Peter Ehrlich

585 timestamped statements across 6 topics — auto-found in recorded discussions, each timestamp jumps to the exact moment. Summaries Peter gave as host are listed separately below.

Congenital Lung Lesions (CPAM) · guest expert Neuroblastoma · guest expert Sarcoma (Ewing/Rhabdo) · guest expert Soft Tissue Sarcoma (lymph nodes) · guest expert Wilms Tumor · guest expert

Featured statements

▶ Ep 65 · 14:19
If you feel that you would have to do a major liver or bowel resection at the same time, that is a situation in which we would not recommend doing a primary nephrectomy.
quote · Pediatric Oncology
▶ Ep 24 · 46:14
When you look at the outcomes of patients with tumor that extends into the cava or even up to the atrium, that's not a negative prognostic factor
quote · Congenital Lung Lesions (CPAM)
▶ Ep 24 · 26:08
Fifteen percent of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant.
quote · Congenital Lung Lesions (CPAM)
▶ Ep 65 · 26:08
15% of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant.
quote · Pediatric Oncology
▶ Ep 8 · 32:50
The main factor that predicts outcome in stage 3 is whether they're lymph node positive or not.
quote · Neuroblastoma
▶ Ep 2 · 23:37
The two main factors that contribute to late effects are radiation and doxorubicin.
quote · Wilms Tumor

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Peter's statements about Congenital Lung Lesions (CPAM) 55 statements

Open the Congenital Lung Lesions (CPAM) collection →

Wilms Tumor: Audio Chapter

▶ Ep 24 · 3:49
quote The classic feature is something called a sign where you have the kidney. The normal kidney being displaced into a horseshoe pattern and fitting inside that horseshoe pattern is a tumor and so it looks like the normal kidney is grabbing the mass that's coming out of it. ↗
▶ Ep 24 · 3:49
clinical The 'claw sign' on CT—normal kidney displaced into a horseshoe pattern around a mass—is a classic feature of Wilms tumor. ↗
▶ Ep 24 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing into them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 24 · 6:23
guideline In North America, the preferred approach for resectable Wilms tumor is primary nephrectomy (total nephrectomy and ureterectomy with lymph node sampling). ↗
▶ Ep 24 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 24 · 7:01
guideline Preoperative chemotherapy is recommended if tumor extends into the IVC beyond the infrahepatic vena cava, if tumor is so large it compromises respiratory status, if major liver or bowel resection would be required, if only one functioning kidney exists, or if bilateral tumors are present. ↗
▶ Ep 24 · 10:24
clinical If a tumor requires major liver or bowel resection, biopsy and preoperative chemotherapy are preferred because complication rates are higher when these organs are resected at the same time as the kidney, and most tumors will respond to chemotherapy. ↗
▶ Ep 24 · 10:48
quote There's no reason to do that and and overall the consequence in that case of of upstaging, where does that so it's not really upstaging ↗
▶ Ep 24 · 11:18
guideline Biopsy with residual gross tumor has always been treated as stage 3 abdominal disease, requiring three-drug chemotherapy plus flank radiation. ↗
▶ Ep 24 · 14:33
clinical Evidence suggests higher risk of tumor rupture when tumors reach 13-15 centimeters or larger, which may warrant consideration of preoperative chemotherapy. ↗
▶ Ep 24 · 17:19
guideline For biopsy, open biopsy provides large tissue sections; large-core needle biopsy (10-20 cores) has proven accurate in several series. Fine needle aspiration or single-pass true-cut biopsy cannot diagnose anaplasia and should not be used. ↗
▶ Ep 24 · 20:00
guideline COG stage 1 is tumor limited to kidney, completely resected, no capsular invasion, no rupture or biopsy, vessels of renal sinus not involved, negative margins, and negative regional lymph nodes. ↗
▶ Ep 24 · 20:28
guideline COG stage 2 is complete resection with negative margins but tumor extends beyond kidney through capsular penetration, renal sinus invasion, or blood vessel involvement within the nephrectomy specimen outside the primary kidney. ↗
▶ Ep 24 · 21:00
guideline COG stage 3 includes: biopsy with gross residual tumor, positive lymph nodes, peritoneal surface penetration with implants, positive margins, microscopic residual from intraoperative spill, incomplete resection, piecemeal removal, or renal vein division with tumor present. ↗
▶ Ep 24 · 21:58
guideline COG stage 4 is hematogenous metastasis to lung, liver (most common), bone, or brain. Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 24 · 23:08
guideline Stage 1-2 abdominal disease without lung metastases receives two-drug chemotherapy (vincristine and dactinomycin) for shorter duration without abdominal radiation, significantly reducing late effects including renal failure, second malignancies, and cardiovascular disease. ↗
▶ Ep 24 · 24:15
clinical If a patient has a lung lesion but stage 1-2 abdominal disease after primary nephrectomy with negative lymph nodes, the child avoids abdominal radiation (though still receives chemotherapy for the lung lesion). ↗
▶ Ep 24 · 24:15
quote Just because they have a lung lesion doesn't mean that you shouldn't take out the primary tumor ↗
▶ Ep 24 · 26:08
quote Fifteen percent of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 24 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer, a significant late effect. ↗
▶ Ep 24 · 26:24
clinical Recent COG data shows approximately 40% of patients with pulmonary metastases who have complete response at 6 weeks can avoid pulmonary radiation without affecting event-free or overall survival, with 80-85% not relapsing. ↗
▶ Ep 24 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 24 · 28:09
clinical For a single lung lesion remaining at 6 weeks that did not respond to chemotherapy, thoracoscopic biopsy is reasonable because 50-60% of such lesions may not be cancer (could be scar), and if benign, the patient would not need pulmonary radiation. ↗
▶ Ep 24 · 28:09
quote About 50 to 60% of the time those lesions may not turn out to be cancer. They could be scarred. They could be a variety of things. ↗
▶ Ep 24 · 30:16
guideline SIOP protocols use preoperative chemotherapy for all patients at higher doses than COG, with evaluation at 4 and 8 weeks, then resection followed by post-chemotherapy pathology-based risk stratification (low, intermediate, high risk). ↗
▶ Ep 24 · 31:19
clinical In SIOP protocols, predominantly blastema component after preoperative chemotherapy is a negative prognostic factor, but blastema percentage does not correlate with outcome in COG primary nephrectomy patients. ↗
▶ Ep 24 · 32:50
quote The main factor that predicts outcome in stage 3 is whether they're lymph node positive or not. ↗
▶ Ep 24 · 32:50
clinical The main factor predicting outcome in stage 3 disease is whether lymph nodes are positive, along with genetic changes including loss of heterozygosity and 1Q gain. ↗
▶ Ep 24 · 33:58
quote When you look at the outcomes for stage 1 and stage 2 patients between the children's oncology group and the psyop groups, they're basically identical. ↗
▶ Ep 24 · 33:58
clinical Outcomes for stage 1 and stage 2 patients are basically identical between COG and SIOP treatment approaches. ↗
▶ Ep 24 · 34:46
clinical Some Wilms tumor patients present with low hemoglobin because the tumor ruptures internally and bleeds. ↗
▶ Ep 24 · 35:11
quote There is something called acquired von Willebrand's disease which these patients get. In the majority of cases it is meaningless, but there have been reports in a few case series where these patients may bleed a lot. ↗
▶ Ep 24 · 35:11
clinical Acquired von Willebrand disease occurs in Wilms tumor patients; in most cases it is meaningless, but a few case series report significant intraoperative bleeding until tumor removal. ↗
▶ Ep 24 · 36:25
clinical Right-sided tumors can cause complications including adrenal vein injury, duodenal injury (due to proximity), superior mesenteric artery injury, and IVC injury due to anatomic distortion. ↗
▶ Ep 24 · 38:20
quote These tumors tend to be large and although ideally you would like to identify the renal artery and the renal vein, it's been well recognized. It's even back in Gross's book that these, if you can't do that, then you shouldn't try and do it up front. ↗
▶ Ep 24 · 42:31
clinical Wilms tumors can cause intense inflammatory reaction making them adherent to diaphragm or liver; taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 24 · 43:32
clinical A small subset of very young patients (<24 months) with stage 1 favorable histology tumors <550g can be treated with surgery alone without chemotherapy, with >95% overall survival. Those who relapse (about 10%) have 100% salvage with chemotherapy. ↗
▶ Ep 24 · 46:14
quote When you look at the outcomes of patients with tumor that extends into the cava or even up to the atrium, that's not a negative prognostic factor ↗
▶ Ep 24 · 46:27
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 24 · 47:43
quote The major complication rate in patients goes up. Those include mortalities, number of blood transfusions, ICU stay, complications go up ↗
▶ Ep 24 · 48:49
clinical Major complication rate for primary surgery with tumor extending beyond infrahepatic IVC is 26-30%, including mortality, increased transfusions, and ICU stay, supporting preoperative chemotherapy for these cases. ↗
▶ Ep 24 · 51:28
quote Todd, I, I've read 6000 operative notes, OK. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 24 · 52:39
clinical Favorable histology Wilms tumor has three components: blastema, stroma, and epithelial (triphasic tumor). Tumors with only two components are also considered favorable histology. ↗
▶ Ep 24 · 54:41
clinical Patients with loss of heterozygosity of both 1p and 16q (5-7% of patients) have significantly worse outcomes regardless of stage. Stage 1-2 patients with LOH have about 10% lower overall survival; stage 3-4 patients have 18% lower survival. ↗
▶ Ep 24 · 55:07
guideline Patients with both 1p and 16q loss of heterozygosity receive augmented therapy: doxorubicin is added for stage 1-2 disease, and five-drug regimen M is used for stage 3-4 disease. ↗
▶ Ep 24 · 55:58
clinical Unfavorable histology is classified as focal anaplasia or diffuse anaplasia based on number of high-power fields showing anaplasia, with different treatments for each. ↗
▶ Ep 24 · 56:51
clinical Renal cell carcinoma in children has no good therapy, particularly for metastatic disease. ↗
▶ Ep 24 · 57:01
clinical Clear cell sarcoma of the kidney has reasonable treatment outcomes, particularly for low stages. Rhabdoid tumors have poor outcomes except for stage 1; most present at stage 3-4 with terrible outcomes. ↗
▶ Ep 24 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 24 · 58:07
guideline The strategy for bilateral Wilms tumor is preoperative chemotherapy to shrink tumors enough to allow partial nephrectomy of at least one kidney (ideally both) to avoid dialysis. ↗
▶ Ep 24 · 58:40
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% compared to 88% for unilateral tumors; overall survival was 80% vs. 95%. ↗
▶ Ep 24 · 59:37
clinical Maximum tumor response to chemotherapy in most children with Wilms tumor occurs by 12 weeks, and early response at 6 weeks predicts late response. ↗
▶ Ep 24 · 1:00:31
epidemiological In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. In a recent COG study of 250 enrolled patients, only one turned out to have rhabdoid tumor. ↗
▶ Ep 24 · 1:01:56
guideline Biopsy is recommended for bilateral tumors in older patients (8-10 years) or those with syndromes like von Hippel-Lindau where renal cell carcinoma is more likely. ↗
▶ Ep 24 · 1:02:16
clinical If biopsying bilateral tumors, both kidneys should be biopsied because there is discordant pathology in up to 20% of patients. ↗
Peter's statements about Neuroblastoma 110 statements

