# Wilms Tumor Protocol Violations: Practice Gap discussion at Update Course 2018 — GCMD Library

At the 6th Annual Pediatric Surgery Update Course, Drs Charles Snyder, Craig Lillehei and David Powell discussthe top ten practice gaps of 2018. Here they discuss Wilms Tumor Protocol violations, focusing on ipsilateral lymph node sampling, disease staging, when to perform partial nephrectomies, and when primary nephrectomies are contraindicated.

Type: video · 9 min · posted 2018-09-16
Canonical: https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345

## Chapters
- [0:01](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=1) Case Presentation and Audience Polling
- [1:52](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=112) Lymph Node Sampling Requirement and Protocol Differences
- [4:33](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=273) Management of Pulmonary Metastases
- [7:12](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=432) Resolution Criteria and Educational Impact

## Statements
- "When doing a nephrectomy for Wilms tumor, lymph nodes must be sampled according to protocols" (guideline) [1:54](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=114)
- "If lymph nodes are not documented as histologically negative, they are assumed to be positive, which bumps up the stage and requires increased chemotherapy" (guideline) [2:01](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=121)
- "Failure to sample lymph nodes during Wilms nephrectomy is an identified practice gap by the Cancer Committee and COG publications" (epidemiological) [2:19](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=139)
- "The management approach is based on US protocols as opposed to European SIOP protocols" (guideline) [2:30](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=150)
- "In Hong Kong, they tend to go with the American protocol for Wilms tumor but use either European or American protocols for various other tumors" — Ken Wong (clinical) [3:23](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=203)
- "Just because you have metastatic disease in the lung doesn't mean you shouldn't treat the primary with a nephrectomy" (guideline) [4:07](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=247)
- "Primary nephrectomy changes whether or not the patient will get radiation therapy" (clinical) [4:20](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=260)
- "There is a local stage for Wilms tumor and a patient staging for Wilms tumor" (clinical) [4:26](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=266)
- "On the ACS pediatric surgery blog, overwhelmingly the presence of lymph node mets meant people did biopsy and chemotherapy, which is incorrect" (epidemiological) [4:33](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=273)
- "Regardless of pulmonary metastatic disease, if you think you have a primary that can come out without removing other organs, you should do that because it decreases radiation therapy" (guideline) [4:44](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=284)
- "The child will get metastatic stage 4 chemotherapy no matter what, but biopsy counts as local spillage and requires radiation therapy to the flank or abdomen" (clinical) [5:04](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=304)
- "You should treat local disease differently than systemic disease" (guideline) [5:17](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=317)
- "Whether to biopsy lung masses depends on how many are present; with multiple lesions, a correct assumption of metastatic disease can be made" (clinical) [5:20](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=320)
- "Oncologists want measurable disease to see if it responds to chemotherapy" (clinical) [5:45](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=345)
- "If you treat the patient and lung nodules go away, you presume that is metastatic disease; if there is a residual nodule after treatment, that is an indication to resect it" — Dan (clinical) [6:03](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=363)
- "Previously, if a nodule wasn't present on plain film, it didn't matter even if seen on CT, but now CT is the diagnostic test of choice and impacts therapy" — Dan (clinical) [6:24](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=384)
- "For single nodules, patients are treated and if the nodule resolves, it is presumed to be metastatic Wilms tumor" — Dan (clinical) [6:41](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=401)
- "There are radiographic criteria for single nodules; if it looks like a met you treat it, if it doesn't look like a met you can biopsy it to prove it's not a met and avoid chemotherapy" (clinical) [6:54](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=414)
- "What you avoid with nodule resolution is radiation therapy to the lungs, not chemotherapy" — Dan (clinical) [7:12](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=432)
- "If after 6 weeks lung nodules have resolved regardless of number, there is no radiation to the lungs" — Dan (clinical) [7:18](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=438)
- "To avoid radiation, lung nodules have to disappear; if there is a residual nodule you don't know if it's scar or active tumor and have to biopsy" — Dan (clinical) [7:43](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=463)
- "Nodules have to resolve to avoid radiation therapy" — Dan (clinical) [7:58](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=478)
- "In SIOP protocols, they do a percutaneous biopsy of the tumor and treat with chemotherapy" (guideline) [8:01](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=481)
- "APSA has addressed the lymph node sampling practice gap through expert questions, educational efforts at annual meetings, and the American College of Surgeons registry has seen improvement with fewer patients getting nephrectomies without lymph node sampling" (epidemiological) [9:29](https://library.globalcastmd.com/watch/wilms-tumor-protocol-violations-practice-gap-discussion-at-update-course-2018-345?t=569)

