Università di Roma La Sapienza

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1 Università di Roma La Sapienza U.O.C. Chirurgia Pediatrica - Policlinico Umberto I Direttore: Prof Francesco Cozzi Chirurgia nephron-sparing per tumori renali primitivi in età pediatrica. Prof. Denis A. Cozzi

2 Background Clinical and experimental data suggest that hyperfiltration following removal of a critical mass of renal tissue causes a progressive glomerular damage. Anderson KD et al. J Urol, 1985

3 Background (cont.) Patients with a reduction of renal mass of more than 50% are at increased risk of renal failure. Novick et al. N Engl J Med, 1991

4 Aim of the study To evaluate the feasibility and safety of nephron-sparing surgery (NSS) in children with syncronous bilateral Wilms tumour (BWT).

5 Methods Review of available reports from Wilms tumour major paediatric oncology cooperative groups

6 Results of treatment for bilateral Wilms tumor Studies NWTS-1 ( ) NWTS-2/3 ( ) NWTS-4 ( ) UKCCS ( ) SIOP/Ger (1994 / 01) No. of Patients Preoperative Chemotherapy (%) Cozzi DA and Zani A. Seminars Ped Surg, 2006

7 Results of treatment for bilateral Wilms tumor Studies NWTS-1 ( ) NWTS-2/3 ( ) NWTS-4 ( ) UKCCS ( ) SIOP/Ger (1994 / 01) No. of Patients No. of kidneys receiving NSS (%) Cozzi DA and Zani A. Seminars Ped Surg, 2006

8 Results of treatment for bilateral Wilms tumor Overall survival rate (%) NWTS-1 Mean follow-up (years) NWTS-2 and NWTS UKCCS SIOP/Ger Cozzi DA and Zani A. Seminars Ped Surg, 2006

9 Results of treatment for bilateral Wilms tumor Studies NWTS-1 ( ) NWTS-2/3 ( ) NWTS-4 ( ) UKCCS ( ) SIOP/Ger (1994 / 01) No. of Patients Nephrectomy No. patients (%) Cozzi DA and Zani A. Seminars Ped Surg, 2006

10 Conclusion In children with syncronous BWT, NSS does not impair the excellent outcome. Cozzi DA and Zani A. Seminars Ped Surg, 2006

11 Conclusion (cont.) Nearly half of the patients remain with less than 50% of renal parenchyma. Cozzi DA and Zani A. Seminars Ped Surg, 2006

12 Implication A more aggressive NSS approach seems justified. Cozzi DA and Zani A. Seminars Ped Surg, 2006

13 Background The major emphasis of both the NWTSG and SIOP is reducing the morbidity of treatment for low-risk patients while maintaining the excellent survival rate.

14 Background Nephron-sparing surgery for children with unilateral renal tumour and normal contralateral kidney is a controversial issue. In nephrectomized children, the risk of renal failure due to hyperfiltration is considered low.

15 Wilms tumor : survival rate (SIOP-9: ) 100% 80% 60% 40% 20% I fav. I stand/ana. II N0 IIN1+III IV unfav. 0% Months

16 Adults after partial removal of a solitary kidney g/day 3 Urinary protein p = ± ± ± 4 Amount of kidney remaining (%) Novick et al. N Engl J Med, 1991

17 Adults after partial removal of a solitary kidney g/day 3 Urinary protein 2 1 p = ± 2 81 ± ± 46 Follow-up (months) Novick et al. N Engl J Med, 1991

18 Long-term follow-up of patients undergone unilateral nephrectomy in childhood Creatinine clearance (ml/min/1.73m 2 ) p =N.S Interval since nephrectomy (years) Robitaille et al. Lancet, 1985

19 Adults born with unilateral agenesis or nephrectomized in childhood GFR (ml/1.73m 2 /min) Urinary albumin (µg/1.73m 2 /min) Follow-up (years) Wikstad et al. Pediatr Nephrol, 1988

20 Longitudinal changes of postoperative serum creatinine standard deviation scores (Values are Means ± SE) Serum creatinine SDS r 2 =0.49 p= Follow-up (years) Cozzi F et al. J Urol, 2005

21 Enucleative Surgery for Stage I Nephroblastoma With a Normal Contralateral Kidney. Cozzi F et al. J Urol, 1996

22 Nephron-Sparing Surgery for Unilateral Primary Renal Tumour in Children. Cozzi DA et al. J Ped Surg, 2001

23 Patient characteristics Unilateral primary renal tumours (37 children) (January 1992 August 2006) Nephrectomy Nephron-sparing surgery No of patients 26 No of patients 11 All stages Stage I Event-free Survival 85 % Event-free Survival 100 % Mean follow-up 8 yrs Mean follow-up 8 yrs

