title: Wilms tumor: Successes and challenges in management outside of cooperative clinical trials.
abstract: OBJECTIVE
  Management of Wilms tumor (WT) in children depends on a multidisciplinary approach to treatment, and outcomes have significantly improved as reported by cooperative group clinical trials. Here, we review the clinical outcomes of patients with WT and identify challenges and barriers encountered in multidisciplinary management outside of cooperative clinical trials.
  
  
  METHODS
  We retrospectively reviewed the clinical records of 35 children with WT treated between April 2002 and June 2013 at the Children's Cancer Institute in Lebanon.
  
  
  RESULTS
  Upfront resection was performed in 23 cases. Biopsies were performed for Stage V tumors (n=4), those with unresectable tumors or inferior vena caval thrombus (n=5), and patients who had partial surgery performed elsewhere prior to presentation (n=2). One patient died due to toxicity prior to surgery. The tumor was Stage I in eight patients, Stage II in five patients, Stages III and IV in nine patients each, and bilateral (Stage V) in four patients. Adherence to The National Wilms Tumor Study-5 recommendations was adequate. At the time of analysis, 30 patients were free of disease and four patients had relapse-all having metastatic disease initially.
  
  
  CONCLUSIONS
  The National Wilms Tumor Study-5 therapy resulted in favorable outcomes in children with nonmetastatic Wilms tumor in the setting of a multidisciplinary approach to therapy and resolution of financial barriers to medical care. Upstaging due to prior intervention and lung radiation therapy to all those with computed tomography-detected lung nodules may both have resulted in overtreatment of a subset of patients. Finally, the relatively high incidence of bilateral tumors suggests the need for further genetic and molecular studies in this patient population.
authors.affiliation: Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.
authors.forename: Wissam
authors.initials: W
authors.lastname: Rabeh
authors.affiliation: Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
authors.forename: Samir
authors.initials: S
authors.lastname: Akel
authors.affiliation: Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon.
authors.forename: Toufic
authors.initials: T
authors.lastname: Eid
authors.affiliation: Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.
authors.forename: Samar
authors.initials: S
authors.lastname: Muwakkit
authors.affiliation: Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.
authors.forename: Miguel
authors.initials: M
authors.lastname: Abboud
authors.affiliation: Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.
authors.forename: Hassan
authors.initials: H
authors.lastname: El Solh
authors.affiliation: Children's Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon. Electronic address: rs88@aub.edu.lb.
authors.forename: Raya
authors.initials: R
authors.lastname: Saab
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D019468:Disease Management; D005260:Female; D006801:Humans; D007223:Infant; D053208:Kaplan-Meier Estimate; D007668:Kidney / Q000473:pathology / Q000601:surgery; D007680:Kidney Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D007861:Lebanon / Q000453:epidemiology; D008297:Male; D012189:Retrospective Studies; D009396:Wilms Tumor / Q000453:epidemiology / Q000473:pathology / Q000601:surgery / Q000628:therapy*
keywords: Nephroblastoma; Pediatric cancer; Wilms tumor