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Der Urologe

, Volume 54, Issue 12, pp 1784–1791 | Cite as

Aktuelle chirurgische Behandlungskonzepte beim Wilms-Tumor

Ein Update
  • J. FuchsEmail author
Urologische Forschung

Zusammenfassung

Hintergrund

Die multimodalen Behandlungskonzepte beim Wilms-Tumor haben in den letzten 50 Jahren zu einer eindrucksvollen Verbesserung der stadienunabhängigen Überlebensraten auf > 90 % geführt. Die aktuellen Herausforderungen sind v. a. die noch unzureichenden Therapieergebnisse von Kindern mit Hochrisikotumoren aber auch Tumorrezidiven.

Material und Methode

Das Manuskript stellt die aktuellen chirurgischen Konzepte als eine essentielle Therapiesäule der Behandlung von Wilms-Tumoren dar. Grundlage für den Reviewartikel bildet eine selektive Literaturrecherche mit Fokussierung auf die letzten 5 Jahre.

Ergebnisse

In der Behandlung des unilateralen Wilms-Tumors werden mit der nierenerhaltenden Tumorresektion analoge Behandlungsergebnisse wie mit der konventionellen Tumornephrektomie erzielt. Das chirurgische Panel der in Europa basierten „International Society of Pediatric Oncology“ (SIOP) hat eine neue Nomenklatur für die nierenerhaltende Tumorresektion erstellt, um damit einen prospektiven Datenvergleich zu ermöglichen. Die laparoskopische Tumornephrektomie stellt einen alternativen Zugangsweg mit gleichem Outcome wie beim offenen Vorgehen dar. Bei bilateralen Tumoren ist die nierenerhaltende Chirurgie der Goldstandard. Die komplette chirurgische Resektion von Lungen- und Lebermetastasen hat einen signifikanten Einfluss auf das Überleben der Kinder.

Schlussfolgerungen

Mit der Neuauflage von nationalen und internationalen Therapieoptimierungsprotokollen sollten Guidelines für die nierenerhaltende Tumorresektion und die minimal-invasive Tumornephrektomie etabliert werden. Die Risikostratifizierung für Kinder gilt es individueller, mit dem Ziel einer Reduktion von Spätfolgen bei mindestens analogem Outcome zu gestalten. Die unbefriedigenden Überlebensraten bei Tumorrezidiven erfordern aufgrund der geringen Fallzahlen in den Einzelstudien eine internationale Kollaboration.

Schlüsselwörter

Risikostratifizierung Tumorresektion, nierenerhaltende Minimal-invasive Chirurgie Cavathrombose Metastasen 

Surgical concepts in the treatment of Wilms tumor

An update

Abstract

Background

Treatment results of Wilms tumors have been impressively improved over the past 50 years resulting in a stage-independent overall survival of greater than 90 %. However, unsatisfying treatment results still remain in children with high-risk tumors and tumor relapses.

Materials and methods

This review highlights the current concepts of Wilms tumor surgery as a cornerstone of the treatment strategy for this malignancy. A selective literature review focusing on the past 5 years served as the basis for this article.

Results

Nephron-sparing surgery is associated with an analogue outcome compared to tumor nephrectomy in unilateral Wilms tumors. The surgical panel of the International Society of Pediatric Oncology (SIOP) group has recently introduced a novel nomenclature for organ-preserving resection procedures in order to facilitate a prospective comparison of data. The minimally invasive approach represents an alternative technique with adequate outcome. In bilateral disease, nephron-sparing procedures are gold standard. Complete resection of lung and liver metastases has a significant impact on patients’ survival.

Conclusions

Surgical guidelines for nephron-sparing surgery and minimally invasive tumor nephrectomy need to be established and implemented within newly formulated treatment protocols of the different national and international treatment trials. Risk stratification of patients needs to be more individualized with the aim of reducing late effects while at least maintaining the same survival rates. The unsatisfying treatment results of tumor relapses—associated with low patient numbers within the different trials—emphasize the need for international collaboration.

