nephrectomy.The Journal of urology 04/2014; DOI:10.1016/j.juro.2014.04.003 · 3.75 Impact Factor
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ABSTRACT: Introduction Sampling lymph nodes (LNs) is independently associated with decreased recurrence and improved survival for Wilms tumor (WT). Despite sampling, we noted cases where a few or no LNs were identified after resection of WT. We hypothesized fewer LNs were identified when submitted en bloc with the tumor, compared with when submitted separately. Patients/Materials and Methods We conducted a retrospective chart review from 2003 to 2012 of WT resection cases, examining the type of LN dissection, the specimens submitted to pathology, number of LNs evaluated, and complications associated with the procedure. Results We identified 74 children with WT; 59 of 74 (79.7%) had unilateral disease and 15 of 74 (20.3%) had bilateral disease. With unilateral disease, more LNs were identified by separate versus en bloc sampling (5.2 ± 0.6 vs. 4.4 ± 1.2 nodes, p = 0.61). Both the methods identified fewer LNs compared with en bloc + separate sampling (12.5 ± 2.7 nodes, p < 0.001 and p = 0.04, respectively). The majority of children with bilateral disease (10/15, 66.6%) did not have LN sampling intraoperatively. When submitted separately, 83.3 ± 3.8% of all LNs were identified in the separate specimen, and two en bloc specimens that were noted to have adenopathy intraoperatively had no LNs pathologically identified. Few cases had complications, which did not appear associated with LN sampling. Conclusions En bloc + separate sampling yields the most LNs during resection of WT. We recommend using this technique to facilitate the maximum number of LNs evaluated in WT. Low rates of LN sampling in bilateral disease may indicate decreased regard for sampling when tumor stage is already known.European Journal of Pediatric Surgery 08/2014; 25(01). DOI:10.1055/s-0034-1386637 · 0.98 Impact Factor
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ABSTRACT: The aim was to report a multicentric study with a longer follow-up to evaluate the laparoscopic radical nephrectomy in children with renal cancer. This was a retrospective multicentric study, from October 2005 to January 2012, of children who underwent a laparoscopic radical nephrectomy for small renal malignant tumors. Seventeen children were included in this study. Sixteen underwent chemotherapy before surgery according the SIOP (Société Internationale d'Oncologie Pédiatrique) protocol and one was treated by surgery only for a carcinoma. All except one could be treated by laparoscopy; the biggest tumoral size was 8 cm. The median hospital stay was 3 days (2-10). The pathologic examination showed 15 Wilms' tumors, one clear cell sarcoma and one TFE3 renal cell carcinoma. With a median follow-up of 42 months (range 12 and 77 months) after laparoscopic radical nephrectomy, 15 children had no oncological complications (port site or local recurrence, pulmonary metastasis) and one had a local recurrence without intraoperative tumoral rupture. The child with TFE3 renal cell carcinoma died 4 years after surgery from brain and lung metastases without local recurrence. No small bowel obstruction occurred. Radical nephrectomy in children for Wilms' tumor or other renal cancer can be safely performed laparoscopically and our indications can be summarized, for trained laparoscopic surgeons, by small tumors under about 8 cm diameter, especially without crossing the lateral edge of the vertebra on the CT scan at the time of surgery.Journal of pediatric urology 11/2013; 10(3). DOI:10.1016/j.jpurol.2013.11.005 · 1.41 Impact Factor