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Wilms Tumor: Audio Chapter

▶ Ep 8 · 3:49
quote The classic feature is something called a sign where you have the kidney. The normal kidney being displaced into a horseshoe pattern and fitting inside that horseshoe pattern is a tumor and so it looks like the normal kidney is grabbing the mass that's coming out of it. ↗
▶ Ep 8 · 3:49
quote The classic feature is something called a sign where you have the kidney. The normal kidney being displaced into a horseshoe pattern and fitting inside that horseshoe pattern is a tumor and so it looks like the normal kidney is grabbing the mass that's coming out of it. ↗
▶ Ep 8 · 3:49
clinical The 'claw sign' on CT—normal kidney displaced into a horseshoe pattern around a mass—is a classic feature of Wilms tumor. ↗
▶ Ep 8 · 3:49
clinical The 'claw sign' on CT—normal kidney displaced into a horseshoe pattern around a mass—is a classic feature of Wilms tumor. ↗
▶ Ep 8 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing into them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 8 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing into them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 8 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 8 · 6:23
guideline In North America, the preferred approach for resectable Wilms tumor is primary nephrectomy (total nephrectomy and ureterectomy with lymph node sampling). ↗
▶ Ep 8 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 8 · 6:23
guideline In North America, the preferred approach for resectable Wilms tumor is primary nephrectomy (total nephrectomy and ureterectomy with lymph node sampling). ↗
▶ Ep 8 · 7:01
guideline Preoperative chemotherapy is recommended if tumor extends into the IVC beyond the infrahepatic vena cava, if tumor is so large it compromises respiratory status, if major liver or bowel resection would be required, if only one functioning kidney exists, or if bilateral tumors are present. ↗
▶ Ep 8 · 7:01
guideline Preoperative chemotherapy is recommended if tumor extends into the IVC beyond the infrahepatic vena cava, if tumor is so large it compromises respiratory status, if major liver or bowel resection would be required, if only one functioning kidney exists, or if bilateral tumors are present. ↗
▶ Ep 8 · 10:24
clinical If a tumor requires major liver or bowel resection, biopsy and preoperative chemotherapy are preferred because complication rates are higher when these organs are resected at the same time as the kidney, and most tumors will respond to chemotherapy. ↗
▶ Ep 8 · 10:24
clinical If a tumor requires major liver or bowel resection, biopsy and preoperative chemotherapy are preferred because complication rates are higher when these organs are resected at the same time as the kidney, and most tumors will respond to chemotherapy. ↗
▶ Ep 8 · 10:48
quote There's no reason to do that and and overall the consequence in that case of of upstaging, where does that so it's not really upstaging ↗
▶ Ep 8 · 10:48
quote There's no reason to do that and and overall the consequence in that case of of upstaging, where does that so it's not really upstaging ↗
▶ Ep 8 · 11:18
guideline Biopsy with residual gross tumor has always been treated as stage 3 abdominal disease, requiring three-drug chemotherapy plus flank radiation. ↗
▶ Ep 8 · 11:18
guideline Biopsy with residual gross tumor has always been treated as stage 3 abdominal disease, requiring three-drug chemotherapy plus flank radiation. ↗
▶ Ep 8 · 14:33
clinical Evidence suggests higher risk of tumor rupture when tumors reach 13-15 centimeters or larger, which may warrant consideration of preoperative chemotherapy. ↗
▶ Ep 8 · 14:33
clinical Evidence suggests higher risk of tumor rupture when tumors reach 13-15 centimeters or larger, which may warrant consideration of preoperative chemotherapy. ↗
▶ Ep 8 · 17:19
guideline For biopsy, open biopsy provides large tissue sections; large-core needle biopsy (10-20 cores) has proven accurate in several series. Fine needle aspiration or single-pass true-cut biopsy cannot diagnose anaplasia and should not be used. ↗
▶ Ep 8 · 17:19
guideline For biopsy, open biopsy provides large tissue sections; large-core needle biopsy (10-20 cores) has proven accurate in several series. Fine needle aspiration or single-pass true-cut biopsy cannot diagnose anaplasia and should not be used. ↗
▶ Ep 8 · 20:00
guideline COG stage 1 is tumor limited to kidney, completely resected, no capsular invasion, no rupture or biopsy, vessels of renal sinus not involved, negative margins, and negative regional lymph nodes. ↗
▶ Ep 8 · 20:00
guideline COG stage 1 is tumor limited to kidney, completely resected, no capsular invasion, no rupture or biopsy, vessels of renal sinus not involved, negative margins, and negative regional lymph nodes. ↗
▶ Ep 8 · 20:28
guideline COG stage 2 is complete resection with negative margins but tumor extends beyond kidney through capsular penetration, renal sinus invasion, or blood vessel involvement within the nephrectomy specimen outside the primary kidney. ↗
▶ Ep 8 · 20:28
guideline COG stage 2 is complete resection with negative margins but tumor extends beyond kidney through capsular penetration, renal sinus invasion, or blood vessel involvement within the nephrectomy specimen outside the primary kidney. ↗
▶ Ep 8 · 21:00
guideline COG stage 3 includes: biopsy with gross residual tumor, positive lymph nodes, peritoneal surface penetration with implants, positive margins, microscopic residual from intraoperative spill, incomplete resection, piecemeal removal, or renal vein division with tumor present. ↗
▶ Ep 8 · 21:00
guideline COG stage 3 includes: biopsy with gross residual tumor, positive lymph nodes, peritoneal surface penetration with implants, positive margins, microscopic residual from intraoperative spill, incomplete resection, piecemeal removal, or renal vein division with tumor present. ↗
▶ Ep 8 · 21:58
guideline COG stage 4 is hematogenous metastasis to lung, liver (most common), bone, or brain. Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 8 · 21:58
guideline COG stage 4 is hematogenous metastasis to lung, liver (most common), bone, or brain. Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 8 · 23:08
guideline Stage 1-2 abdominal disease without lung metastases receives two-drug chemotherapy (vincristine and dactinomycin) for shorter duration without abdominal radiation, significantly reducing late effects including renal failure, second malignancies, and cardiovascular disease. ↗
▶ Ep 8 · 23:08
guideline Stage 1-2 abdominal disease without lung metastases receives two-drug chemotherapy (vincristine and dactinomycin) for shorter duration without abdominal radiation, significantly reducing late effects including renal failure, second malignancies, and cardiovascular disease. ↗
▶ Ep 8 · 24:15
clinical If a patient has a lung lesion but stage 1-2 abdominal disease after primary nephrectomy with negative lymph nodes, the child avoids abdominal radiation (though still receives chemotherapy for the lung lesion). ↗
▶ Ep 8 · 24:15
quote Just because they have a lung lesion doesn't mean that you shouldn't take out the primary tumor ↗
▶ Ep 8 · 24:15
quote Just because they have a lung lesion doesn't mean that you shouldn't take out the primary tumor ↗
▶ Ep 8 · 24:15
clinical If a patient has a lung lesion but stage 1-2 abdominal disease after primary nephrectomy with negative lymph nodes, the child avoids abdominal radiation (though still receives chemotherapy for the lung lesion). ↗
▶ Ep 8 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer, a significant late effect. ↗
▶ Ep 8 · 26:08
quote Fifteen percent of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 8 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer, a significant late effect. ↗
▶ Ep 8 · 26:08
quote Fifteen percent of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 8 · 26:24
clinical Recent COG data shows approximately 40% of patients with pulmonary metastases who have complete response at 6 weeks can avoid pulmonary radiation without affecting event-free or overall survival, with 80-85% not relapsing. ↗
▶ Ep 8 · 26:24
clinical Recent COG data shows approximately 40% of patients with pulmonary metastases who have complete response at 6 weeks can avoid pulmonary radiation without affecting event-free or overall survival, with 80-85% not relapsing. ↗
▶ Ep 8 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 8 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 8 · 28:09
quote About 50 to 60% of the time those lesions may not turn out to be cancer. They could be scarred. They could be a variety of things. ↗
▶ Ep 8 · 28:09
clinical For a single lung lesion remaining at 6 weeks that did not respond to chemotherapy, thoracoscopic biopsy is reasonable because 50-60% of such lesions may not be cancer (could be scar), and if benign, the patient would not need pulmonary radiation. ↗
▶ Ep 8 · 28:09
clinical For a single lung lesion remaining at 6 weeks that did not respond to chemotherapy, thoracoscopic biopsy is reasonable because 50-60% of such lesions may not be cancer (could be scar), and if benign, the patient would not need pulmonary radiation. ↗
▶ Ep 8 · 28:09
quote About 50 to 60% of the time those lesions may not turn out to be cancer. They could be scarred. They could be a variety of things. ↗
▶ Ep 8 · 30:16
guideline SIOP protocols use preoperative chemotherapy for all patients at higher doses than COG, with evaluation at 4 and 8 weeks, then resection followed by post-chemotherapy pathology-based risk stratification (low, intermediate, high risk). ↗
▶ Ep 8 · 30:16
guideline SIOP protocols use preoperative chemotherapy for all patients at higher doses than COG, with evaluation at 4 and 8 weeks, then resection followed by post-chemotherapy pathology-based risk stratification (low, intermediate, high risk). ↗
▶ Ep 8 · 31:19
clinical In SIOP protocols, predominantly blastema component after preoperative chemotherapy is a negative prognostic factor, but blastema percentage does not correlate with outcome in COG primary nephrectomy patients. ↗
▶ Ep 8 · 31:19
clinical In SIOP protocols, predominantly blastema component after preoperative chemotherapy is a negative prognostic factor, but blastema percentage does not correlate with outcome in COG primary nephrectomy patients. ↗
▶ Ep 8 · 32:50
clinical The main factor predicting outcome in stage 3 disease is whether lymph nodes are positive, along with genetic changes including loss of heterozygosity and 1Q gain. ↗
▶ Ep 8 · 32:50
quote The main factor that predicts outcome in stage 3 is whether they're lymph node positive or not. ↗
▶ Ep 8 · 32:50
quote The main factor that predicts outcome in stage 3 is whether they're lymph node positive or not. ↗
▶ Ep 8 · 32:50
clinical The main factor predicting outcome in stage 3 disease is whether lymph nodes are positive, along with genetic changes including loss of heterozygosity and 1Q gain. ↗
▶ Ep 8 · 33:58
clinical Outcomes for stage 1 and stage 2 patients are basically identical between COG and SIOP treatment approaches. ↗
▶ Ep 8 · 33:58
quote When you look at the outcomes for stage 1 and stage 2 patients between the children's oncology group and the psyop groups, they're basically identical. ↗
▶ Ep 8 · 33:58
clinical Outcomes for stage 1 and stage 2 patients are basically identical between COG and SIOP treatment approaches. ↗
▶ Ep 8 · 33:58
quote When you look at the outcomes for stage 1 and stage 2 patients between the children's oncology group and the psyop groups, they're basically identical. ↗
▶ Ep 8 · 34:46
clinical Some Wilms tumor patients present with low hemoglobin because the tumor ruptures internally and bleeds. ↗
▶ Ep 8 · 34:46
clinical Some Wilms tumor patients present with low hemoglobin because the tumor ruptures internally and bleeds. ↗
▶ Ep 8 · 35:11
quote There is something called acquired von Willebrand's disease which these patients get. In the majority of cases it is meaningless, but there have been reports in a few case series where these patients may bleed a lot. ↗
▶ Ep 8 · 35:11
clinical Acquired von Willebrand disease occurs in Wilms tumor patients; in most cases it is meaningless, but a few case series report significant intraoperative bleeding until tumor removal. ↗
▶ Ep 8 · 35:11
quote There is something called acquired von Willebrand's disease which these patients get. In the majority of cases it is meaningless, but there have been reports in a few case series where these patients may bleed a lot. ↗
▶ Ep 8 · 35:11
clinical Acquired von Willebrand disease occurs in Wilms tumor patients; in most cases it is meaningless, but a few case series report significant intraoperative bleeding until tumor removal. ↗
▶ Ep 8 · 36:25
clinical Right-sided tumors can cause complications including adrenal vein injury, duodenal injury (due to proximity), superior mesenteric artery injury, and IVC injury due to anatomic distortion. ↗
▶ Ep 8 · 36:25
clinical Right-sided tumors can cause complications including adrenal vein injury, duodenal injury (due to proximity), superior mesenteric artery injury, and IVC injury due to anatomic distortion. ↗
▶ Ep 8 · 38:20
quote These tumors tend to be large and although ideally you would like to identify the renal artery and the renal vein, it's been well recognized. It's even back in Gross's book that these, if you can't do that, then you shouldn't try and do it up front. ↗
▶ Ep 8 · 38:20
quote These tumors tend to be large and although ideally you would like to identify the renal artery and the renal vein, it's been well recognized. It's even back in Gross's book that these, if you can't do that, then you shouldn't try and do it up front. ↗
▶ Ep 8 · 42:31
clinical Wilms tumors can cause intense inflammatory reaction making them adherent to diaphragm or liver; taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 8 · 42:31
clinical Wilms tumors can cause intense inflammatory reaction making them adherent to diaphragm or liver; taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 8 · 43:32
clinical A small subset of very young patients (<24 months) with stage 1 favorable histology tumors <550g can be treated with surgery alone without chemotherapy, with >95% overall survival. Those who relapse (about 10%) have 100% salvage with chemotherapy. ↗
▶ Ep 8 · 43:32
clinical A small subset of very young patients (<24 months) with stage 1 favorable histology tumors <550g can be treated with surgery alone without chemotherapy, with >95% overall survival. Those who relapse (about 10%) have 100% salvage with chemotherapy. ↗
▶ Ep 8 · 46:14
quote When you look at the outcomes of patients with tumor that extends into the cava or even up to the atrium, that's not a negative prognostic factor ↗
▶ Ep 8 · 46:14
quote When you look at the outcomes of patients with tumor that extends into the cava or even up to the atrium, that's not a negative prognostic factor ↗
▶ Ep 8 · 46:27
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 8 · 46:27
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 8 · 47:43
quote The major complication rate in patients goes up. Those include mortalities, number of blood transfusions, ICU stay, complications go up ↗
▶ Ep 8 · 47:43
quote The major complication rate in patients goes up. Those include mortalities, number of blood transfusions, ICU stay, complications go up ↗
▶ Ep 8 · 48:49
clinical Major complication rate for primary surgery with tumor extending beyond infrahepatic IVC is 26-30%, including mortality, increased transfusions, and ICU stay, supporting preoperative chemotherapy for these cases. ↗
▶ Ep 8 · 48:49
clinical Major complication rate for primary surgery with tumor extending beyond infrahepatic IVC is 26-30%, including mortality, increased transfusions, and ICU stay, supporting preoperative chemotherapy for these cases. ↗
▶ Ep 8 · 51:28
quote Todd, I, I've read 6000 operative notes, OK. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 8 · 51:28
quote Todd, I, I've read 6000 operative notes, OK. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 8 · 52:39
clinical Favorable histology Wilms tumor has three components: blastema, stroma, and epithelial (triphasic tumor). Tumors with only two components are also considered favorable histology. ↗
▶ Ep 8 · 52:39
clinical Favorable histology Wilms tumor has three components: blastema, stroma, and epithelial (triphasic tumor). Tumors with only two components are also considered favorable histology. ↗
▶ Ep 8 · 54:41
clinical Patients with loss of heterozygosity of both 1p and 16q (5-7% of patients) have significantly worse outcomes regardless of stage. Stage 1-2 patients with LOH have about 10% lower overall survival; stage 3-4 patients have 18% lower survival. ↗
▶ Ep 8 · 54:41
clinical Patients with loss of heterozygosity of both 1p and 16q (5-7% of patients) have significantly worse outcomes regardless of stage. Stage 1-2 patients with LOH have about 10% lower overall survival; stage 3-4 patients have 18% lower survival. ↗
▶ Ep 8 · 55:07
guideline Patients with both 1p and 16q loss of heterozygosity receive augmented therapy: doxorubicin is added for stage 1-2 disease, and five-drug regimen M is used for stage 3-4 disease. ↗
▶ Ep 8 · 55:07
guideline Patients with both 1p and 16q loss of heterozygosity receive augmented therapy: doxorubicin is added for stage 1-2 disease, and five-drug regimen M is used for stage 3-4 disease. ↗
▶ Ep 8 · 55:58
clinical Unfavorable histology is classified as focal anaplasia or diffuse anaplasia based on number of high-power fields showing anaplasia, with different treatments for each. ↗
▶ Ep 8 · 55:58
clinical Unfavorable histology is classified as focal anaplasia or diffuse anaplasia based on number of high-power fields showing anaplasia, with different treatments for each. ↗
▶ Ep 8 · 56:51
clinical Renal cell carcinoma in children has no good therapy, particularly for metastatic disease. ↗
▶ Ep 8 · 56:51
clinical Renal cell carcinoma in children has no good therapy, particularly for metastatic disease. ↗
▶ Ep 8 · 57:01
clinical Clear cell sarcoma of the kidney has reasonable treatment outcomes, particularly for low stages. Rhabdoid tumors have poor outcomes except for stage 1; most present at stage 3-4 with terrible outcomes. ↗
▶ Ep 8 · 57:01
clinical Clear cell sarcoma of the kidney has reasonable treatment outcomes, particularly for low stages. Rhabdoid tumors have poor outcomes except for stage 1; most present at stage 3-4 with terrible outcomes. ↗
▶ Ep 8 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 8 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 8 · 58:07
guideline The strategy for bilateral Wilms tumor is preoperative chemotherapy to shrink tumors enough to allow partial nephrectomy of at least one kidney (ideally both) to avoid dialysis. ↗
▶ Ep 8 · 58:07
guideline The strategy for bilateral Wilms tumor is preoperative chemotherapy to shrink tumors enough to allow partial nephrectomy of at least one kidney (ideally both) to avoid dialysis. ↗
▶ Ep 8 · 58:40
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% compared to 88% for unilateral tumors; overall survival was 80% vs. 95%. ↗
▶ Ep 8 · 58:40
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% compared to 88% for unilateral tumors; overall survival was 80% vs. 95%. ↗
▶ Ep 8 · 59:37
clinical Maximum tumor response to chemotherapy in most children with Wilms tumor occurs by 12 weeks, and early response at 6 weeks predicts late response. ↗
▶ Ep 8 · 59:37
clinical Maximum tumor response to chemotherapy in most children with Wilms tumor occurs by 12 weeks, and early response at 6 weeks predicts late response. ↗
▶ Ep 8 · 1:00:31
epidemiological In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. In a recent COG study of 250 enrolled patients, only one turned out to have rhabdoid tumor. ↗
▶ Ep 8 · 1:00:31
epidemiological In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. In a recent COG study of 250 enrolled patients, only one turned out to have rhabdoid tumor. ↗
▶ Ep 8 · 1:01:56
guideline Biopsy is recommended for bilateral tumors in older patients (8-10 years) or those with syndromes like von Hippel-Lindau where renal cell carcinoma is more likely. ↗
▶ Ep 8 · 1:01:56
guideline Biopsy is recommended for bilateral tumors in older patients (8-10 years) or those with syndromes like von Hippel-Lindau where renal cell carcinoma is more likely. ↗
▶ Ep 8 · 1:02:16
clinical If biopsying bilateral tumors, both kidneys should be biopsied because there is discordant pathology in up to 20% of patients. ↗
▶ Ep 8 · 1:02:16
clinical If biopsying bilateral tumors, both kidneys should be biopsied because there is discordant pathology in up to 20% of patients. ↗
Peter's statements about Pediatric Oncology 103 statements