Keywords

Risk stratification Nephron-sparing surgery Minimally invasive surgery Cava thrombosis Metastases 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt. J. Fuchs gibt an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Green DM (2013) The evolution of treatment for Wilms tumor. J Pediatr Surg 48(1):14–19PubMedCrossRefGoogle Scholar
  2. 2.
    Raffensperger J (2015) Max Wilms and his tumor. J Pediatr Surg 50(2):356–359PubMedCrossRefGoogle Scholar
  3. 3.
    Davidoff AM (2012) Wilms tumor. Adv Pediatr 59(1):247–267PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Furtwangler R, Nourkami N, Alkassar M et al (2011) Update on relapses in unilateral nephroblastoma registered in 3 consecutive SIOP/GPOH studies – a report from the GPOH-nephroblastoma study group. Klin Padiatr 223(3):113–119PubMedCrossRefGoogle Scholar
  5. 5.
    Ko EY, Ritchey ML (2009) Current management of Wilms‘ tumor in children. J Pediatr Urol 5(1):56–65PubMedCrossRefGoogle Scholar
  6. 6.
    Fuchs J, Kienecker K, Furtwangler R et al (2009) Surgical aspects in the treatment of patients with unilateral wilms tumor: a report from the SIOP 93-01/German Society of Pediatric Oncology and Hematology. Ann Surg 249(4):666–671PubMedCrossRefGoogle Scholar
  7. 7.
    Schenk JP, Schrader C, Zieger B et al (2006) Reference radiology in nephroblastoma: accuracy and relevance for preoperative chemotherapy. Rofo 178(1):38–45PubMedCrossRefGoogle Scholar
  8. 8.
    Schenk JP, Graf N, Gunther P et al (2008) Role of MRI in the management of patients with nephroblastoma. Eur Radiol 18(4):683–691PubMedCrossRefGoogle Scholar
  9. 9.
    Dome JS, Perlman EJ, Graf N (2014) Risk stratification for wilms tumor: current approach and future directions. Am Soc Clin Oncol Educ Book 2014:215–223CrossRefGoogle Scholar
  10. 10.
    Kieran K, Anderson JR, Dome JS et al (2013) Is adrenalectomy necessary during unilateral nephrectomy for Wilms Tumor? A report from the Children’s Oncology Group. J Pediatr Surg 48(7):1598–1603PubMedCrossRefGoogle Scholar
  11. 11.
    Warmann SW, Godzinski J, Van TH et al (2014) Minimally invasive nephrectomy for Wilms tumors in children – data from SIOP 2001. J Pediatr Surg 49(11):1544–1548PubMedCrossRefGoogle Scholar
  12. 12.
    Shamberger RC, Guthrie KA, Ritchey ML et al (1999) Surgery-related factors and local recurrence of Wilms tumor in National Wilms Tumor Study 4. Ann Surg 229(2):292–297PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Green DM, Donckerwolcke R, Evans AE, D’Angio GJ (1995) Late effects of treatment for Wilms tumor. Hematol Oncol Clin North Am 9(6):1317–1327PubMedGoogle Scholar
  14. 14.
    Lee JS, Padilla B, Dubois SG et al (2015) Second malignant neoplasms among children, adolescents and young adults with Wilms tumor. Pediatr Blood Cancer 62(7):1359–1364Google Scholar
  15. 15.
    Nourkami N, Furtwangler R, Alkassar M, Graf N (2009) Secondary neoplasms after Wilms‘ tumor in Germany. Strahlenther Onkol 185(Suppl 2):11–12PubMedCrossRefGoogle Scholar
  16. 16.
    Paulino AC, Wen BC, Brown CK et al (2000) Late effects in children treated with radiation therapy for Wilms‘ tumor. Int J Radiat Oncol Biol Phys 46(5):1239–1246PubMedCrossRefGoogle Scholar
  17. 17.
    Cozzi F, Schiavetti A, Bonanni M et al (1993) Enucleative surgery for stage I nephroblastoma with a normal contralateral kidney. J Urol 156(5):1788–1791CrossRefGoogle Scholar
  18. 18.
