Editing Pediatrics: Renal and Adrenal Oncology (section)

==== Pre-operative Chemotherapy ====
* '''<span style="color:#ff0000">Indications</span>''' (Campbell’s and [https://wjps.bmj.com/content/2/3/e000038 §]) '''(7):'''
*# '''<span style="color:#ff0000">Solitary kidney'''
*# '''<span style="color:#ff0000">Bilateral tumours'''
*# '''<span style="color:#ff0000">Tumor extension into the IVC above the hepatic veins'''
*# '''<span style="color:#ff0000">Tumor involving contiguous structures whereby removing the kidney tumor would require removal of the other organs, such as spleen, pancreas, or colon'''
*# '''<span style="color:#ff0000">Tumors inoperable at surgical exploration'''
*# '''<span style="color:#ff0000">Tumour not amenable to partial nephrectomy [in patients with indication for nephron-sparing surgery]'''
*#* Most Wilms tumors are too large at diagnosis to allow partial nephrectomy. After preoperative chemotherapy, partial nephrectomy can be performed in 10-5% of patients
*# '''<span style="color:#ff0000">Extensive pulmonary metastases'''
** '''Bilateral tumors'''
*** Occurs in 5-10% of WT cases
*** Associated with worse outcomes
*** Increased risk of renal impairment
*** MRI is the imaging modality of choice
*** '''Because bilateral Wilms is overwhelmingly likely in a child 1-7 years old with bilateral renal masses,''' '''preoperative biopsy is not indicated''' and will up stage the disease to local stage III
*** '''Preoperative chemotherapy''' with vincristine, actinomycin and doxorubicin '''will be given''' for 2 cycles (6 weeks), after which imaging is repeated.
*** '''LN sampling on each side must be included with surgical intervention for patients with bilateral renal tumors, just like all patients with WT'''
* '''Tumors not responding to chemotherapy require bilateral open biopsy to determine histology.'''
** '''Open biopsies are recommended because they are more accurate than percutaneous needle biopsies when assessing for anaplasia, and bilateral biopsies are recommended'''