Open the Pediatric Oncology collection →

Wilms Tumor: Audio Chapter

▶ Ep 65 · 3:49
clinical Wilms tumors characteristically show a 'claw sign' on imaging where normal kidney is displaced into a horseshoe pattern, appearing to grab the mass coming out of it. ↗
▶ Ep 65 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing around them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 65 · 6:23
guideline In North America, the Children's Oncology Group recommends primary nephrectomy and ureterectomy with lymph node sampling for the majority of children with renal tumors. ↗
▶ Ep 65 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 65 · 7:01
guideline Preoperative chemotherapy is recommended if the tumor compromises the child's respiratory status, making them a poor operative candidate. ↗
▶ Ep 65 · 7:33
guideline If tumor extends into the inferior vena cava beyond the intrahepatic level (behind the liver or up to the atrium), preoperative chemotherapy is recommended. ↗
▶ Ep 65 · 7:57
guideline Massive tumors that would require resection of large parts of liver or bowel should receive preoperative chemotherapy because the majority will respond. ↗
▶ Ep 65 · 8:21
guideline If the child has only one functioning kidney, preoperative chemotherapy is recommended to avoid nephrectomy. ↗
▶ Ep 65 · 8:33
guideline Children with bilateral renal tumors, Wilms tumor predisposition syndromes (Wagr, Denys-Drash, Beckwith-Wiedemann), or multicentric tumors should not undergo primary nephrectomy. ↗
▶ Ep 65 · 10:38
clinical Complication rates are higher if liver or bowel must be resected at the same time as the kidney. ↗
▶ Ep 65 · 11:18
guideline If gross tumor is left behind or the tumor is only biopsied, it is treated as a stage 3 abdominal tumor requiring 3-drug chemotherapy plus flank radiation. ↗
▶ Ep 65 · 14:19
quote If you feel that you would have to do a major liver or bowel resection at the same time, that is a situation in which we would not recommend doing a primary nephrectomy. ↗
▶ Ep 65 · 19:44
guideline In the COG staging system, treatment is determined by both local abdominal stage and disease stage. ↗
▶ Ep 65 · 20:01
guideline Stage 1 tumor is limited to the kidney, completely resected, with no capsular invasion, no rupture or biopsy prior to removal, no renal sinus vessel involvement, negative margins, and negative regional lymph nodes. ↗
▶ Ep 65 · 20:28
guideline Stage 2 tumor is completely resected with negative margins but extends beyond the kidney through capsular penetration, renal sinus soft tissue invasion, or blood vessel involvement outside the primary kidney. ↗
▶ Ep 65 · 21:00
guideline Stage 3 includes tumors that are biopsied with gross residual, have positive lymph nodes, penetrate the peritoneal surface with implants, have positive margins, have microscopic residual from intraoperative spill, cannot be completely resected, or must be removed in pieces. ↗
▶ Ep 65 · 21:58
guideline Stage 4 is hematogenous metastasis to lung, liver, bone, or brain. ↗
▶ Ep 65 · 22:06
guideline Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 65 · 23:08
guideline Patients with stage 1 or 2 abdominal disease without lung metastases receive only 2-drug chemotherapy (vincristine and dactinomycin) for shorter duration with lower toxicity and significantly lower risk of late effects. ↗
▶ Ep 65 · 23:37
clinical The main late effects of Wilms tumor treatment are renal failure, second malignancies, pregnancy problems in females, hypertension, and cardiovascular disease, primarily caused by radiation and doxorubicin. ↗
▶ Ep 65 · 23:37
quote The two main factors that contribute to late effects are radiation and doxorubicin. ↗
▶ Ep 65 · 24:06
guideline If a child has stage 1 or 2 abdominal disease, they do not require abdominal radiation regardless of lung metastases status. ↗
▶ Ep 65 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer. ↗
▶ Ep 65 · 26:08
quote 15% of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 65 · 26:20
clinical Pulmonary radiation causes pneumonitis and long-term restrictive lung disease. ↗
▶ Ep 65 · 26:24
clinical A recent COG study showed that approximately 40% of patients with pulmonary metastases who achieve complete response by 6 weeks of chemotherapy do not need pulmonary radiation, with 80-85% remaining relapse-free. ↗
▶ Ep 65 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 65 · 30:31
guideline In the SIOP protocols, all patients start with chemotherapy without biopsy in most cases, using higher doses of two drugs, with evaluation at 4 and 8 weeks before proceeding to resection. ↗
▶ Ep 65 · 31:06
guideline SIOP uses post-chemotherapy, post-nephrectomy classification into low risk, intermediate risk, and high risk based on percentage of blastemal components and presence of anaplasia. ↗
▶ Ep 65 · 35:11
clinical Some children with Wilms tumor develop acquired von Willebrand disease; in the majority of cases it is meaningless, but a few case series report significant bleeding during surgery until the tumor is removed. ↗
▶ Ep 65 · 41:24
guideline Positive surgical margins or tumor rupture (intraoperative or microscopic) automatically makes the patient stage 3. ↗
▶ Ep 65 · 42:31
guideline Taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 65 · 43:32
clinical Very low-risk patients (stage I, <550g, <2 years, favorable histology) can be treated with surgery alone; 90-95% are cured without chemotherapy, and those who relapse have 100% survival with delayed chemotherapy. ↗
▶ Ep 65 · 46:14
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 65 · 46:38
guideline If IVC tumor thrombus extends into the renal vein but is not adherent and comes out in one piece, it is considered stage 2. ↗
▶ Ep 65 · 47:43
clinical Major complication rates (including mortality, blood transfusions, ICU stay) increase significantly when tumor extends beyond the infrahepatic IVC to the hepatic veins or atrium, with 26-30% major morbidity in primary resection cases. ↗
▶ Ep 65 · 51:28
quote I've read 6000 operative notes. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 65 · 54:41
clinical Loss of heterozygosity at both 1p and 16q occurs in 5-7% of patients and is associated with significantly worse outcomes regardless of stage. ↗
▶ Ep 65 · 55:23
epidemiological Stage 1-2 patients with loss of heterozygosity at 1p and 16q have approximately 10% lower overall survival than those without these genetic changes. ↗
▶ Ep 65 · 55:45
clinical Stage 3-4 patients with loss of heterozygosity at 1p and 16q have approximately 18% lower overall survival and receive 5-drug regimen M chemotherapy. ↗
▶ Ep 65 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 65 · 58:51
epidemiological Event-free survival for unilateral Wilms tumor is approximately 88% with overall survival of 95%. ↗
▶ Ep 65 · 58:51
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% with overall survival of only 80%. ↗
▶ Ep 65 · 59:37
clinical The maximum response of most children with Wilms tumor to chemotherapy occurs by 12 weeks. ↗
▶ Ep 65 · 1:00:31
clinical In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. ↗
▶ Ep 65 · 1:01:02
clinical Open biopsy to determine favorable vs. unfavorable histology in Wilms tumor is not very accurate initially. ↗
▶ Ep 65 · 1:01:12
epidemiological In a recent COG bilateral Wilms study of 250 patients, only one patient who met enrollment criteria turned out to have rhabdoid tumor instead of Wilms tumor. ↗
▶ Ep 65 · 1:02:14
epidemiological Discordant pathology occurs in up to 20% of bilateral Wilms tumor patients when both kidneys are biopsied. ↗