    Godzinski J, Graf N, Audry G (2014) Current concepts in surgery for Wilms tumor – the risk and function-adapted strategy. Eur J Pediatr Surg 24(6):457–460PubMedCrossRefGoogle Scholar
  19. 19.
    Luithle T, Szavay P, Furtwangler R et al (2007) Treatment of cystic nephroma and cystic partially differentiated nephroblastoma – a report from the SIOP/GPOH study group. J Urol 177(1):294–296PubMedCrossRefGoogle Scholar
  20. 20.
    Wilde JC, Aronson DC, Sznajder B et al (2014) Nephron sparing surgery (NSS) for unilateral wilms tumor (UWT): the SIOP 2001 experience. Pediatr Blood Cancer 61(12):2175–2179PubMedCrossRefGoogle Scholar
  21. 21.
    Cozzi DA, Ceccanti S, Cozzi F (2014) RE: long-term renal outcome in adolescent and young adult patients nephrectomized for unilateral Wilms tumor. Pediatr Blood Cancer 61(9):1715PubMedCrossRefGoogle Scholar
  22. 22.
    Godzinski J, Van Tinteren H, Kraker J de et al (2014) Nephroblastoma: does the decrease in tumor volume under preoperative chemotherapy predict the lymph nodes status at surgery? Pediatr Blood Cancer 57(7):1266–1269CrossRefGoogle Scholar
  23. 23.
    Fuchs J, Schafbuch L, Ebinger M et al (2014) Minimally invasive surgery for pediatric tumors – current state of the art. Front Pediatr 2:48PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Fuchs J (2015) The role of minimally invasive surgery in pediatric solid tumors. Pediatr Surg Int 31(3):213–228PubMedCrossRefGoogle Scholar
  25. 25.
    Varlet F, Petit T, Leclair MD et al (2014) Laparoscopic treatment of renal cancer in children: a multicentric study and review of oncologic and surgical complications. J Pediatr Urol 10(3):500–505PubMedCrossRefGoogle Scholar
  26. 26.
    Chui CH, Lee AC (2011) Peritoneal metastases after laparoscopic nephron-sparing surgery for localized Wilms tumor. J Pediatr Surg 46(3):e19–e21PubMedCrossRefGoogle Scholar
  27. 27.
    Hamilton TE, Shamberger RC (2012) Wilms tumor: recent advances in clinical care and biology. Semin Pediatr Surg 21(1):15–20PubMedCrossRefGoogle Scholar
  28. 28.
    Hamilton TE, Ritchey ML, Haase GM et al (2011) The management of synchronous bilateral Wilms tumor: a report from the National Wilms Tumor Study Group. Ann Surg 253(5):1004–1010PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Hubertus J, Gunther B, Becker K et al (2015) Development of hypertension is less frequent after bilateral nephron sparing surgery for bilateral Wilms tumor in a long-term survey. J Urol 193(1):262–266PubMedCrossRefGoogle Scholar
  30. 30.
    Kieran K, Davidoff AM (2015) Nephron-sparing surgery for bilateral Wilms tumor. Pediatr Surg Int 31(3):229–236PubMedCrossRefGoogle Scholar
  31. 31.
    Fuchs J, Wunsch L, Flemming P et al (1999) Nephron-sparing surgery in synchronous bilateral Wilms‘ tumors. J Pediatr Surg 34(10):1505–1509PubMedCrossRefGoogle Scholar
  32. 32.
    Fuchs J, Szavay P, Seitz G et al (2011) Nephron sparing surgery for synchronous bilateral nephroblastoma involving the renal hilus. J Urol 186(4):1430–1436PubMedCrossRefGoogle Scholar
  33. 33.
    Shamberger RC, Haase GM, Argani P et al (2006) Bilateral Wilms‘ tumors with progressive or nonresponsive disease. J Pediatr Surg 41(4):652–657PubMedCrossRefGoogle Scholar
  34. 34.
    Kieran K, Williams MA, Dome JS et al (2013) Margin status and tumor recurrence after nephron-sparing surgery for bilateral Wilms tumor. J Pediatr Surg 48(7):1481–1485PubMedCrossRefGoogle Scholar
  35. 35.
    Daum R, Roth H, Zachariou Z (1994) Tumor infiltration of the vena cava in nephroblastoma. Eur J Pediatr Surg 4(1):16–20PubMedCrossRefGoogle Scholar
