Prognostic impact of pre‐referral tumor resection in unilateral Wilms tumor: A single‐institute experience from a lower middle‐income country

Abstract

IntroductionThe objectives of this study were to evaluate the prognostic impact of pre‐referral surgical resection of Wilms tumor (WT) performed at non‐oncology centers, and to strategize an improved care plan for this very curable pediatric tumor.MethodsIn this study conducted in a large pediatric cancer center in Pakistan, we retrospectively reviewed the electronic medical records (EMR) of 149 patients with unilateral WT from September 2008 to August 2017. Based on treatment approach, patients were categorized into two groups: (i) pre‐referral tumor resection (PTR: n = 75), and (ii) post‐neoadjuvant chemo nephrectomy (PCN: n = 74).ResultsThe proportion of metastatic disease in PTR and PCN groups was 33.3% and 35.1%, respectively. In the PTR subset, median time to admission after PTR was 5 weeks (mean 11, SEM 2.8, range: 2–202) weeks, with 53.3% (n = 40) presenting more than 4 weeks after PTR. Twenty patients had no cross‐sectional imaging prior to PTR and underwent surgery after abdominal ultrasound only. On baseline imaging at our center, 58.7% (n = 44) of the PTR group had radiologically evaluable disease (four metastases only, 19 local residual tumor only, 21 both localized tumor and visible metastases). Disease staging was uncertain in 23 patients because of no or inadequate histology specimens and/or lymph node sampling in patients with no evaluable disease. Statistically significant differences were recorded for the two subsets regarding tumor volume, extent and nodularity, renal vein and renal sinus involvement, lymph node status, tumor rupture and histopathologic features, and tumor stage, with a 10‐year event‐free survival (EFS) for PCN and PTR of 74.3% and 50.7%, respectively (p < .001). In the PTR group, EFS for those presenting within 4 weeks and later was 91.4% versus 15.0%, respectively (p < .0001).ConclusionSuboptimal pre‐referral surgical intervention results in poor survival outcomes in unilateral WT. Our findings highlight the need for a comprehensive action plan for educating healthcare professionals engaged in WT diagnosis and referral process. PCN in a multidisciplinary team approach can reduce surgical morbidity and seems to be a better strategy to improve the survival rates in low‐resource settings.

Comment on: Prognostic impact of pre‐referral tumor resection in unilateral Wilms tumor: A single‐institute experience from a lower middle‐income country

“…pre-referral surgical resection of unilateral WT and concluded that the suboptimal pre-referral surgical intervention with no preoperative chemotherapy and delayed chemotherapy following the surgical resection led to poor survival outcomes in unilateral WT. 1 I would like to highlight some issues and propositions for this study while I applaud and congratulate the authors for their highly comprehensive and valuable study.…”