Wilms Tumor: Audio Chapter

▶ Ep 258 · 3:49
quote The classic feature is something called a sign where you have the kidney. The normal kidney being displaced into a horseshoe pattern and fitting inside that horseshoe pattern is a tumor and so it looks like the normal kidney is grabbing the mass that's coming out of it. ↗
▶ Ep 258 · 3:49
clinical The 'claw sign' on CT—normal kidney displaced into a horseshoe pattern around a mass—is a classic feature of Wilms tumor. ↗
▶ Ep 258 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing into them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 258 · 6:23
guideline In North America, the preferred approach for resectable Wilms tumor is primary nephrectomy (total nephrectomy and ureterectomy with lymph node sampling). ↗
▶ Ep 258 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 258 · 7:01
guideline Preoperative chemotherapy is recommended if tumor extends into the IVC beyond the infrahepatic vena cava, if tumor is so large it compromises respiratory status, if major liver or bowel resection would be required, if only one functioning kidney exists, or if bilateral tumors are present. ↗
▶ Ep 258 · 10:24
clinical If a tumor requires major liver or bowel resection, biopsy and preoperative chemotherapy are preferred because complication rates are higher when these organs are resected at the same time as the kidney, and most tumors will respond to chemotherapy. ↗
▶ Ep 258 · 10:48
quote There's no reason to do that and and overall the consequence in that case of of upstaging, where does that so it's not really upstaging ↗
▶ Ep 258 · 11:18
guideline Biopsy with residual gross tumor has always been treated as stage 3 abdominal disease, requiring three-drug chemotherapy plus flank radiation. ↗
▶ Ep 258 · 14:33
clinical Evidence suggests higher risk of tumor rupture when tumors reach 13-15 centimeters or larger, which may warrant consideration of preoperative chemotherapy. ↗
▶ Ep 258 · 17:19
guideline For biopsy, open biopsy provides large tissue sections; large-core needle biopsy (10-20 cores) has proven accurate in several series. Fine needle aspiration or single-pass true-cut biopsy cannot diagnose anaplasia and should not be used. ↗
▶ Ep 258 · 20:00
guideline COG stage 1 is tumor limited to kidney, completely resected, no capsular invasion, no rupture or biopsy, vessels of renal sinus not involved, negative margins, and negative regional lymph nodes. ↗
▶ Ep 258 · 20:28
guideline COG stage 2 is complete resection with negative margins but tumor extends beyond kidney through capsular penetration, renal sinus invasion, or blood vessel involvement within the nephrectomy specimen outside the primary kidney. ↗
▶ Ep 258 · 21:00
guideline COG stage 3 includes: biopsy with gross residual tumor, positive lymph nodes, peritoneal surface penetration with implants, positive margins, microscopic residual from intraoperative spill, incomplete resection, piecemeal removal, or renal vein division with tumor present. ↗
▶ Ep 258 · 21:58
guideline COG stage 4 is hematogenous metastasis to lung, liver (most common), bone, or brain. Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 258 · 23:08
guideline Stage 1-2 abdominal disease without lung metastases receives two-drug chemotherapy (vincristine and dactinomycin) for shorter duration without abdominal radiation, significantly reducing late effects including renal failure, second malignancies, and cardiovascular disease. ↗
▶ Ep 258 · 24:15
clinical If a patient has a lung lesion but stage 1-2 abdominal disease after primary nephrectomy with negative lymph nodes, the child avoids abdominal radiation (though still receives chemotherapy for the lung lesion). ↗
▶ Ep 258 · 24:15
quote Just because they have a lung lesion doesn't mean that you shouldn't take out the primary tumor ↗
▶ Ep 258 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer, a significant late effect. ↗
▶ Ep 258 · 26:08
quote Fifteen percent of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 258 · 26:24
clinical Recent COG data shows approximately 40% of patients with pulmonary metastases who have complete response at 6 weeks can avoid pulmonary radiation without affecting event-free or overall survival, with 80-85% not relapsing. ↗
▶ Ep 258 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 258 · 28:09
clinical For a single lung lesion remaining at 6 weeks that did not respond to chemotherapy, thoracoscopic biopsy is reasonable because 50-60% of such lesions may not be cancer (could be scar), and if benign, the patient would not need pulmonary radiation. ↗
▶ Ep 258 · 28:09
quote About 50 to 60% of the time those lesions may not turn out to be cancer. They could be scarred. They could be a variety of things. ↗
▶ Ep 258 · 30:16
guideline SIOP protocols use preoperative chemotherapy for all patients at higher doses than COG, with evaluation at 4 and 8 weeks, then resection followed by post-chemotherapy pathology-based risk stratification (low, intermediate, high risk). ↗
▶ Ep 258 · 31:19
clinical In SIOP protocols, predominantly blastema component after preoperative chemotherapy is a negative prognostic factor, but blastema percentage does not correlate with outcome in COG primary nephrectomy patients. ↗
▶ Ep 258 · 32:50
clinical The main factor predicting outcome in stage 3 disease is whether lymph nodes are positive, along with genetic changes including loss of heterozygosity and 1Q gain. ↗
▶ Ep 258 · 32:50
quote The main factor that predicts outcome in stage 3 is whether they're lymph node positive or not. ↗
▶ Ep 258 · 33:58
clinical Outcomes for stage 1 and stage 2 patients are basically identical between COG and SIOP treatment approaches. ↗
▶ Ep 258 · 33:58
quote When you look at the outcomes for stage 1 and stage 2 patients between the children's oncology group and the psyop groups, they're basically identical. ↗
▶ Ep 258 · 34:46
clinical Some Wilms tumor patients present with low hemoglobin because the tumor ruptures internally and bleeds. ↗
▶ Ep 258 · 35:11
quote There is something called acquired von Willebrand's disease which these patients get. In the majority of cases it is meaningless, but there have been reports in a few case series where these patients may bleed a lot. ↗
▶ Ep 258 · 35:11
clinical Acquired von Willebrand disease occurs in Wilms tumor patients; in most cases it is meaningless, but a few case series report significant intraoperative bleeding until tumor removal. ↗
▶ Ep 258 · 36:25
clinical Right-sided tumors can cause complications including adrenal vein injury, duodenal injury (due to proximity), superior mesenteric artery injury, and IVC injury due to anatomic distortion. ↗
▶ Ep 258 · 38:20
quote These tumors tend to be large and although ideally you would like to identify the renal artery and the renal vein, it's been well recognized. It's even back in Gross's book that these, if you can't do that, then you shouldn't try and do it up front. ↗
▶ Ep 258 · 42:31
clinical Wilms tumors can cause intense inflammatory reaction making them adherent to diaphragm or liver; taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 258 · 43:32
clinical A small subset of very young patients (<24 months) with stage 1 favorable histology tumors <550g can be treated with surgery alone without chemotherapy, with >95% overall survival. Those who relapse (about 10%) have 100% salvage with chemotherapy. ↗
▶ Ep 258 · 46:14
quote When you look at the outcomes of patients with tumor that extends into the cava or even up to the atrium, that's not a negative prognostic factor ↗
▶ Ep 258 · 46:27
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 258 · 47:43
quote The major complication rate in patients goes up. Those include mortalities, number of blood transfusions, ICU stay, complications go up ↗
▶ Ep 258 · 48:49
clinical Major complication rate for primary surgery with tumor extending beyond infrahepatic IVC is 26-30%, including mortality, increased transfusions, and ICU stay, supporting preoperative chemotherapy for these cases. ↗
▶ Ep 258 · 51:28
quote Todd, I, I've read 6000 operative notes, OK. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 258 · 52:39
clinical Favorable histology Wilms tumor has three components: blastema, stroma, and epithelial (triphasic tumor). Tumors with only two components are also considered favorable histology. ↗
▶ Ep 258 · 54:41
clinical Patients with loss of heterozygosity of both 1p and 16q (5-7% of patients) have significantly worse outcomes regardless of stage. Stage 1-2 patients with LOH have about 10% lower overall survival; stage 3-4 patients have 18% lower survival. ↗
▶ Ep 258 · 55:07
guideline Patients with both 1p and 16q loss of heterozygosity receive augmented therapy: doxorubicin is added for stage 1-2 disease, and five-drug regimen M is used for stage 3-4 disease. ↗
▶ Ep 258 · 55:58
clinical Unfavorable histology is classified as focal anaplasia or diffuse anaplasia based on number of high-power fields showing anaplasia, with different treatments for each. ↗
▶ Ep 258 · 56:51
clinical Renal cell carcinoma in children has no good therapy, particularly for metastatic disease. ↗
▶ Ep 258 · 57:01
clinical Clear cell sarcoma of the kidney has reasonable treatment outcomes, particularly for low stages. Rhabdoid tumors have poor outcomes except for stage 1; most present at stage 3-4 with terrible outcomes. ↗
▶ Ep 258 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 258 · 58:07
guideline The strategy for bilateral Wilms tumor is preoperative chemotherapy to shrink tumors enough to allow partial nephrectomy of at least one kidney (ideally both) to avoid dialysis. ↗
▶ Ep 258 · 58:40
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% compared to 88% for unilateral tumors; overall survival was 80% vs. 95%. ↗
▶ Ep 258 · 59:37
clinical Maximum tumor response to chemotherapy in most children with Wilms tumor occurs by 12 weeks, and early response at 6 weeks predicts late response. ↗
▶ Ep 258 · 1:00:31
epidemiological In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. In a recent COG study of 250 enrolled patients, only one turned out to have rhabdoid tumor. ↗
▶ Ep 258 · 1:01:56
guideline Biopsy is recommended for bilateral tumors in older patients (8-10 years) or those with syndromes like von Hippel-Lindau where renal cell carcinoma is more likely. ↗
▶ Ep 258 · 1:02:16
clinical If biopsying bilateral tumors, both kidneys should be biopsied because there is discordant pathology in up to 20% of patients. ↗
Peter's statements about Sarcoma (Ewing/Rhabdo) 55 statements