## Transcript
A 2 year old, otherwise asymptomatic female presents with a unilateral 10 centimeter renal tumor in the left kidney. In addition to identifying the renal mass, computerized tomography reveals multiple lesions in both lungs. The next best step in management of this patient with a metastatic renal tumor is. Open, we're hearing lots of hums up here already. We haven't even talked about the open renal and lung biopsy. Renal biopsy followed by adjuvant chemotherapy. Left total nephroureterectomy, left total nephroureterectomy with retroperal lymph node sampling, and left partial nephrectomy. I'll say that this is a practice gap that's been identified not just by the Absent Cancer Committee, but documented in the literature as well. You go right to the answer or give it a little, you're watching the polls. Well, what's fun about the polls is when you first look at the polls here in our studio yeah, we're 30 seconds ahead. So what you see is a sampling of people in this room, and then if you wait about 30 seconds, you see the rest of the world and the polls always change. So the wisdom of the group is wisdom of the crowd here. David, I recall doing the nephroureterectomy and making a hole in the diaphragm and biopsying. Or taking out lung lesions, closing the. Well, well, we can, we can have that discussion too. That's there are going to be two kind of learning points for this question. I think we're far enough along. It's pretty split. Yeah. Half the audience, half the audience said left nephro left nephroureterectomy with lymph node sampling, and the other half said renal biopsy followed by adjuvant chemotherapy. So let's, as I said, there's kind of two learning objectives here. The first is that When you're doing a nephrectomy for Wilm's tumor, you have to sample lymph nodes. You just have to. According to the protocols, if you don't document histologically negative lymph nodes, they're kind of assumed to be positive, that bumps up the stage, and that requires chemotherapy or increases your chemotherapy for that. So you really need to take lymph nodes if you're going to do a nephrectomy for Wilms tumor. That's an identified practice gap, as I say, by the Cancer Committee, by the COG publications, and that just needs to change. It's not that big a deal. I think it's important to mention though that. This question is based in the US with our protocols as opposed to to Europe where colleagues have PIO and there may be other organizations. So anyway, it's I'd be interested in follow up on a tumor this size for those who are on psyop protocols so they do differently. The other learning objective I think they biopsy everything. I think I don't, I never hear back. I don't know. Ask. Let's ask. I don't know. Did Davenport ever comevan still on the. I would love to get, uh, so David or Giovanna or Ken, actually, I'm curious, uh, your thoughts on this question. So let's first start with uh Ken Wong. For this, uh, for this kid, I, I would be with the specialist, uh, taking the kidney out and also do the lymph node sampling. Um, so on, on Wilms tumor, we tend to go with the Americans sort of protocol, but we in Hong Kong, with various tumors, we, we, uh, we go with either Europeans or Americans. We don't stick with one group or the other group. So we just But this one Americans. OK. All right, David. Uh, I have to admit I don't do oncology, but, uh, I think I would go for a biopsy and lymph node. OK. All right, so I, I, I guess the problem I had with the question was that if they've got uh Lymph node sampling if they already have meds in the lung. Excellent segue. So the other, the second learning point here is that just because you have lymph nodes, or you have metastatic disease in the lung doesn't mean you shouldn't treat the primary with a nephrectomy. Because that changes whether or not you're going to get radiation therapy as well. So as Dr. Ehrlich would point out, there's kind of a local stage for Wilms's tumor, and then there's a patient staging for Wilms's tumor. And this a question just like this came up on the ACS pediatric surgery blog, and overwhelmingly the presence of lymph node mets meant people did biopsy. And and chemotherapy, which is incorrect, regardless of the presence of pulmonary metastatic disease, if you think you have a primary that can come out without removing other organs, you should do that as well because it decreases the radiation therapy and the lymph node and the lung that's probably will get treated. Correct, chemotherapy. The child's going to get the metastatic stage 4 chemo no matter what, but it