Sapienza Università di Roma U.O.C. Chirurgia Pediatrica - Policlinico Umberto I Tumore di Wilms rotto: chirurgia o chemioterapia? Denis A. Cozzi Caso clinico personale Maschio, 10 anni Riscontro di massa addominale palpabile Asintomatico Strategia terapeutica Quali opzioni? Indicazioni alla chemioterapia neoadiuvante: protocollo americano T. di Wilms bilaterale T. di Wilms ad insorgenza su rene unico T. di Wilms con coinvolgimento di organi adiacenti e/o estensione tumorale nella cavale sopraepatica NWTS-5 Staging system III. Residual nonhematogenous tumor is present, confined to the abdomen. Any one of the following may occur: 1. Lymph nodes within the abdomen or pelvis are found to be involved by the tumor (renal hilar, pariaortic, or beyond). 2. The tumor has penetrated through the peritoneal surface. 3. Tumor implants are found on the peritoneal surface. 4. Gross or microscopic tumor remains postoperatively (e.g., tumor cells are found at the margin of surgical resection on microscopic examination). 5. The tumor is not completely resectable because of local infiltration into vital structures. 6. Tumor spill, not confined to the flank, occurred either before or during surgery. Preoperative chemotherapy in Wilms’ tumor with contained retroperitoneal rupture All 3 patients received post-op flank radiation Rutigliano DN, et al. J Ped Surg 2007 Preoperative chemotherapy in Wilms’ tumor with contained retroperitoneal rupture Neoadjuvant chemotherapy may decrease the chance of abdominal rupture at the time of surgery and avoid total abdominal radiation in favor of a more localized flank radiation. Rutigliano DN, et al. J Ped Surg 2007 SIOP-2001 Staging system SIOP Postoperative Treatment Strategies for Patients With Localized Wilms Tumors According to Histologic Risk Group and Local Stage Brisse HJ, et al. Cancer 2008 Abdominal pain (n=28) Drop of hemoglubin (n=12) 5 11 8 3 4 8 History of abdominal trauma (n=20) Wilms Tumor Presenting With Abdominal Pain: A Special Subgroup of Patients Abdominal pain (n=31) No abdominal pain (n=216) Stage I 6% 47% Stage II 23% 15% Stage III 52% 23% Stage IV 20% 15% Davidoff AM, et al. Ann Surg Onc 1998 Retroperitoneal rupture Brisse HJ, et al. Cancer 2008 Intraperitoneal rupture Brisse HJ, et al. Cancer 2008 Intraperitoneal rupture Brisse HJ, et al. Cancer 2008 Intraperitoneal rupture Post-Chemotherapy Brisse HJ, et al. Cancer 2008 Peritoneal recurrence (4 months post-op) Brisse HJ, et al. Cancer 2008 Survival rate 5-year OS & EFS rates: 94.4% & 85.5%. Local control rate significantly higher for retroperitoneal-only vs intraperitoneal ruptures Brisse HJ, et al. Cancer 2008 Conclusione (i) Pazienti con TW stadio I/II e presenza alla diagnosi di una rottura retroperitoneale localizzata possono esser trattati meno aggressivamente dei pazienti di stadio III. Does the pre-treatment tumour rupture influence the outcome in patients with nephroblastoma submitted to preoperative chemotherapy? Godzinski J, Heij H, Cecchetto G, et al. Pediatr Blood Cancer. 2005; 45:387. Conclusione (ii) Rotture intraperitoneali, descritte all’imaging o all’intervento, devono esser classificate come stadio III e trattate più aggressivamente con chemio e irradiazione di tutto l’addome. Caso clinico personale Quale strategia terapeutica? Nefrectomia upfront Caso clinico personale AdenoCa renale tipo papillare, moderatamente differenziato (G2) Non infiltrata la capsula d’organo; vasi, uretere, grasso perirenale e 12 linfonodi esenti da infiltrazione neoplastica. pT1a, pN0, pMx, stadio I Follow-up: disease-free a 7 anni post-op. Conclusione (iii) Non vi è attualmente evidenza che il rischio di recidiva addominale sia aumentato in pazienti con imaging alla diagnosi caratterizzato da una rottura localizzata retroperitoneale.