title: The efficacy and toxicity of SIOP preoperative chemotherapy in Malawian children with a Wilms tumour.
abstract: BACKGROUND
  In Malawi, preoperative chemotherapy for Wilms tumour is a logical strategy, but detailed information on toxicity and efficacy in such a resource limited setting has been unavailable.
  
  
  METHODS
  Patients diagnosed with a unilateral Wilms tumour received preoperative chemotherapy-a two-drug 4-week regimen for localized disease and 6 weeks of a three-drug regimen for metastatic disease. Estimated maximum tumour diameter, decrease in tumour size, resectability, stage distribution and haematological toxicity during therapy were documented.
  
  
  RESULTS
  At diagnosis, 28% of 72 patients had an estimated maximum tumour diameter of more than 25 cm; 29% of patients had metastases. Eight children (11%) died during preoperative chemotherapy. More than half (59%) of the patients developed moderate neutropenia (neutrophils <1.0 × 10(9) /L; CTC grade 3) and 27% severe neutropenia (CTC grade 4 neutrophils <0.5 × 10.9/L). Grade 4 neutropenia occurred significantly more frequently in children receiving the three-drug regimen compared to the two-drug regimen; 50% (10/20) versus 15% (6/40) (P = 0.004). Fifty-seven percent of all patients had CTC grade 4 anaemia (Hb < 6.5 g/dL) during treatment. Most tumours (92%, 56/61) showed a response to chemotherapy but 14% (8/58) remained unresectable.
  
  
  CONCLUSIONS
  Preoperative chemotherapy for Wilms tumour causes considerable haematological toxicity and treatment-related mortality in malnourished Malawian children. A significant number of children have unresectable disease despite preoperative chemotherapy. To reduce treatment related mortality, consideration should be given to starting treatment with reduced doses in acutely malnourished patients.
authors.affiliation: Department of Paediatric Oncology, Emma Children's Hospital/AMC, Amsterdam, The Netherlands. trijnisraels@hotmail.com
authors.forename: Trijn
authors.initials: T
authors.lastname: Israels
authors.forename: George
authors.initials: G
authors.lastname: Chagaluka
authors.forename: Dalida
authors.initials: D
authors.lastname: Pidini
authors.forename: Huib
authors.initials: H
authors.lastname: Caron
authors.forename: Jan
authors.initials: J
authors.lastname: de Kraker
authors.forename: Steve
authors.initials: S
authors.lastname: Kamiza
authors.forename: Eric
authors.initials: E
authors.lastname: Borgstein
authors.forename: Liz
authors.initials: L
authors.lastname: Molyneux
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D003609:Dactinomycin / Q000008:administration & dosage; D003906:Developing Countries; D005260:Female; D006801:Humans; D007223:Infant; D007680:Kidney Neoplasms / Q000188:drug therapy* / Q000601:surgery; D008295:Malawi; D008297:Male; D009392:Nephrectomy; D014750:Vincristine / Q000008:administration & dosage; D009396:Wilms Tumor / Q000188:drug therapy* / Q000601:surgery
chemical_list: D003609:Dactinomycin; D014750:Vincristine