  36. 36.
    Shamberger RC, Ritchey ML, Haase GM et al (2001) Intravascular extension of Wilms tumor. Ann Surg 234(1):116–121PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Szavay P, Luithle T, Semler O et al (2004) Surgery of cavoatrial tumor thrombus in nephroblastoma: a report of the SIOP/GPOH study. Pediatr Blood Cancer 43(1):40–45PubMedCrossRefGoogle Scholar
  38. 38.
    Bader MI, Abdelaal K, Rogers T, Arul SG (2013) A surgical approach to Wilms‘ tumour with retrohepatic vena caval extension. Pediatr Surg Int 29(3):229–232PubMedCrossRefGoogle Scholar
  39. 39.
    Schettini ST, Fonseca JH da, Abib SC et al (2000) Management of Wilms‘ tumor with intracardiac extension. Pediatr Surg Int 16(7):529–532PubMedCrossRefGoogle Scholar
  40. 40.
    Ehrlich PF, Ferrer FA, Ritchey ML et al (2009) Hepatic metastasis at diagnosis in patients with Wilms tumor is not an independent adverse prognostic factor for stage IV Wilms tumor: a report from the Children’s Oncology Group/National Wilms Tumor Study Group. Ann Surg 250(4):642–648PubMedPubMedCentralGoogle Scholar
  41. 41.
    Szavay P, Luithle T, Graf N et al (2006) Primary hepatic metastases in nephroblastoma – a report of the SIOP/GPOH Study. J Pediatr Surg 41(1):168–172PubMedCrossRefGoogle Scholar
  42. 42.
    Fuchs J, Szavay P, Luithle T et al (2008) Surgical implications for liver metastases in nephroblastoma – data from the SIOP/GPOH study. Surg Oncol 17(1):33–40PubMedCrossRefGoogle Scholar
  43. 43.
    Fuchs J, Seitz G, Handgretinger R et al (2012) Surgical treatment of lung metastases in patients with embryonal pediatric solid tumors: an update. Semin Pediatr Surg 21(1):79–87PubMedCrossRefGoogle Scholar
  44. 44.
    Verschuur A, Van TH, Graf N et al (2012) Treatment of pulmonary metastases in children with stage IV nephroblastoma with risk-based use of pulmonary radiotherapy. J Clin Oncol 30(28):3533–3539PubMedCrossRefGoogle Scholar
  45. 45.
    Warmann SW, Furtwangler R, Blumenstock G et al (2011) Tumor biology influences the prognosis of nephroblastoma patients with primary pulmonary metastases: results from SIOP 93-01/GPOH and SIOP 2001/GPOH. Ann Surg 254(1):155–162PubMedCrossRefGoogle Scholar
  46. 46.
    Warmann SW, Nourkami N, Fruhwald M et al (2012) Primary lung metastases in pediatric malignant non-Wilms renal tumors: data from SIOP 93-01/GPOH and SIOP 2001/GPOH. Klin Padiatr 224(3):148–152PubMedCrossRefGoogle Scholar
  47. 47.
    Ha TC, Spreafico F, Graf N et al (2013) An international strategy to determine the role of high dose therapy in recurrent Wilms‘ tumour. Eur J Cancer 49(1):194–210PubMedCrossRefGoogle Scholar
  48. 48.
    Ehrlich PF, Anderson JR, Ritchey ML et al (2013) Clinicopathologic findings predictive of relapse in children with stage III favorable-histology Wilms tumor. J Clin Oncol 31(9):1196–1201PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Lall A, Pritchard-Jones K, Walker J et al (2006) Wilms‘ tumor with intracaval thrombus in the UK Children’s Cancer Study Group UKW3 trial. J Pediatr Surg 41(2):382–387PubMedCrossRefGoogle Scholar
  50. 50.
    Shamberger RC, Ritchey ML, Haase GM et al (2001) Intravascular extension of Wilms tumor. Ann Surg 234(1):116–121PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  1. 1.Abteilung für Kinderchirurgie und KinderurologieUniversitätsklinikum TübingenTübingenDeutschland

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