Open the Sarcoma (Ewing/Rhabdo) collection →

Wilms Tumor: Audio Chapter

▶ Ep 12 · 3:49
quote The classic feature is something called a sign where you have the kidney. The normal kidney being displaced into a horseshoe pattern and fitting inside that horseshoe pattern is a tumor and so it looks like the normal kidney is grabbing the mass that's coming out of it. ↗
▶ Ep 12 · 3:49
clinical The 'claw sign' on CT—normal kidney displaced into a horseshoe pattern around a mass—is a classic feature of Wilms tumor. ↗
▶ Ep 12 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing into them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 12 · 6:23
guideline In North America, the preferred approach for resectable Wilms tumor is primary nephrectomy (total nephrectomy and ureterectomy with lymph node sampling). ↗
▶ Ep 12 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 12 · 7:01
guideline Preoperative chemotherapy is recommended if tumor extends into the IVC beyond the infrahepatic vena cava, if tumor is so large it compromises respiratory status, if major liver or bowel resection would be required, if only one functioning kidney exists, or if bilateral tumors are present. ↗
▶ Ep 12 · 10:24
clinical If a tumor requires major liver or bowel resection, biopsy and preoperative chemotherapy are preferred because complication rates are higher when these organs are resected at the same time as the kidney, and most tumors will respond to chemotherapy. ↗
▶ Ep 12 · 10:48
quote There's no reason to do that and and overall the consequence in that case of of upstaging, where does that so it's not really upstaging ↗
▶ Ep 12 · 11:18
guideline Biopsy with residual gross tumor has always been treated as stage 3 abdominal disease, requiring three-drug chemotherapy plus flank radiation. ↗
▶ Ep 12 · 14:33
clinical Evidence suggests higher risk of tumor rupture when tumors reach 13-15 centimeters or larger, which may warrant consideration of preoperative chemotherapy. ↗
▶ Ep 12 · 17:19
guideline For biopsy, open biopsy provides large tissue sections; large-core needle biopsy (10-20 cores) has proven accurate in several series. Fine needle aspiration or single-pass true-cut biopsy cannot diagnose anaplasia and should not be used. ↗
▶ Ep 12 · 20:00
guideline COG stage 1 is tumor limited to kidney, completely resected, no capsular invasion, no rupture or biopsy, vessels of renal sinus not involved, negative margins, and negative regional lymph nodes. ↗
▶ Ep 12 · 20:28
guideline COG stage 2 is complete resection with negative margins but tumor extends beyond kidney through capsular penetration, renal sinus invasion, or blood vessel involvement within the nephrectomy specimen outside the primary kidney. ↗
▶ Ep 12 · 21:00
guideline COG stage 3 includes: biopsy with gross residual tumor, positive lymph nodes, peritoneal surface penetration with implants, positive margins, microscopic residual from intraoperative spill, incomplete resection, piecemeal removal, or renal vein division with tumor present. ↗
▶ Ep 12 · 21:58
guideline COG stage 4 is hematogenous metastasis to lung, liver (most common), bone, or brain. Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 12 · 23:08
guideline Stage 1-2 abdominal disease without lung metastases receives two-drug chemotherapy (vincristine and dactinomycin) for shorter duration without abdominal radiation, significantly reducing late effects including renal failure, second malignancies, and cardiovascular disease. ↗
▶ Ep 12 · 24:15
clinical If a patient has a lung lesion but stage 1-2 abdominal disease after primary nephrectomy with negative lymph nodes, the child avoids abdominal radiation (though still receives chemotherapy for the lung lesion). ↗
▶ Ep 12 · 24:15
quote Just because they have a lung lesion doesn't mean that you shouldn't take out the primary tumor ↗
▶ Ep 12 · 26:08
quote Fifteen percent of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 12 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer, a significant late effect. ↗
▶ Ep 12 · 26:24
clinical Recent COG data shows approximately 40% of patients with pulmonary metastases who have complete response at 6 weeks can avoid pulmonary radiation without affecting event-free or overall survival, with 80-85% not relapsing. ↗
▶ Ep 12 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 12 · 28:09
quote About 50 to 60% of the time those lesions may not turn out to be cancer. They could be scarred. They could be a variety of things. ↗
▶ Ep 12 · 28:09
clinical For a single lung lesion remaining at 6 weeks that did not respond to chemotherapy, thoracoscopic biopsy is reasonable because 50-60% of such lesions may not be cancer (could be scar), and if benign, the patient would not need pulmonary radiation. ↗
▶ Ep 12 · 30:16
guideline SIOP protocols use preoperative chemotherapy for all patients at higher doses than COG, with evaluation at 4 and 8 weeks, then resection followed by post-chemotherapy pathology-based risk stratification (low, intermediate, high risk). ↗
▶ Ep 12 · 31:19
clinical In SIOP protocols, predominantly blastema component after preoperative chemotherapy is a negative prognostic factor, but blastema percentage does not correlate with outcome in COG primary nephrectomy patients. ↗
▶ Ep 12 · 32:50
quote The main factor that predicts outcome in stage 3 is whether they're lymph node positive or not. ↗
▶ Ep 12 · 32:50
clinical The main factor predicting outcome in stage 3 disease is whether lymph nodes are positive, along with genetic changes including loss of heterozygosity and 1Q gain. ↗
▶ Ep 12 · 33:58
quote When you look at the outcomes for stage 1 and stage 2 patients between the children's oncology group and the psyop groups, they're basically identical. ↗
▶ Ep 12 · 33:58
clinical Outcomes for stage 1 and stage 2 patients are basically identical between COG and SIOP treatment approaches. ↗
▶ Ep 12 · 34:46
clinical Some Wilms tumor patients present with low hemoglobin because the tumor ruptures internally and bleeds. ↗
▶ Ep 12 · 35:11
clinical Acquired von Willebrand disease occurs in Wilms tumor patients; in most cases it is meaningless, but a few case series report significant intraoperative bleeding until tumor removal. ↗
▶ Ep 12 · 35:11
quote There is something called acquired von Willebrand's disease which these patients get. In the majority of cases it is meaningless, but there have been reports in a few case series where these patients may bleed a lot. ↗
▶ Ep 12 · 36:25
clinical Right-sided tumors can cause complications including adrenal vein injury, duodenal injury (due to proximity), superior mesenteric artery injury, and IVC injury due to anatomic distortion. ↗
▶ Ep 12 · 38:20
quote These tumors tend to be large and although ideally you would like to identify the renal artery and the renal vein, it's been well recognized. It's even back in Gross's book that these, if you can't do that, then you shouldn't try and do it up front. ↗
▶ Ep 12 · 42:31
clinical Wilms tumors can cause intense inflammatory reaction making them adherent to diaphragm or liver; taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 12 · 43:32
clinical A small subset of very young patients (<24 months) with stage 1 favorable histology tumors <550g can be treated with surgery alone without chemotherapy, with >95% overall survival. Those who relapse (about 10%) have 100% salvage with chemotherapy. ↗
▶ Ep 12 · 46:14
quote When you look at the outcomes of patients with tumor that extends into the cava or even up to the atrium, that's not a negative prognostic factor ↗
▶ Ep 12 · 46:27
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 12 · 47:43
quote The major complication rate in patients goes up. Those include mortalities, number of blood transfusions, ICU stay, complications go up ↗
▶ Ep 12 · 48:49
clinical Major complication rate for primary surgery with tumor extending beyond infrahepatic IVC is 26-30%, including mortality, increased transfusions, and ICU stay, supporting preoperative chemotherapy for these cases. ↗
▶ Ep 12 · 51:28
quote Todd, I, I've read 6000 operative notes, OK. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 12 · 52:39
clinical Favorable histology Wilms tumor has three components: blastema, stroma, and epithelial (triphasic tumor). Tumors with only two components are also considered favorable histology. ↗
▶ Ep 12 · 54:41
clinical Patients with loss of heterozygosity of both 1p and 16q (5-7% of patients) have significantly worse outcomes regardless of stage. Stage 1-2 patients with LOH have about 10% lower overall survival; stage 3-4 patients have 18% lower survival. ↗
▶ Ep 12 · 55:07
guideline Patients with both 1p and 16q loss of heterozygosity receive augmented therapy: doxorubicin is added for stage 1-2 disease, and five-drug regimen M is used for stage 3-4 disease. ↗
▶ Ep 12 · 55:58
clinical Unfavorable histology is classified as focal anaplasia or diffuse anaplasia based on number of high-power fields showing anaplasia, with different treatments for each. ↗
▶ Ep 12 · 56:51
clinical Renal cell carcinoma in children has no good therapy, particularly for metastatic disease. ↗
▶ Ep 12 · 57:01
clinical Clear cell sarcoma of the kidney has reasonable treatment outcomes, particularly for low stages. Rhabdoid tumors have poor outcomes except for stage 1; most present at stage 3-4 with terrible outcomes. ↗
▶ Ep 12 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 12 · 58:07
guideline The strategy for bilateral Wilms tumor is preoperative chemotherapy to shrink tumors enough to allow partial nephrectomy of at least one kidney (ideally both) to avoid dialysis. ↗
▶ Ep 12 · 58:40
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% compared to 88% for unilateral tumors; overall survival was 80% vs. 95%. ↗
▶ Ep 12 · 59:37
clinical Maximum tumor response to chemotherapy in most children with Wilms tumor occurs by 12 weeks, and early response at 6 weeks predicts late response. ↗
▶ Ep 12 · 1:00:31
epidemiological In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. In a recent COG study of 250 enrolled patients, only one turned out to have rhabdoid tumor. ↗
▶ Ep 12 · 1:01:56
guideline Biopsy is recommended for bilateral tumors in older patients (8-10 years) or those with syndromes like von Hippel-Lindau where renal cell carcinoma is more likely. ↗
▶ Ep 12 · 1:02:16
clinical If biopsying bilateral tumors, both kidneys should be biopsied because there is discordant pathology in up to 20% of patients. ↗
Peter's statements about Soft Tissue Sarcoma (lymph nodes) 55 statements

Open the Soft Tissue Sarcoma (lymph nodes) collection →

Wilms Tumor: Audio Chapter

▶ Ep 9 · 3:49
clinical The 'claw sign' on CT—normal kidney displaced into a horseshoe pattern around a mass—is a classic feature of Wilms tumor. ↗
▶ Ep 9 · 3:49
quote The classic feature is something called a sign where you have the kidney. The normal kidney being displaced into a horseshoe pattern and fitting inside that horseshoe pattern is a tumor and so it looks like the normal kidney is grabbing the mass that's coming out of it. ↗
▶ Ep 9 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing into them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 9 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 9 · 6:23
guideline In North America, the preferred approach for resectable Wilms tumor is primary nephrectomy (total nephrectomy and ureterectomy with lymph node sampling). ↗
▶ Ep 9 · 7:01
guideline Preoperative chemotherapy is recommended if tumor extends into the IVC beyond the infrahepatic vena cava, if tumor is so large it compromises respiratory status, if major liver or bowel resection would be required, if only one functioning kidney exists, or if bilateral tumors are present. ↗
▶ Ep 9 · 10:24
clinical If a tumor requires major liver or bowel resection, biopsy and preoperative chemotherapy are preferred because complication rates are higher when these organs are resected at the same time as the kidney, and most tumors will respond to chemotherapy. ↗
▶ Ep 9 · 10:48
quote There's no reason to do that and and overall the consequence in that case of of upstaging, where does that so it's not really upstaging ↗
▶ Ep 9 · 11:18
guideline Biopsy with residual gross tumor has always been treated as stage 3 abdominal disease, requiring three-drug chemotherapy plus flank radiation. ↗
▶ Ep 9 · 14:33
clinical Evidence suggests higher risk of tumor rupture when tumors reach 13-15 centimeters or larger, which may warrant consideration of preoperative chemotherapy. ↗
▶ Ep 9 · 17:19
guideline For biopsy, open biopsy provides large tissue sections; large-core needle biopsy (10-20 cores) has proven accurate in several series. Fine needle aspiration or single-pass true-cut biopsy cannot diagnose anaplasia and should not be used. ↗
▶ Ep 9 · 20:00
guideline COG stage 1 is tumor limited to kidney, completely resected, no capsular invasion, no rupture or biopsy, vessels of renal sinus not involved, negative margins, and negative regional lymph nodes. ↗
▶ Ep 9 · 20:28
guideline COG stage 2 is complete resection with negative margins but tumor extends beyond kidney through capsular penetration, renal sinus invasion, or blood vessel involvement within the nephrectomy specimen outside the primary kidney. ↗
▶ Ep 9 · 21:00
guideline COG stage 3 includes: biopsy with gross residual tumor, positive lymph nodes, peritoneal surface penetration with implants, positive margins, microscopic residual from intraoperative spill, incomplete resection, piecemeal removal, or renal vein division with tumor present. ↗
▶ Ep 9 · 21:58
guideline COG stage 4 is hematogenous metastasis to lung, liver (most common), bone, or brain. Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 9 · 23:08
guideline Stage 1-2 abdominal disease without lung metastases receives two-drug chemotherapy (vincristine and dactinomycin) for shorter duration without abdominal radiation, significantly reducing late effects including renal failure, second malignancies, and cardiovascular disease. ↗
▶ Ep 9 · 24:15
quote Just because they have a lung lesion doesn't mean that you shouldn't take out the primary tumor ↗
▶ Ep 9 · 24:15
clinical If a patient has a lung lesion but stage 1-2 abdominal disease after primary nephrectomy with negative lymph nodes, the child avoids abdominal radiation (though still receives chemotherapy for the lung lesion). ↗
▶ Ep 9 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer, a significant late effect. ↗
▶ Ep 9 · 26:08
quote Fifteen percent of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 9 · 26:24
clinical Recent COG data shows approximately 40% of patients with pulmonary metastases who have complete response at 6 weeks can avoid pulmonary radiation without affecting event-free or overall survival, with 80-85% not relapsing. ↗
▶ Ep 9 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 9 · 28:09
clinical For a single lung lesion remaining at 6 weeks that did not respond to chemotherapy, thoracoscopic biopsy is reasonable because 50-60% of such lesions may not be cancer (could be scar), and if benign, the patient would not need pulmonary radiation. ↗
▶ Ep 9 · 28:09
quote About 50 to 60% of the time those lesions may not turn out to be cancer. They could be scarred. They could be a variety of things. ↗
▶ Ep 9 · 30:16
guideline SIOP protocols use preoperative chemotherapy for all patients at higher doses than COG, with evaluation at 4 and 8 weeks, then resection followed by post-chemotherapy pathology-based risk stratification (low, intermediate, high risk). ↗
▶ Ep 9 · 31:19
clinical In SIOP protocols, predominantly blastema component after preoperative chemotherapy is a negative prognostic factor, but blastema percentage does not correlate with outcome in COG primary nephrectomy patients. ↗
▶ Ep 9 · 32:50
quote The main factor that predicts outcome in stage 3 is whether they're lymph node positive or not. ↗
▶ Ep 9 · 32:50
clinical The main factor predicting outcome in stage 3 disease is whether lymph nodes are positive, along with genetic changes including loss of heterozygosity and 1Q gain. ↗
▶ Ep 9 · 33:58
quote When you look at the outcomes for stage 1 and stage 2 patients between the children's oncology group and the psyop groups, they're basically identical. ↗
▶ Ep 9 · 33:58
clinical Outcomes for stage 1 and stage 2 patients are basically identical between COG and SIOP treatment approaches. ↗
▶ Ep 9 · 34:46
clinical Some Wilms tumor patients present with low hemoglobin because the tumor ruptures internally and bleeds. ↗
▶ Ep 9 · 35:11
quote There is something called acquired von Willebrand's disease which these patients get. In the majority of cases it is meaningless, but there have been reports in a few case series where these patients may bleed a lot. ↗
▶ Ep 9 · 35:11
clinical Acquired von Willebrand disease occurs in Wilms tumor patients; in most cases it is meaningless, but a few case series report significant intraoperative bleeding until tumor removal. ↗
▶ Ep 9 · 36:25
clinical Right-sided tumors can cause complications including adrenal vein injury, duodenal injury (due to proximity), superior mesenteric artery injury, and IVC injury due to anatomic distortion. ↗
▶ Ep 9 · 38:20
quote These tumors tend to be large and although ideally you would like to identify the renal artery and the renal vein, it's been well recognized. It's even back in Gross's book that these, if you can't do that, then you shouldn't try and do it up front. ↗
▶ Ep 9 · 42:31
clinical Wilms tumors can cause intense inflammatory reaction making them adherent to diaphragm or liver; taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 9 · 43:32
clinical A small subset of very young patients (<24 months) with stage 1 favorable histology tumors <550g can be treated with surgery alone without chemotherapy, with >95% overall survival. Those who relapse (about 10%) have 100% salvage with chemotherapy. ↗
▶ Ep 9 · 46:14
quote When you look at the outcomes of patients with tumor that extends into the cava or even up to the atrium, that's not a negative prognostic factor ↗
▶ Ep 9 · 46:27
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 9 · 47:43
quote The major complication rate in patients goes up. Those include mortalities, number of blood transfusions, ICU stay, complications go up ↗
▶ Ep 9 · 48:49
clinical Major complication rate for primary surgery with tumor extending beyond infrahepatic IVC is 26-30%, including mortality, increased transfusions, and ICU stay, supporting preoperative chemotherapy for these cases. ↗
▶ Ep 9 · 51:28
quote Todd, I, I've read 6000 operative notes, OK. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 9 · 52:39
clinical Favorable histology Wilms tumor has three components: blastema, stroma, and epithelial (triphasic tumor). Tumors with only two components are also considered favorable histology. ↗
▶ Ep 9 · 54:41
clinical Patients with loss of heterozygosity of both 1p and 16q (5-7% of patients) have significantly worse outcomes regardless of stage. Stage 1-2 patients with LOH have about 10% lower overall survival; stage 3-4 patients have 18% lower survival. ↗
▶ Ep 9 · 55:07
guideline Patients with both 1p and 16q loss of heterozygosity receive augmented therapy: doxorubicin is added for stage 1-2 disease, and five-drug regimen M is used for stage 3-4 disease. ↗
▶ Ep 9 · 55:58
clinical Unfavorable histology is classified as focal anaplasia or diffuse anaplasia based on number of high-power fields showing anaplasia, with different treatments for each. ↗
▶ Ep 9 · 56:51
clinical Renal cell carcinoma in children has no good therapy, particularly for metastatic disease. ↗
▶ Ep 9 · 57:01
clinical Clear cell sarcoma of the kidney has reasonable treatment outcomes, particularly for low stages. Rhabdoid tumors have poor outcomes except for stage 1; most present at stage 3-4 with terrible outcomes. ↗
▶ Ep 9 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 9 · 58:07
guideline The strategy for bilateral Wilms tumor is preoperative chemotherapy to shrink tumors enough to allow partial nephrectomy of at least one kidney (ideally both) to avoid dialysis. ↗
▶ Ep 9 · 58:40
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% compared to 88% for unilateral tumors; overall survival was 80% vs. 95%. ↗
▶ Ep 9 · 59:37
clinical Maximum tumor response to chemotherapy in most children with Wilms tumor occurs by 12 weeks, and early response at 6 weeks predicts late response. ↗
▶ Ep 9 · 1:00:31
epidemiological In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. In a recent COG study of 250 enrolled patients, only one turned out to have rhabdoid tumor. ↗
▶ Ep 9 · 1:01:56
guideline Biopsy is recommended for bilateral tumors in older patients (8-10 years) or those with syndromes like von Hippel-Lindau where renal cell carcinoma is more likely. ↗
▶ Ep 9 · 1:02:16
clinical If biopsying bilateral tumors, both kidneys should be biopsied because there is discordant pathology in up to 20% of patients. ↗
Peter's statements about Wilms Tumor 207 statements