24 Nephron-Sparing Surgery Chemotherapy Pre-operative Two-drug regimen (SIOP) Post-operative : Three-drug regimen : Two-drug regimen

25 Nephron-Sparing Surgery Procedures No. of patients 11 No. of tumour enucleation 7 No. of partial nephrectomy 5

26 LT (46%) RT (54%)

27 LT (57%) RT (43%)

28 Oncocitoma LT (40%) RT (60%)

29 LT (62%) RT (38%)

30 LT (62%) RT (38%)

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32 LT (31%) RT (69%)

33 Cozzi F et al. J Urol, 2003 LT 25% RT 75%

34 DMSA uptake of kidney remnant after NSS Split renal function (%) mos. 5.6 yrs. Mean Follow-up BAPS Meeting, Dublin 2005

35 DMSA uptake of kidney remnant after NSS Split renal function (%) mos. 5.6 yrs. Mean Follow-up p= n.s. BAPS Meeting, Dublin 2005

36 Ultrasound measured renal volume and DMSA measured renal function Split renal volume (%) r 2 = 0.81 p = Split renal function (%) BAPS Meeting, Dublin 2005

37 Conclusion (i) Following NSS, split renal function of the affected kidney remnant is satisfactory, stable, and well correlated with split renal volume. BAPS Meeting, Dublin 2005

38 Renal function and blood pressure measurements following surgery (Values are Means ± SD) Nephrectomy (16 patients) NSS (10 patients) p value Post-surgery interval (months) 71.9± ± Creatinine (mg/dl) 0.79± ± Systolic pressure (mmhg) 112.5± ±9.1 <0.001 Dyastolic pressure (mmhg) 72.5± ± Creatinine SDS 1.27± ± Systolic pressure SDS 0.72± ± Dyastolic pressure SDS 0.87± ± Cozzi F et al. J Urol, 2005

39 Conclusion (ii) Ablative renal surgery is followed by a progressive renal dysfunction. Nephron sparing surgery has a renal function advantage over nephrectomy. Cozzi F et al. J Urol, 2005

40 Nephron-sparing surgery in children with unilateral renal tumour: a systematic literature review. SIOP Meeting, Geneve 2006

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43 Aim of the study To evaluate the oncological risk of NSS in children with primary renal tumour and normal contralateral kidney.

44 Methods Comprehensive review of the Literature: Electronic search (MEDLINE, OVID, EMBASE) Hand-search (reference lists of articles, abstracts from conference proceedings)

45 Patients ( ) No. of eligible studies 20 No. of collected patients 124

46 Japan India Patient per country Italy Poland Austria The Netherlands Switzerland France USA Canada New Zeland Australia Germany Portugal No. of patients

47 Results Overall No. of patients 124 Local recurrence 7 (5.6%) Survival rate 95.1 % Follow-up (mean) 4 yrs

48 Benign or low-risk Wilms tumours No. of patients 17 Local recurrence 0 Survival rate 100 % Follow-up (mean) 3.6 yrs

49 Benign or low-risk Wilms tumours No. of patients Cystic partially differentiated nephroblastoma 7 Cystic nephroma 5 Congenital mesoblastic nephroma 4 Oncocytoma 1

50 Stage I Intermediate-risk Wilms tumour No. of patients 60 Local recurrence 4 (6.6 %) Survival rate 98.3 % Follow-up (mean) 4 yrs

51 Patients at increased risk of metachronous Wilms tumour No. of patients Hyperplastic nephroblastomatosis 4 Beckwith-Wiedemann syndrome 2 Hemihypertrophy 1 Aniridia, hypospadias, cryptorchidism 1

52 Intermediate-risk Wilms tumour (no data on staging) No. of patients 32 Local recurrence 0 Survival rate 94 % Follow-up -

53 High-risk or stage II / III Intermediate- risk Wilms tumour No. of patients 15 Local recurrence 3 (20%) Survival rate 80 % Follow-up -

54 NSS for unilateral Wilms tumour: pre-op chemotherapy No. of patients Benign / Low-risk WT Intermediate / High-risk WT 0 Preoperative chemotherapy Primary surgery

55 NSS and pre-op chemotherapy for Wilms tumour in horseshoe kidneys 40 No. of patients P =0.04 Primary surgery Preoperative chemotherapy 0 Complete nephrectomy Partial nephrectomy Neville H et al. JPS 2002

56 Conclusion (iii) In children with benign or low / intermediate- risk histology stage I WT and a normal opposite kidney, the oncological risk of NSS is low, probably because histology and staging are related to the biology of the tumour.

57 Implication A prospective trial of less aggressive intervention should be considered for select patients with unilateral WT and normal opposite kidney. Ross J, Cleveland, Ohio Zani A et al. J Urol Mar;173(3):946-8; discussion 948

58 Grazie SIUP Meeting, Ischia 2007