Treatment of Recurrent Wilms Tumor and Other Childhood Kidney Tumors
Treatment of Standard-Risk Relapsed Wilms Tumor
Treatment of High-Risk Relapsed Wilms Tumor
Treatment of Recurrent Clear Cell Sarcoma of the Kidney
Treatment Options Under Clinical Evaluation
Current Clinical Trials
Approximately 15% of patients with favorable histology Wilms tumor and 50% of patients with anaplastic Wilms tumor experience recurrence. Historically, the salvage rate for patients with recurrent favorable histology Wilms tumor was 25% to 40%. As a result of modern treatment combinations, the outcome after recurrence has increased up to 60%.[2,3] A number of potential prognostic features influencing outcome post-recurrence have been analyzed, but it is difficult to separate whether these factors are independent of each other. In addition, the following prognostic factors appear to be changing over time as therapy for primary and recurrent Wilms tumor evolves:
- Anaplastic histology.
- Advanced tumor stage.
- Gender: Gender was predictive of outcome, with males faring worse than females.[2,5]
NWTS-5 showed that time to recurrence and site of recurrence were no longer prognostically significant.[2,5] However, patients who experienced a pulmonary relapse within 12 months of diagnosis had a poorer prognosis (5-year OS, 47%) than did patients who experienced a pulmonary relapse 12 months or more after diagnosis (5-year OS, 75%).
Based on the above, the following three risk categories have been identified:
- Standard risk: Patients with favorable histology Wilms tumor with relapse after therapy with only vincristine and/or dactinomycin. These patients are expected to have an event-free survival (EFS) of 70% to 80%. These patients make up approximately 30% of recurrences.
- High risk: Patients with favorable histology Wilms tumor with relapse after therapy with three or more agents. These patients account for 45% to 50% of children with Wilms tumor who relapse and have survival rates in the 40% to 50% range.
- Very high risk: Patients with recurrent anaplastic or blastemal-predominant Wilms tumor. These patients are expected to have survival rates in the 10% range and they make up 10% to 15% of all Wilms tumor relapses.[3,7]
In children who had small, stage I Wilms tumor and were treated with surgery alone, the EFS was 84%. All but one child who relapsed was salvaged with treatment tailored to the site of recurrence. Wilms tumor patients whose initial therapy consisted of immediate nephrectomy followed by chemotherapy with vincristine and dactinomycin who relapse can be successfully retreated. Fifty-eight patients were treated on the National Wilms Tumor Study-5 (COG-Q9401) relapse protocol with surgical excision when feasible, radiation therapy, and alternating courses of vincristine, doxorubicin and cyclophosphamide, and etoposide and cyclophosphamide. Four-year EFS after relapse was 71% and overall survival (OS) was 82%. For patients whose site of relapse was only the lungs, the 4-year EFS rate was 68% and OS rate was 81%.Treatment of High-Risk Relapsed Wilms Tumor
Approximately 50% of unilateral Wilms tumor patients who relapse or progress after initial treatment with vincristine, dactinomycin, and doxorubicin and radiation can be successfully retreated. Sixty patients were treated on the NWTS-5 relapse protocol with alternating courses of cyclophosphamide/etoposide and carboplatin/etoposide, surgery, and radiation therapy. The 4-year EFS rate with high-risk Wilms tumor was 42% and OS rate was 48%. For high-risk patients who relapsed in the lungs only the 4-year EFS rate was 49% and OS rate was 53%.
Patients with stages II, III, and IV anaplastic-histology tumors at diagnosis have a very poor prognosis upon recurrence. The combination of ifosfamide, etoposide, and carboplatin has demonstrated activity in this group of patients, but significant hematologic toxic effects have been observed. While high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation has been utilized for recurrent high-risk favorable-histology patients,[10-12] an intergroup study of the former Pediatric Oncology Group and the former Children’s Cancer Group used a salvage induction regimen of cyclophosphamide and etoposide (CE) alternating with carboplatin and etoposide (PE) followed by delayed surgery. Disease-free patients were assigned to maintenance chemotherapy with five cycles of alternating CE and PE, and the remainder of patients to ablative therapy and autologous marrow transplant. All patients received local radiation therapy. The 3-year survival was 52% for all eligible patients, while the 3-year survival was 64% for the chemotherapy consolidation subgroup and 42% for the autologous marrow transplant subgroup.; [Level of evidence: 2A] The outcome of hematopoietic stem cell rescue in selected patients may be superior;[12,14] however, patients with gross residual disease going into transplant do not do as well. Patients in whom such salvage attempts fail should be offered treatment on available phase I or phase II studies.Treatment of Recurrent Clear Cell Sarcoma of the Kidney
Treatment of patients with recurrent clear cell sarcoma of the kidney depends on initial therapy. Cyclophosphamide and carboplatin should be considered if not used initially. Patients with recurrent clear cell sarcoma of the kidney involving the brain have responded to treatment with ifosfamide, carboplatin, and etoposide (ICE) coupled with local control consisting of either surgical resection and/or radiation.[Level of evidence: 2A] In NWTS-5, patients with clear cell sarcoma of the kidney and brain metastases have been successfully treated with combination chemotherapy, surgery, and radiation therapy.