changed once you do the biopsy, then that counts as local spillage and you require radiation therapy, you know, to the flank of the abdomen depending on what happens. So you should treat the local disease different than the systemic. What happened to the Uh, idea that you need to biopsy with the lung masses depends on my, my impression is to confirm that there's metastatic depend depends on how many are there. This child had multiple, so I think they can make a, make a correct, correct assumption that's a meth. And what, what Mac was getting at, what if you have 11 in the lower lobe in the lower lobe. Well, and what the, what the oncologists want is measurable disease to see if it responds to chemotherapy. What the surgeons kind of want is to document it or to get it out. So I'm not sure I know the right answer to that. Treat the patient and they go away, then you presume that that's metastatic disease. If you treat them and there's a residual nodule, then that's an indication to go resect that. How about for just one nodule, for just even with just one nodule, you treat it without a biopsy, and it's CT CT persistence. Right or not. Yeah, and right, so we used to say if it wasn't present on a plane film, you didn't care about it. It wasn't present even if you saw something on CT, but now I believe CT is the diagnostic test of choice. And so that impacts your therapy. The single nodule question is a good one. I don't want to misinform people on what that is, but I believe that um. That those patients are treated and if it resolves, then you presume that that was metastatic Wilm's tumor. When I last discussed this with Dr. Shamberger, there were not specific, but there were radiographic criteria for that single nodule. And if you thought, if it looked like a met. You just. If it didn't look like a met, you could biopsy it, prove that it was not a met, and that avoided the chemotherapy. Well, I think to everybody's previous comment, what you, what you avoid is the radiation therapy to the lungs. So if after 6 weeks, the lung nodules have resolved regardless of how many there are, then you don't give, there is no radiation to the lungs. And Dan, actually I want to, so I have a question for you, and then Giovanna had a comment when they do. Resolve after chemotherapy, do they leave a scar that you still end up needing to biopsy, or do they usually just disappear? Typically, I mean in order to avoid radiation, they have to disappear. If there's residual nodule, then you don't know whether it's a scar or active tumor. Then you have to biopsy. So if it goes substantially or you just or they just continue on with therapy and they get the radiation therapy. They have to resolve to avoid the radiation therapy. Giovanna just wanted to reiterate that in psyop they do a percutaneous biopsy and treat with chemotherapy, which is Of the tumor or of the lung the tumor of the tumor itself. Very good. Who's next? Do we cover all the take-home points. Yeah, that's a great point. So what's the, what's the, the tweet? Two take-home points are, uh, if you're doing a nephrectomy for William's tumor, remember to take lymph nodes and that there is both a local and a systemic staging in the United States. And just because there's pulmonary metastases doesn't mean you shouldn't do a primary nephrectomy. Yeah, I think I would and you wouldn't biopsy the, the, um, lung nodules, you say that last part again. If there is a, uh, Dave, what you just said, you're the last part of so that the presence of pulmonary metastasis should not in the United States should not prevent you from doing a primary nephrectomy. Just because of that metastatic disease, if you think you can take it out without taking out other organs. Yeah, and uh a little plug for uh Peter Ehrlich did a great podcast on Wilm's tumor and it's, if you go, we can, it's actually, we can give you the link to that and you can listen to it. He goes into great detail in exactly this point. So, uh. I'll find the link right now and post it. I will share that this has been something that APSA has hit really hard with expert questions and NAT and trying to do things at annual meetings, and I've been informed that the college has the American College of Surgeons is kind of keeping track of the registry stuff here and has seen some improvement in, has seen fewer patients getting nephrectomies without lymph node sampling since we started doing some of these educational efforts. Our next question.

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Not medical advice · citation policy: https://library.globalcastmd.com/ai