Treatment of stage II patients with intraoperative spill

In a review of 499 patients from the NWTS-4 trial with stage II FH Wilms tumor, 95 of the patients experienced tumor spill. The 8-year RFS and OS rates for patients who experienced intraoperative tumor spill and were treated with vincristine and dactinomycin without flank radiation therapy were lower (75.7% and 90.3%, respectively) than the rates for those who did not experience tumor spill (85% and 95.6%, respectively). None of these differences achieved statistical significance.[217]

On the NWTS-3, NWTS-4, and NWTS-5 trials, patients with intraoperative spill were divided into two groups: (1) those with diffuse spillage involving the whole abdominal cavity; and (2) those with local spillage confined to the flank. Patients with diffuse spillage were treated with radiation therapy to the entire abdomen and three-drug chemotherapy (vincristine, dactinomycin, and doxorubicin), whereas patients with local spillage were treated with vincristine and dactinomycin only. Based on an analysis of patients treated on NWTS-3 and NWTS-4 indicating that patients with stage II disease and local spillage had inferior OS compared with patients with stage II disease without local spillage, COG studies treat patients with local spillage with doxorubicin and flank radiation.[277] This approach is controversial and has not been tested; therefore, it should not be considered standard.