Oncologic Fidelity of Minimally Invasive Surgery to Resect Neoadjuvant-Treated Wilms Tumors

Abstract

Background The Children's Oncology Group recommends upfront resection of Wilms tumor (WT), however, unique scenarios warrant neoadjuvant chemotherapy and delayed resection. We hypothesized that in the context of neoadjuvant chemotherapy, minimally invasive surgery (MIS) to resect WT achieves equivalent oncologic fidelity and better maintains therapy schedules. Methods A retrospective analysis of WT treated between 2010-2021 at a free-standing children's hospital was performed. Patient and disease specific characteristics were collected, and pre-resection tumor volumes (TV) were calculated. Impact of MIS or open resection on oncologic fidelity and time to resume chemotherapy was analyzed. Results For the study period, 62 patients were treated for 65 WT, and 14 patients (22.6%) received neoadjuvant chemotherapy to treat 17 WT (26.2%): 7 Stage I (all predisposition syndromes), 2 stage III, 7 stage IV, and 1 stage V (bilateral). MIS was utilized to resect 6 WT from 5 patients. For partial nephrectomy, pre-resection TV was 0.38 ml if MIS and 10.38 ml if open ( P = .025). For radical nephrectomy, pre-resection TV was 31.58 ml if MIS and 175.00 ml if open ( P = .101). No significant differences between surgical approach were detected regarding pathologic variables or survival. Epidural use was significantly greater with open procedures ( P = .001). Length of stay was 2.00 days after MIS compared to 6.00 for open resection ( P = .004). Time to resume chemotherapy was 7.00 days after MIS versus 27.00 for open ( P = .004). Conclusion After neoadjuvant chemotherapy for WT, MIS partial and radical nephrectomies achieved equivalent oncologic fidelity, reduced epidural use and post-operative stays, and better maintained adjuvant therapy timelines when compared to open resections.

Systematic Review and Meta-analysis of Laparoscopic Versus Open Radical Nephrectomy for Paediatric Renal Tumours with Focus on Wilms’ Tumour

“…The conviction that laparoscopic resection of solid tumors is associated with reduced surgical morbidity in children is mainly based on evidence from adults, as randomized controlled studies are lacking in children; 47,48 however, adults have different physiology resulting in slower recovery after open surgery, as well as different tumor biology and treatment, making this extrapolation unreliable. 47,48 Reported results from comparisons of perioperative complications, [5][6][7]9,14,27,29,30 as well as recovery time, 6,7,9,14,27,29 between LRN and ORN for pediatric RT differ. Also, the degree of bias in these results due to the lack of postoperative care standardization in the two groups is unknown, considering the known tendency for less nasogastric drainage and opioid use and for earlier discharge after laparoscopic surgery.…”

“…Feasibility of laparoscopic approaches to pediatric RT, primarily WT, has been well reported during the last decade by several groups, with the main proposed benefits being: faster recovery (and hence earlier onset of adjuvant treatment), [5][6][7][8] as well as reduced postoperative morbidity related to pain, incisional hernias and adhesive bowel obstruction. 5,[8][9][10] Results of suggested advantages vary among studies, however, and at the same time, legitimate fears about possible adverse effects on cancer-related outcomes persist.…”

“…4,5,8,11 The surgical panel of the International Society of Pediatric Oncology Renal Tumor Study Group (SIOP-RTSG) recommends that only localized central RT not extending beyond the ipsilateral border of the spinal column should be considered for laparoscopy. 1,12 These criteria were, however, challenged in practice by some groups, 9,13,14 whereas several tumor volume 6,7,14,15 and diameter 4,5,11 cutoff values have been also suggested as a guide for patient selection. A meta-analysis of reported outcomes is lacking in the literature and, therefore, the overall estimate of the benefits and risks of LRN over ORN for pediatric renal cancer is unknown.…”

Nephron sparing surgery and surgical management of intravascular extension of Wilms tumor

“…Minimally invasive surgery (MIS) is associated with lower postoperative ileus, faster recovery, and shorter time to resume chemotherapy after surgery. Although the few data available on MIS for NSS is encouraging, namely due to the previously mentioned advantages, one must be aware of the biased case selection, since most patients that received MIS had very small tumors 42 . Also, MIS for TN is also associated with inadequate lymph node sampling (LNS) and increased risk of intraoperative tumor spillage 43 …”

“…Although the few data available on MIS for NSS is encouraging, namely due to the previously mentioned advantages, one must be aware of the biased case selection, since most patients that received MIS had very small tumors. 42 Also, MIS for TN is also associated with inadequate lymph node sampling (LNS) and increased risk of intraoperative tumor spillage. 43 These techniques can assist in a successful accomplishment of NSS but further research is warranted to elucidate their exact role.…”