Open the Wilms Tumor collection →

Wilms Tumor: Audio Chapter

▶ Ep 2 · 3:49
clinical Wilms tumors characteristically show a 'claw sign' on imaging where normal kidney is displaced into a horseshoe pattern, appearing to grab the mass coming out of it. ↗
▶ Ep 2 · 3:49
clinical Wilms tumors characteristically show a 'claw sign' on imaging where normal kidney is displaced into a horseshoe pattern, appearing to grab the mass coming out of it. ↗
▶ Ep 2 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing around them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 2 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing around them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 2 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 2 · 6:23
guideline In North America, the Children's Oncology Group recommends primary nephrectomy and ureterectomy with lymph node sampling for the majority of children with renal tumors. ↗
▶ Ep 2 · 6:23
guideline In North America, the Children's Oncology Group recommends primary nephrectomy and ureterectomy with lymph node sampling for the majority of children with renal tumors. ↗
▶ Ep 2 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 2 · 7:01
guideline Preoperative chemotherapy is recommended if the tumor compromises the child's respiratory status, making them a poor operative candidate. ↗
▶ Ep 2 · 7:01
guideline Preoperative chemotherapy is recommended if the tumor compromises the child's respiratory status, making them a poor operative candidate. ↗
▶ Ep 2 · 7:33
guideline If tumor extends into the inferior vena cava beyond the intrahepatic level (behind the liver or up to the atrium), preoperative chemotherapy is recommended. ↗
▶ Ep 2 · 7:33
guideline If tumor extends into the inferior vena cava beyond the intrahepatic level (behind the liver or up to the atrium), preoperative chemotherapy is recommended. ↗
▶ Ep 2 · 7:57
guideline Massive tumors that would require resection of large parts of liver or bowel should receive preoperative chemotherapy because the majority will respond. ↗
▶ Ep 2 · 7:57
guideline Massive tumors that would require resection of large parts of liver or bowel should receive preoperative chemotherapy because the majority will respond. ↗
▶ Ep 2 · 8:21
guideline If the child has only one functioning kidney, preoperative chemotherapy is recommended to avoid nephrectomy. ↗
▶ Ep 2 · 8:21
guideline If the child has only one functioning kidney, preoperative chemotherapy is recommended to avoid nephrectomy. ↗
▶ Ep 2 · 8:33
guideline Children with bilateral renal tumors, Wilms tumor predisposition syndromes (Wagr, Denys-Drash, Beckwith-Wiedemann), or multicentric tumors should not undergo primary nephrectomy. ↗
▶ Ep 2 · 8:33
guideline Children with bilateral renal tumors, Wilms tumor predisposition syndromes (Wagr, Denys-Drash, Beckwith-Wiedemann), or multicentric tumors should not undergo primary nephrectomy. ↗
▶ Ep 2 · 10:38
clinical Complication rates are higher if liver or bowel must be resected at the same time as the kidney. ↗
▶ Ep 2 · 10:38
clinical Complication rates are higher if liver or bowel must be resected at the same time as the kidney. ↗
▶ Ep 2 · 11:18
guideline If gross tumor is left behind or the tumor is only biopsied, it is treated as a stage 3 abdominal tumor requiring 3-drug chemotherapy plus flank radiation. ↗
▶ Ep 2 · 11:18
guideline If gross tumor is left behind or the tumor is only biopsied, it is treated as a stage 3 abdominal tumor requiring 3-drug chemotherapy plus flank radiation. ↗
▶ Ep 2 · 14:19
quote If you feel that you would have to do a major liver or bowel resection at the same time, that is a situation in which we would not recommend doing a primary nephrectomy. ↗
▶ Ep 2 · 14:19
quote If you feel that you would have to do a major liver or bowel resection at the same time, that is a situation in which we would not recommend doing a primary nephrectomy. ↗
▶ Ep 2 · 19:44
guideline In the COG staging system, treatment is determined by both local abdominal stage and disease stage. ↗
▶ Ep 2 · 19:44
guideline In the COG staging system, treatment is determined by both local abdominal stage and disease stage. ↗
▶ Ep 2 · 20:01
guideline Stage 1 tumor is limited to the kidney, completely resected, with no capsular invasion, no rupture or biopsy prior to removal, no renal sinus vessel involvement, negative margins, and negative regional lymph nodes. ↗
▶ Ep 2 · 20:01
guideline Stage 1 tumor is limited to the kidney, completely resected, with no capsular invasion, no rupture or biopsy prior to removal, no renal sinus vessel involvement, negative margins, and negative regional lymph nodes. ↗
▶ Ep 2 · 20:28
guideline Stage 2 tumor is completely resected with negative margins but extends beyond the kidney through capsular penetration, renal sinus soft tissue invasion, or blood vessel involvement outside the primary kidney. ↗
▶ Ep 2 · 20:28
guideline Stage 2 tumor is completely resected with negative margins but extends beyond the kidney through capsular penetration, renal sinus soft tissue invasion, or blood vessel involvement outside the primary kidney. ↗
▶ Ep 2 · 21:00
guideline Stage 3 includes tumors that are biopsied with gross residual, have positive lymph nodes, penetrate the peritoneal surface with implants, have positive margins, have microscopic residual from intraoperative spill, cannot be completely resected, or must be removed in pieces. ↗
▶ Ep 2 · 21:00
guideline Stage 3 includes tumors that are biopsied with gross residual, have positive lymph nodes, penetrate the peritoneal surface with implants, have positive margins, have microscopic residual from intraoperative spill, cannot be completely resected, or must be removed in pieces. ↗
▶ Ep 2 · 21:58
guideline Stage 4 is hematogenous metastasis to lung, liver, bone, or brain. ↗
▶ Ep 2 · 21:58
guideline Stage 4 is hematogenous metastasis to lung, liver, bone, or brain. ↗
▶ Ep 2 · 22:06
guideline Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 2 · 22:06
guideline Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 2 · 23:08
guideline Patients with stage 1 or 2 abdominal disease without lung metastases receive only 2-drug chemotherapy (vincristine and dactinomycin) for shorter duration with lower toxicity and significantly lower risk of late effects. ↗
▶ Ep 2 · 23:08
guideline Patients with stage 1 or 2 abdominal disease without lung metastases receive only 2-drug chemotherapy (vincristine and dactinomycin) for shorter duration with lower toxicity and significantly lower risk of late effects. ↗
▶ Ep 2 · 23:37
clinical The main late effects of Wilms tumor treatment are renal failure, second malignancies, pregnancy problems in females, hypertension, and cardiovascular disease, primarily caused by radiation and doxorubicin. ↗
▶ Ep 2 · 23:37
quote The two main factors that contribute to late effects are radiation and doxorubicin. ↗
▶ Ep 2 · 23:37
quote The two main factors that contribute to late effects are radiation and doxorubicin. ↗
▶ Ep 2 · 23:37
clinical The main late effects of Wilms tumor treatment are renal failure, second malignancies, pregnancy problems in females, hypertension, and cardiovascular disease, primarily caused by radiation and doxorubicin. ↗
▶ Ep 2 · 24:06
guideline If a child has stage 1 or 2 abdominal disease, they do not require abdominal radiation regardless of lung metastases status. ↗
▶ Ep 2 · 24:06
guideline If a child has stage 1 or 2 abdominal disease, they do not require abdominal radiation regardless of lung metastases status. ↗
▶ Ep 2 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer. ↗
▶ Ep 2 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer. ↗
▶ Ep 2 · 26:08
quote 15% of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 2 · 26:08
quote 15% of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 2 · 26:20
clinical Pulmonary radiation causes pneumonitis and long-term restrictive lung disease. ↗
▶ Ep 2 · 26:20
clinical Pulmonary radiation causes pneumonitis and long-term restrictive lung disease. ↗
▶ Ep 2 · 26:24
clinical A recent COG study showed that approximately 40% of patients with pulmonary metastases who achieve complete response by 6 weeks of chemotherapy do not need pulmonary radiation, with 80-85% remaining relapse-free. ↗
▶ Ep 2 · 26:24
clinical A recent COG study showed that approximately 40% of patients with pulmonary metastases who achieve complete response by 6 weeks of chemotherapy do not need pulmonary radiation, with 80-85% remaining relapse-free. ↗
▶ Ep 2 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 2 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 2 · 30:31
guideline In the SIOP protocols, all patients start with chemotherapy without biopsy in most cases, using higher doses of two drugs, with evaluation at 4 and 8 weeks before proceeding to resection. ↗
▶ Ep 2 · 30:31
guideline In the SIOP protocols, all patients start with chemotherapy without biopsy in most cases, using higher doses of two drugs, with evaluation at 4 and 8 weeks before proceeding to resection. ↗
▶ Ep 2 · 31:06
guideline SIOP uses post-chemotherapy, post-nephrectomy classification into low risk, intermediate risk, and high risk based on percentage of blastemal components and presence of anaplasia. ↗
▶ Ep 2 · 31:06
guideline SIOP uses post-chemotherapy, post-nephrectomy classification into low risk, intermediate risk, and high risk based on percentage of blastemal components and presence of anaplasia. ↗
▶ Ep 2 · 35:11
clinical Some children with Wilms tumor develop acquired von Willebrand disease; in the majority of cases it is meaningless, but a few case series report significant bleeding during surgery until the tumor is removed. ↗
▶ Ep 2 · 35:11
clinical Some children with Wilms tumor develop acquired von Willebrand disease; in the majority of cases it is meaningless, but a few case series report significant bleeding during surgery until the tumor is removed. ↗
▶ Ep 2 · 41:24
guideline Positive surgical margins or tumor rupture (intraoperative or microscopic) automatically makes the patient stage 3. ↗
▶ Ep 2 · 41:24
guideline Positive surgical margins or tumor rupture (intraoperative or microscopic) automatically makes the patient stage 3. ↗
▶ Ep 2 · 42:31
guideline Taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 2 · 42:31
guideline Taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 2 · 43:32
clinical Very low-risk patients (stage I, <550g, <2 years, favorable histology) can be treated with surgery alone; 90-95% are cured without chemotherapy, and those who relapse have 100% survival with delayed chemotherapy. ↗
▶ Ep 2 · 43:32
clinical Very low-risk patients (stage I, <550g, <2 years, favorable histology) can be treated with surgery alone; 90-95% are cured without chemotherapy, and those who relapse have 100% survival with delayed chemotherapy. ↗
▶ Ep 2 · 43:48
quote These patients that no matter what you did, whether you treated them with surgery, whether you added 1 drug of chemotherapy, 2 drugs of chemotherapy, 3 drugs, radiation, that they had excellent overall survival. ↗
▶ Ep 2 · 46:14
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 2 · 46:14
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 2 · 46:38
guideline If IVC tumor thrombus extends into the renal vein but is not adherent and comes out in one piece, it is considered stage 2. ↗
▶ Ep 2 · 46:38
guideline If IVC tumor thrombus extends into the renal vein but is not adherent and comes out in one piece, it is considered stage 2. ↗
▶ Ep 2 · 47:43
clinical Major complication rates (including mortality, blood transfusions, ICU stay) increase significantly when tumor extends beyond the infrahepatic IVC to the hepatic veins or atrium, with 26-30% major morbidity in primary resection cases. ↗
▶ Ep 2 · 47:43
clinical Major complication rates (including mortality, blood transfusions, ICU stay) increase significantly when tumor extends beyond the infrahepatic IVC to the hepatic veins or atrium, with 26-30% major morbidity in primary resection cases. ↗
▶ Ep 2 · 51:28
quote I've read 6000 operative notes. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 2 · 51:28
quote I've read 6000 operative notes. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 2 · 54:41
clinical Loss of heterozygosity at both 1p and 16q occurs in 5-7% of patients and is associated with significantly worse outcomes regardless of stage. ↗
▶ Ep 2 · 54:41
clinical Loss of heterozygosity at both 1p and 16q occurs in 5-7% of patients and is associated with significantly worse outcomes regardless of stage. ↗
▶ Ep 2 · 55:23
epidemiological Stage 1-2 patients with loss of heterozygosity at 1p and 16q have approximately 10% lower overall survival than those without these genetic changes. ↗
▶ Ep 2 · 55:23
epidemiological Stage 1-2 patients with loss of heterozygosity at 1p and 16q have approximately 10% lower overall survival than those without these genetic changes. ↗
▶ Ep 2 · 55:45
clinical Stage 3-4 patients with loss of heterozygosity at 1p and 16q have approximately 18% lower overall survival and receive 5-drug regimen M chemotherapy. ↗
▶ Ep 2 · 55:45
clinical Stage 3-4 patients with loss of heterozygosity at 1p and 16q have approximately 18% lower overall survival and receive 5-drug regimen M chemotherapy. ↗
▶ Ep 2 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 2 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 2 · 58:51
epidemiological Event-free survival for unilateral Wilms tumor is approximately 88% with overall survival of 95%. ↗
▶ Ep 2 · 58:51
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% with overall survival of only 80%. ↗
▶ Ep 2 · 58:51
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% with overall survival of only 80%. ↗
▶ Ep 2 · 58:51
epidemiological Event-free survival for unilateral Wilms tumor is approximately 88% with overall survival of 95%. ↗
▶ Ep 2 · 59:37
clinical The maximum response of most children with Wilms tumor to chemotherapy occurs by 12 weeks. ↗
▶ Ep 2 · 59:37
clinical The maximum response of most children with Wilms tumor to chemotherapy occurs by 12 weeks. ↗
▶ Ep 2 · 1:00:31
clinical In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. ↗
▶ Ep 2 · 1:00:31
clinical In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. ↗
▶ Ep 2 · 1:01:02
clinical Open biopsy to determine favorable vs. unfavorable histology in Wilms tumor is not very accurate initially. ↗
▶ Ep 2 · 1:01:02
clinical Open biopsy to determine favorable vs. unfavorable histology in Wilms tumor is not very accurate initially. ↗
▶ Ep 2 · 1:01:12
epidemiological In a recent COG bilateral Wilms study of 250 patients, only one patient who met enrollment criteria turned out to have rhabdoid tumor instead of Wilms tumor. ↗
▶ Ep 2 · 1:01:12
epidemiological In a recent COG bilateral Wilms study of 250 patients, only one patient who met enrollment criteria turned out to have rhabdoid tumor instead of Wilms tumor. ↗
▶ Ep 2 · 1:02:14
epidemiological Discordant pathology occurs in up to 20% of bilateral Wilms tumor patients when both kidneys are biopsied. ↗
▶ Ep 2 · 1:02:14
epidemiological Discordant pathology occurs in up to 20% of bilateral Wilms tumor patients when both kidneys are biopsied. ↗

