title: The use of preoperative chemotherapy in Wilms' tumor with contained retroperitoneal rupture.
abstract: OBJECTIVE
  The National Wilms Tumor Study currently describes 3 indications for the use of preoperative chemotherapy: extensive caval involvement, bilateral tumors, and patients who only have a single kidney. However, the management of patients who present with a contained retroperitoneal rupture is not specifically addressed. This is relevant because of the strong possibility of peritoneal contamination when performing a primary resection and the resultant requirement for total abdominal radiation. The use of neoadjuvant chemotherapy in this subgroup of patients may be warranted.
  
  
  METHODS
  We retrospectively reviewed our experience with Wilms' tumor and identified 3 cases with contained rupture at presentation. Details of their initial evaluation and therapy, resection and pathologic findings, and follow-up constitute this report. Institutional review board waiver was obtained for the purposes of this review.
  
  
  RESULTS
  Two male patients, aged 2.9 years, and 1 female patient, aged 9.3 years, were identified. All patients received preoperative chemotherapy with vincristine and dactinomycin (n = 1) plus doxorubicin (n = 2) for 4 to 6 weeks before surgical resection. One patient underwent pretreatment computed tomography-guided biopsy of the kidney mass for diagnostic purposes. Presurgical computed tomographic scans showed resolution of perinephric blood and fluid with tumor shrinkage. Histopathologic analyses showed all tumors were resected with negative margins, and there was no intraoperative tumor spillage. All patients received 1050 to 1080 cGy of flank radiation postoperatively. All patients are currently alive at follow-up without evidence of local recurrence or distant disease.
  
  
  CONCLUSIONS
  Neoadjuvant chemotherapy allowed for complete resection and avoidance of total abdominal radiation in 3 patients with ruptured Wilms' tumor and hematoma within the retroperitoneum. These data support the use of initial chemotherapy in children with retroperitoneal rupture and hematoma of Wilms' tumor at diagnosis.
authors.affiliation: Division of Pediatric Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA.
authors.forename: Daniel N
authors.initials: DN
authors.lastname: Rutigliano
authors.forename: Mark L
authors.initials: ML
authors.lastname: Kayton
authors.forename: Peter
authors.initials: P
authors.lastname: Steinherz
authors.forename: Suzanne
authors.initials: S
authors.lastname: Wolden
authors.forename: Michael P
authors.initials: MP
authors.lastname: La Quaglia
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications / Q000188:drug therapy / Q000601:surgery*; D008297:Male; D020360:Neoadjuvant Therapy; D012187:Retroperitoneal Space; D012422:Rupture, Spontaneous; D009396:Wilms Tumor / Q000150:complications / Q000188:drug therapy / Q000601:surgery*