Management of intravascular thrombus in bilateral Wilms tumor or horseshoe kidney | 4 cases Bilateral Wilms tumor: | 1 case Wilms tumor in a horseshoe kidney: | All with intravenous thrombus | Single institution | Retrospective study | Chart review 2009-2021 | All patients received 12 weeks of neoadjuvant chemotherapy | Two had a staged approach to bilateral tumors | Four underwent nephron sparing surgery | Four had tumor thrombectomy | No patients currently need dialysis | Conclusions: | Nephron sparing surgery can be used for selected cases of Wilms tumor with intravascular thrombus. | If possible, pre-op or intra-op renal venous anatomy mapping should be attempted. | When appropriate, utilize neoadjuvant chemotherapy with staged approaches to each kidney. | https://doi.org/10.1016/j.jpedsurg.2021.07.025 | Alex Halpern, MD | @EmTombash | Source: Sutthatarn P et al. | Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, United States | @StayCurrentMD | Cincinnati Children's | Journal of Pediatric Surgery
Management of Intravascular Thrombus in Bilateral Wilms Tumor or Horseshoe Kidney
Infographic · Dec 2022 · 1 min read
In brief
In brief
This retrospective study of 5 patients demonstrates that nephron-sparing surgery is feasible for bilateral Wilms tumor with intravascular thrombus using 12-week neoadjuvant chemotherapy and staged surgical approaches. Four of five patients underwent successful nephron-sparing procedures with thrombectomy, with no patients requiring renal replacement therapy during follow-up.
- 12 weeks of neoadjuvant chemotherapy enables nephron-sparing surgery in bilateral Wilms tumor with IVC thrombus in most cases
- Staged bilateral surgery (6 weeks apart) allows tumor response assessment and optimizes nephron preservation
- Complete thrombus response to chemotherapy occurred in 1/5 patients, eliminating need for thrombectomy
- Successful nephron-sparing thrombectomy requires branched renal veins or accessory vessels—preoperative mapping is critical
- All patients avoided dialysis/transplant despite CKD stage II-III in 60%, validating aggressive nephron preservation approach
Written by the GCMD Library team from the infographic.
The infographic uses a teal and white color scheme with icon-based patient representations (yellow and gray figures) to show treatment pathways. The layout flows from top to bottom, starting with case composition, followed by treatment steps illustrated with patient icons, and concluding with clinical recommendations. Kidney illustrations and a surgeon icon provide visual context for the surgical procedures discussed.
Pattamon Sutthatarn, Oswaldo Gomez Quevedo, Joesph Gleason, Andrew M. Davidoff, Andrew J. Murphy
Purpose: To describe the oncologic and surgical management of bilateral Wilms tumor or Wilms tumor arising in a horseshoe kidney with intravenous tumor thrombus to help pediatric surgeons negotiate this rare and difficult anatomic circumstance.
Methods: A single-institution, retrospective medical record review identified 4 cases of bilateral WT and one case of WT arising in a horseshoe kidney with intravenous tumor thrombus between 2009 and 2021. The presentation, imaging, chemotherapy regimen, intraoperative approach, and surgical and oncologic outcomes were reviewed for each of these patients.
Results: All patients received a total of 12 weeks of neoadjuvant chemotherapy. In two patients, a staged approach to the bilateral tumors was undertaken with the first side being operated on after six weeks of therapy and the other side undergoing surgery after an additional six weeks of therapy. Of five patients, four underwent nephron-sparing surgery of all tumors and one underwent unilateral radical nephroureterectomy with contralateral nephron-sparing surgery. Tumor thrombectomy was performed in four of five cases; one patient demonstrated a complete response of the intravenous tumor thrombus to neoadjuvant chemotherapy and did not require thrombectomy. Three patients received adjuvant flank radiotherapy. Three patients developed medically managed stage II or III chronic kidney disease and no patient required renal replacement therapy or kidney transplant to date.
Conclusion: Nephron-sparing surgery is feasible and safe to perform in selected cases of bilateral Wilms tumor with intravascular thrombus by utilizing three-drug neoadjuvant chemotherapy, staged approaches to each kidney when appropriate, and detailed preoperative and/or intraoperative mapping of renal venous anatomy. Successful nephron-sparing surgery with tumor thrombectomy is dependent on a branched renal venous system or the presence of accessory renal veins.