Wilms Tumor: Audio Chapter

▶ Ep 10 · 3:49
quote The classic feature is something called a sign where you have the kidney. The normal kidney being displaced into a horseshoe pattern and fitting inside that horseshoe pattern is a tumor and so it looks like the normal kidney is grabbing the mass that's coming out of it. ↗
▶ Ep 10 · 3:49
clinical The 'claw sign' on CT—normal kidney displaced into a horseshoe pattern around a mass—is a classic feature of Wilms tumor. ↗
▶ Ep 10 · 3:49
quote The classic feature is something called a sign where you have the kidney. The normal kidney being displaced into a horseshoe pattern and fitting inside that horseshoe pattern is a tumor and so it looks like the normal kidney is grabbing the mass that's coming out of it. ↗
▶ Ep 10 · 3:49
clinical The 'claw sign' on CT—normal kidney displaced into a horseshoe pattern around a mass—is a classic feature of Wilms tumor. ↗
▶ Ep 10 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing into them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 10 · 4:16
clinical Wilms tumor tends to push structures out of the way rather than growing into them, whereas neuroblastoma grows around structures like blood vessels. ↗
▶ Ep 10 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 10 · 6:23
guideline In North America, the preferred approach for resectable Wilms tumor is primary nephrectomy (total nephrectomy and ureterectomy with lymph node sampling). ↗
▶ Ep 10 · 6:23
guideline In North America, the preferred approach for resectable Wilms tumor is primary nephrectomy (total nephrectomy and ureterectomy with lymph node sampling). ↗
▶ Ep 10 · 6:23
quote In North America we believe and prefer that the next step in the treatment of children with renal tumors is to go ahead and perform surgery. ↗
▶ Ep 10 · 7:01
guideline Preoperative chemotherapy is recommended if tumor extends into the IVC beyond the infrahepatic vena cava, if tumor is so large it compromises respiratory status, if major liver or bowel resection would be required, if only one functioning kidney exists, or if bilateral tumors are present. ↗
▶ Ep 10 · 7:01
guideline Preoperative chemotherapy is recommended if tumor extends into the IVC beyond the infrahepatic vena cava, if tumor is so large it compromises respiratory status, if major liver or bowel resection would be required, if only one functioning kidney exists, or if bilateral tumors are present. ↗
▶ Ep 10 · 10:24
clinical If a tumor requires major liver or bowel resection, biopsy and preoperative chemotherapy are preferred because complication rates are higher when these organs are resected at the same time as the kidney, and most tumors will respond to chemotherapy. ↗
▶ Ep 10 · 10:24
clinical If a tumor requires major liver or bowel resection, biopsy and preoperative chemotherapy are preferred because complication rates are higher when these organs are resected at the same time as the kidney, and most tumors will respond to chemotherapy. ↗
▶ Ep 10 · 10:48
quote There's no reason to do that and and overall the consequence in that case of of upstaging, where does that so it's not really upstaging ↗
▶ Ep 10 · 10:48
quote There's no reason to do that and and overall the consequence in that case of of upstaging, where does that so it's not really upstaging ↗
▶ Ep 10 · 11:18
guideline Biopsy with residual gross tumor has always been treated as stage 3 abdominal disease, requiring three-drug chemotherapy plus flank radiation. ↗
▶ Ep 10 · 11:18
guideline Biopsy with residual gross tumor has always been treated as stage 3 abdominal disease, requiring three-drug chemotherapy plus flank radiation. ↗
▶ Ep 10 · 14:33
clinical Evidence suggests higher risk of tumor rupture when tumors reach 13-15 centimeters or larger, which may warrant consideration of preoperative chemotherapy. ↗
▶ Ep 10 · 14:33
clinical Evidence suggests higher risk of tumor rupture when tumors reach 13-15 centimeters or larger, which may warrant consideration of preoperative chemotherapy. ↗
▶ Ep 10 · 17:19
guideline For biopsy, open biopsy provides large tissue sections; large-core needle biopsy (10-20 cores) has proven accurate in several series. Fine needle aspiration or single-pass true-cut biopsy cannot diagnose anaplasia and should not be used. ↗
▶ Ep 10 · 17:19
guideline For biopsy, open biopsy provides large tissue sections; large-core needle biopsy (10-20 cores) has proven accurate in several series. Fine needle aspiration or single-pass true-cut biopsy cannot diagnose anaplasia and should not be used. ↗
▶ Ep 10 · 20:00
guideline COG stage 1 is tumor limited to kidney, completely resected, no capsular invasion, no rupture or biopsy, vessels of renal sinus not involved, negative margins, and negative regional lymph nodes. ↗
▶ Ep 10 · 20:00
guideline COG stage 1 is tumor limited to kidney, completely resected, no capsular invasion, no rupture or biopsy, vessels of renal sinus not involved, negative margins, and negative regional lymph nodes. ↗
▶ Ep 10 · 20:28
guideline COG stage 2 is complete resection with negative margins but tumor extends beyond kidney through capsular penetration, renal sinus invasion, or blood vessel involvement within the nephrectomy specimen outside the primary kidney. ↗
▶ Ep 10 · 20:28
guideline COG stage 2 is complete resection with negative margins but tumor extends beyond kidney through capsular penetration, renal sinus invasion, or blood vessel involvement within the nephrectomy specimen outside the primary kidney. ↗
▶ Ep 10 · 21:00
guideline COG stage 3 includes: biopsy with gross residual tumor, positive lymph nodes, peritoneal surface penetration with implants, positive margins, microscopic residual from intraoperative spill, incomplete resection, piecemeal removal, or renal vein division with tumor present. ↗
▶ Ep 10 · 21:00
guideline COG stage 3 includes: biopsy with gross residual tumor, positive lymph nodes, peritoneal surface penetration with implants, positive margins, microscopic residual from intraoperative spill, incomplete resection, piecemeal removal, or renal vein division with tumor present. ↗
▶ Ep 10 · 21:58
guideline COG stage 4 is hematogenous metastasis to lung, liver (most common), bone, or brain. Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 10 · 21:58
guideline COG stage 4 is hematogenous metastasis to lung, liver (most common), bone, or brain. Stage 5 is bilateral renal tumor involvement. ↗
▶ Ep 10 · 23:08
guideline Stage 1-2 abdominal disease without lung metastases receives two-drug chemotherapy (vincristine and dactinomycin) for shorter duration without abdominal radiation, significantly reducing late effects including renal failure, second malignancies, and cardiovascular disease. ↗
▶ Ep 10 · 23:08
guideline Stage 1-2 abdominal disease without lung metastases receives two-drug chemotherapy (vincristine and dactinomycin) for shorter duration without abdominal radiation, significantly reducing late effects including renal failure, second malignancies, and cardiovascular disease. ↗
▶ Ep 10 · 24:15
clinical If a patient has a lung lesion but stage 1-2 abdominal disease after primary nephrectomy with negative lymph nodes, the child avoids abdominal radiation (though still receives chemotherapy for the lung lesion). ↗
▶ Ep 10 · 24:15
clinical If a patient has a lung lesion but stage 1-2 abdominal disease after primary nephrectomy with negative lymph nodes, the child avoids abdominal radiation (though still receives chemotherapy for the lung lesion). ↗
▶ Ep 10 · 24:15
quote Just because they have a lung lesion doesn't mean that you shouldn't take out the primary tumor ↗
▶ Ep 10 · 24:15
quote Just because they have a lung lesion doesn't mean that you shouldn't take out the primary tumor ↗
▶ Ep 10 · 26:08
quote Fifteen percent of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 10 · 26:08
quote Fifteen percent of the girls who get pulmonary radiation from Wilms tumor end up getting breast cancer, which is significant. ↗
▶ Ep 10 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer, a significant late effect. ↗
▶ Ep 10 · 26:08
epidemiological Fifteen percent of girls who receive pulmonary radiation for Wilms tumor develop breast cancer, a significant late effect. ↗
▶ Ep 10 · 26:24
clinical Recent COG data shows approximately 40% of patients with pulmonary metastases who have complete response at 6 weeks can avoid pulmonary radiation without affecting event-free or overall survival, with 80-85% not relapsing. ↗
▶ Ep 10 · 26:24
clinical Recent COG data shows approximately 40% of patients with pulmonary metastases who have complete response at 6 weeks can avoid pulmonary radiation without affecting event-free or overall survival, with 80-85% not relapsing. ↗
▶ Ep 10 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 10 · 26:44
quote There was about 40% of the patients, they were not given pulmonary radiation and looking at that group at this point in time looking at relapses, there was about 80% to 85% that did not relapse. ↗
▶ Ep 10 · 28:09
quote About 50 to 60% of the time those lesions may not turn out to be cancer. They could be scarred. They could be a variety of things. ↗
▶ Ep 10 · 28:09
quote About 50 to 60% of the time those lesions may not turn out to be cancer. They could be scarred. They could be a variety of things. ↗
▶ Ep 10 · 28:09
clinical For a single lung lesion remaining at 6 weeks that did not respond to chemotherapy, thoracoscopic biopsy is reasonable because 50-60% of such lesions may not be cancer (could be scar), and if benign, the patient would not need pulmonary radiation. ↗
▶ Ep 10 · 28:09
clinical For a single lung lesion remaining at 6 weeks that did not respond to chemotherapy, thoracoscopic biopsy is reasonable because 50-60% of such lesions may not be cancer (could be scar), and if benign, the patient would not need pulmonary radiation. ↗
▶ Ep 10 · 30:16
guideline SIOP protocols use preoperative chemotherapy for all patients at higher doses than COG, with evaluation at 4 and 8 weeks, then resection followed by post-chemotherapy pathology-based risk stratification (low, intermediate, high risk). ↗
▶ Ep 10 · 30:16
guideline SIOP protocols use preoperative chemotherapy for all patients at higher doses than COG, with evaluation at 4 and 8 weeks, then resection followed by post-chemotherapy pathology-based risk stratification (low, intermediate, high risk). ↗
▶ Ep 10 · 31:19
clinical In SIOP protocols, predominantly blastema component after preoperative chemotherapy is a negative prognostic factor, but blastema percentage does not correlate with outcome in COG primary nephrectomy patients. ↗
▶ Ep 10 · 31:19
clinical In SIOP protocols, predominantly blastema component after preoperative chemotherapy is a negative prognostic factor, but blastema percentage does not correlate with outcome in COG primary nephrectomy patients. ↗
▶ Ep 10 · 32:50
clinical The main factor predicting outcome in stage 3 disease is whether lymph nodes are positive, along with genetic changes including loss of heterozygosity and 1Q gain. ↗
▶ Ep 10 · 32:50
quote The main factor that predicts outcome in stage 3 is whether they're lymph node positive or not. ↗
▶ Ep 10 · 32:50
quote The main factor that predicts outcome in stage 3 is whether they're lymph node positive or not. ↗
▶ Ep 10 · 32:50