Patients with recurrent rhabdoid tumor of the kidney, clear cell sarcoma of the kidney, neuroepithelial tumor of the kidney, and renal cell carcinoma should be considered for treatment on available phase I and phase II clinical trials.Treatment Options Under Clinical Evaluation
The following treatment option is currently under investigation in a Children's Oncology Group (COG) clinical trial. Information about ongoing clinical trials is available from the NCI Web site.
- COG-ADVL1121 (Sorafenib Tosylate in Treating Younger Patients With Relapsed or Refractory Rhabdomyosarcoma, Wilms Tumor, Liver Cancer, or Thyroid Cancer): A phase II study of sorafenib, a Raf kinase and receptor tyrosine kinase inhibitor, in children and young adults with relapsed/refractory rhabdomyosarcoma, Wilms tumor, hepatocellular carcinoma, and papillary thyroid carcinoma. The goal of this study is to determine the objective response rate of sorafenib in children with refractory or relapsed rhabdomyosarcoma. Patients must be aged 2 to 30 years.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent Wilms tumor and other childhood kidney tumors. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.References
- Green DM, Breslow NE, Beckwith JB, et al.: Effect of duration of treatment on treatment outcome and cost of treatment for Wilms' tumor: a report from the National Wilms' Tumor Study Group. J Clin Oncol 16 (12): 3744-51, 1998. [PUBMED Abstract]
- Malogolowkin M, Cotton CA, Green DM, et al.: Treatment of Wilms tumor relapsing after initial treatment with vincristine, actinomycin D, and doxorubicin. A report from the National Wilms Tumor Study Group. Pediatr Blood Cancer 50 (2): 236-41, 2008. [PUBMED Abstract]
- Reinhard H, Schmidt A, Furtwängler R, et al.: Outcome of relapses of nephroblastoma in patients registered in the SIOP/GPOH trials and studies. Oncol Rep 20 (2): 463-7, 2008. [PUBMED Abstract]
- Grundy P, Breslow N, Green DM, et al.: Prognostic factors for children with recurrent Wilms' tumor: results from the Second and Third National Wilms' Tumor Study. J Clin Oncol 7 (5): 638-47, 1989. [PUBMED Abstract]
- Green DM, Cotton CA, Malogolowkin M, et al.: Treatment of Wilms tumor relapsing after initial treatment with vincristine and actinomycin D: a report from the National Wilms Tumor Study Group. Pediatr Blood Cancer 48 (5): 493-9, 2007. [PUBMED Abstract]
- Warmann SW, Furtwängler R, Blumenstock G, et al.: 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): 155-62, 2011. [PUBMED Abstract]
- Dome JS, Cotton CA, Perlman EJ, et al.: Treatment of anaplastic histology Wilms' tumor: results from the fifth National Wilms' Tumor Study. J Clin Oncol 24 (15): 2352-8, 2006. [PUBMED Abstract]
- Shamberger RC, Anderson JR, Breslow NE, et al.: Long-term outcomes for infants with very low risk Wilms tumor treated with surgery alone in National Wilms Tumor Study-5. Ann Surg 251 (3): 555-8, 2010. [PUBMED Abstract]
- Abu-Ghosh AM, Krailo MD, Goldman SC, et al.: Ifosfamide, carboplatin and etoposide in children with poor-risk relapsed Wilms' tumor: a Children's Cancer Group report. Ann Oncol 13 (3): 460-9, 2002. [PUBMED Abstract]
- Garaventa A, Hartmann O, Bernard JL, et al.: Autologous bone marrow transplantation for pediatric Wilms' tumor: the experience of the European Bone Marrow Transplantation Solid Tumor Registry. Med Pediatr Oncol 22 (1): 11-4, 1994. [PUBMED Abstract]
- Pein F, Michon J, Valteau-Couanet D, et al.: High-dose melphalan, etoposide, and carboplatin followed by autologous stem-cell rescue in pediatric high-risk recurrent Wilms' tumor: a French Society of Pediatric Oncology study. J Clin Oncol 16 (10): 3295-301, 1998. [PUBMED Abstract]
- Campbell AD, Cohn SL, Reynolds M, et al.: Treatment of relapsed Wilms' tumor with high-dose therapy and autologous hematopoietic stem-cell rescue: the experience at Children's Memorial Hospital. J Clin Oncol 22 (14): 2885-90, 2004. [PUBMED Abstract]
- Tannous R, Giller R, Holmes E, et al.: Intensive therapy for high risk (HR) relapsed Wilms' tumor (WT): a CCG-4921/POG-9445 study report. [Abstract] Proceedings of the American Society of Clinical Oncology 19: A2315, 2000.
- Spreafico F, Bisogno G, Collini P, et al.: Treatment of high-risk relapsed Wilms tumor with dose-intensive chemotherapy, marrow-ablative chemotherapy, and autologous hematopoietic stem cell support: experience by the Italian Association of Pediatric Hematology and Oncology. Pediatr Blood Cancer 51 (1): 23-8, 2008. [PUBMED Abstract]
- Radulescu VC, Gerrard M, Moertel C, et al.: Treatment of recurrent clear cell sarcoma of the kidney with brain metastasis. Pediatr Blood Cancer 50 (2): 246-9, 2008. [PUBMED Abstract]
- Seibel NL, Sun J, Anderson JR, et al.: Outcome of clear cell sarcoma of the kidney (CCSK) treated on the National Wilms Tumor Study-5 (NWTS). [Abstract] J Clin Oncol 24 (Suppl 18): A-9000, 502s, 2006.