clinical The main factor predicting outcome in stage 3 disease is whether lymph nodes are positive, along with genetic changes including loss of heterozygosity and 1Q gain. ↗
▶ Ep 10 · 33:58
quote When you look at the outcomes for stage 1 and stage 2 patients between the children's oncology group and the psyop groups, they're basically identical. ↗
▶ Ep 10 · 33:58
quote When you look at the outcomes for stage 1 and stage 2 patients between the children's oncology group and the psyop groups, they're basically identical. ↗
▶ Ep 10 · 33:58
clinical Outcomes for stage 1 and stage 2 patients are basically identical between COG and SIOP treatment approaches. ↗
▶ Ep 10 · 33:58
clinical Outcomes for stage 1 and stage 2 patients are basically identical between COG and SIOP treatment approaches. ↗
▶ Ep 10 · 34:46
clinical Some Wilms tumor patients present with low hemoglobin because the tumor ruptures internally and bleeds. ↗
▶ Ep 10 · 34:46
clinical Some Wilms tumor patients present with low hemoglobin because the tumor ruptures internally and bleeds. ↗
▶ Ep 10 · 35:11
clinical Acquired von Willebrand disease occurs in Wilms tumor patients; in most cases it is meaningless, but a few case series report significant intraoperative bleeding until tumor removal. ↗
▶ Ep 10 · 35:11
clinical Acquired von Willebrand disease occurs in Wilms tumor patients; in most cases it is meaningless, but a few case series report significant intraoperative bleeding until tumor removal. ↗
▶ Ep 10 · 35:11
quote There is something called acquired von Willebrand's disease which these patients get. In the majority of cases it is meaningless, but there have been reports in a few case series where these patients may bleed a lot. ↗
▶ Ep 10 · 35:11
quote There is something called acquired von Willebrand's disease which these patients get. In the majority of cases it is meaningless, but there have been reports in a few case series where these patients may bleed a lot. ↗
▶ Ep 10 · 36:25
clinical Right-sided tumors can cause complications including adrenal vein injury, duodenal injury (due to proximity), superior mesenteric artery injury, and IVC injury due to anatomic distortion. ↗
▶ Ep 10 · 36:25
clinical Right-sided tumors can cause complications including adrenal vein injury, duodenal injury (due to proximity), superior mesenteric artery injury, and IVC injury due to anatomic distortion. ↗
▶ Ep 10 · 38:20
quote These tumors tend to be large and although ideally you would like to identify the renal artery and the renal vein, it's been well recognized. It's even back in Gross's book that these, if you can't do that, then you shouldn't try and do it up front. ↗
▶ Ep 10 · 38:20
quote These tumors tend to be large and although ideally you would like to identify the renal artery and the renal vein, it's been well recognized. It's even back in Gross's book that these, if you can't do that, then you shouldn't try and do it up front. ↗
▶ Ep 10 · 42:31
clinical Wilms tumors can cause intense inflammatory reaction making them adherent to diaphragm or liver; taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 10 · 42:31
clinical Wilms tumors can cause intense inflammatory reaction making them adherent to diaphragm or liver; taking a rim of diaphragm or liver capsule to avoid tumor violation does not upstage the tumor if the tumor itself is not divided. ↗
▶ Ep 10 · 43:32
clinical A small subset of very young patients (<24 months) with stage 1 favorable histology tumors <550g can be treated with surgery alone without chemotherapy, with >95% overall survival. Those who relapse (about 10%) have 100% salvage with chemotherapy. ↗
▶ Ep 10 · 43:32
clinical A small subset of very young patients (<24 months) with stage 1 favorable histology tumors <550g can be treated with surgery alone without chemotherapy, with >95% overall survival. Those who relapse (about 10%) have 100% salvage with chemotherapy. ↗
▶ Ep 10 · 46:14
quote When you look at the outcomes of patients with tumor that extends into the cava or even up to the atrium, that's not a negative prognostic factor ↗
▶ Ep 10 · 46:14
quote When you look at the outcomes of patients with tumor that extends into the cava or even up to the atrium, that's not a negative prognostic factor ↗
▶ Ep 10 · 46:27
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 10 · 46:27
clinical IVC tumor extension is not a negative prognostic factor if the tumor is completely resected. ↗
▶ Ep 10 · 47:43
quote The major complication rate in patients goes up. Those include mortalities, number of blood transfusions, ICU stay, complications go up ↗
▶ Ep 10 · 47:43
quote The major complication rate in patients goes up. Those include mortalities, number of blood transfusions, ICU stay, complications go up ↗
▶ Ep 10 · 48:49
clinical Major complication rate for primary surgery with tumor extending beyond infrahepatic IVC is 26-30%, including mortality, increased transfusions, and ICU stay, supporting preoperative chemotherapy for these cases. ↗
▶ Ep 10 · 48:49
clinical Major complication rate for primary surgery with tumor extending beyond infrahepatic IVC is 26-30%, including mortality, increased transfusions, and ICU stay, supporting preoperative chemotherapy for these cases. ↗
▶ Ep 10 · 51:28
quote Todd, I, I've read 6000 operative notes, OK. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 10 · 51:28
quote Todd, I, I've read 6000 operative notes, OK. The amount of time that somebody actually had it go all the way up there like that and stop at the infrapatic cava, I don't even recall reading a case where that happened. ↗
▶ Ep 10 · 52:39
clinical Favorable histology Wilms tumor has three components: blastema, stroma, and epithelial (triphasic tumor). Tumors with only two components are also considered favorable histology. ↗
▶ Ep 10 · 52:39
clinical Favorable histology Wilms tumor has three components: blastema, stroma, and epithelial (triphasic tumor). Tumors with only two components are also considered favorable histology. ↗
▶ Ep 10 · 54:41
clinical Patients with loss of heterozygosity of both 1p and 16q (5-7% of patients) have significantly worse outcomes regardless of stage. Stage 1-2 patients with LOH have about 10% lower overall survival; stage 3-4 patients have 18% lower survival. ↗
▶ Ep 10 · 54:41
clinical Patients with loss of heterozygosity of both 1p and 16q (5-7% of patients) have significantly worse outcomes regardless of stage. Stage 1-2 patients with LOH have about 10% lower overall survival; stage 3-4 patients have 18% lower survival. ↗
▶ Ep 10 · 55:07
guideline Patients with both 1p and 16q loss of heterozygosity receive augmented therapy: doxorubicin is added for stage 1-2 disease, and five-drug regimen M is used for stage 3-4 disease. ↗
▶ Ep 10 · 55:07
guideline Patients with both 1p and 16q loss of heterozygosity receive augmented therapy: doxorubicin is added for stage 1-2 disease, and five-drug regimen M is used for stage 3-4 disease. ↗
▶ Ep 10 · 55:58
clinical Unfavorable histology is classified as focal anaplasia or diffuse anaplasia based on number of high-power fields showing anaplasia, with different treatments for each. ↗
▶ Ep 10 · 55:58
clinical Unfavorable histology is classified as focal anaplasia or diffuse anaplasia based on number of high-power fields showing anaplasia, with different treatments for each. ↗
▶ Ep 10 · 56:51
clinical Renal cell carcinoma in children has no good therapy, particularly for metastatic disease. ↗
▶ Ep 10 · 56:51
clinical Renal cell carcinoma in children has no good therapy, particularly for metastatic disease. ↗
▶ Ep 10 · 57:01
clinical Clear cell sarcoma of the kidney has reasonable treatment outcomes, particularly for low stages. Rhabdoid tumors have poor outcomes except for stage 1; most present at stage 3-4 with terrible outcomes. ↗
▶ Ep 10 · 57:01
clinical Clear cell sarcoma of the kidney has reasonable treatment outcomes, particularly for low stages. Rhabdoid tumors have poor outcomes except for stage 1; most present at stage 3-4 with terrible outcomes. ↗
▶ Ep 10 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 10 · 57:46
epidemiological Bilateral Wilms tumors occur in 8-10% of all children with Wilms tumor. ↗
▶ Ep 10 · 58:07
guideline The strategy for bilateral Wilms tumor is preoperative chemotherapy to shrink tumors enough to allow partial nephrectomy of at least one kidney (ideally both) to avoid dialysis. ↗
▶ Ep 10 · 58:07
guideline The strategy for bilateral Wilms tumor is preoperative chemotherapy to shrink tumors enough to allow partial nephrectomy of at least one kidney (ideally both) to avoid dialysis. ↗
▶ Ep 10 · 58:40
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% compared to 88% for unilateral tumors; overall survival was 80% vs. 95%. ↗
▶ Ep 10 · 58:40
epidemiological Event-free survival for bilateral Wilms tumor on NWTS-5 was 61% compared to 88% for unilateral tumors; overall survival was 80% vs. 95%. ↗
▶ Ep 10 · 59:37
clinical Maximum tumor response to chemotherapy in most children with Wilms tumor occurs by 12 weeks, and early response at 6 weeks predicts late response. ↗
▶ Ep 10 · 59:37
clinical Maximum tumor response to chemotherapy in most children with Wilms tumor occurs by 12 weeks, and early response at 6 weeks predicts late response. ↗
▶ Ep 10 · 1:00:31
epidemiological In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. In a recent COG study of 250 enrolled patients, only one turned out to have rhabdoid tumor. ↗
▶ Ep 10 · 1:00:31
epidemiological In children presenting under 36 months with bilateral renal tumors, it is almost universally Wilms tumor. In a recent COG study of 250 enrolled patients, only one turned out to have rhabdoid tumor. ↗
▶ Ep 10 · 1:01:56
guideline Biopsy is recommended for bilateral tumors in older patients (8-10 years) or those with syndromes like von Hippel-Lindau where renal cell carcinoma is more likely. ↗
▶ Ep 10 · 1:01:56
guideline Biopsy is recommended for bilateral tumors in older patients (8-10 years) or those with syndromes like von Hippel-Lindau where renal cell carcinoma is more likely. ↗
▶ Ep 10 · 1:02:16
clinical If biopsying bilateral tumors, both kidneys should be biopsied because there is discordant pathology in up to 20% of patients. ↗
▶ Ep 10 · 1:02:16
clinical If biopsying bilateral tumors, both kidneys should be biopsied because there is discordant pathology in up to 20% of patients. ↗

Summaries Peter gave as host · 2 summaries

Recaps of what the experts said, with Peter as narrator — not Peter's own clinical position, and never cited in answers.

Summaries Peter gave as host · Pediatric Oncology 1 summary

Open the Pediatric Oncology collection →

Wilms Tumor: Audio Chapter

▶ Ep 65 · 43:48
host summary Peter Ehrlich summarizing a resource: These patients that no matter what you did, whether you treated them with surgery, whether you added 1 drug of chemotherapy, 2 drugs of chemotherapy, 3 drugs, radiation, that they had excellent overall survival. ↗
Summaries Peter gave as host · Wilms Tumor 1 summary

Open the Wilms Tumor collection →

Wilms Tumor: Audio Chapter

▶ Ep 2 · 43:48
host summary Peter Ehrlich summarizing a resource: These patients that no matter what you did, whether you treated them with surgery, whether you added 1 drug of chemotherapy, 2 drugs of chemotherapy, 3 drugs, radiation, that they had excellent overall survival. ↗