THE RISK OF NEPHRECTOMY DURING LOCAL-CONTROL IN ABDOMINAL NEUROBLASTOMA

Methods: Eight hundred sixty-eight children presenting from 1981 to 19 91 were treated on five multiagent chemotherapy protocols by members o f the Pediatric Oncology Group for advanced-stage neuroblastoma with l arge primary tumors crossing the midline or distant metastasis. Of the se children, 696 had abdominal (adrenal or paravertebral) primary tumo rs. One hundred sixteen children underwent greater than 50% surgical r esection of these abdominal primary/tumors before chemotherapy, and 23 3 underwent similar surgery after induction chemotherapy. Results: Amo ng the 349 who underwent surgical resection, 52 children (14.9%) had n ephrectomy or renal infarction during surgery for local control. There was a 25% incidence among those with initial resection (29 patients) and a 9.9% incidence in the postchemotherapy resections (23 patients). Reasons for nephrectomy given by the surgeons included direct involve ment of the kidney by adjacent tumor (17 children), clinical impressio n that the tumor was a Wilms' tumor (11 children), renal vessels could not be separated from the tumor (10 children), extensive tumor surrou nding the kidney (8 children), postoperative renal infarction (4 child ren), marked decrease in unilateral renal function after chemotherapy (1 child), and position of the tumor posterior to the kidney and vena cava making resection without nephrectomy impossible (1 child). Of the patients undergoing nephrectomy, four children had an upper pole neph rectomy in conjunction with their adrenalectomy and resection of the t umor. Pathological review of the resected tumor available in 47 cases demonstrated direct involvement of the renal parenchyma in 18 cases (3 8% of the nephrectomies) and in 5.2% of those undergoing resection. In children undergoing initial resection, the risk for nephrectomy (as c alculated by the methods described by Gart) was more than twice compar ed with those undergoing resection after chemotherapy (P = .012; odds ratio, 2.32; 95% confidence interval of 1.23 to 4.42). Conclusions: Th is review confirms that renal parenchymal involvement does occur in a significant number of children with abdominal neuroblastoma. II also s uggests that preoperative chemotherapy may decrease the number of neph rectomies required to achieve a total or subtotal resection. Copyright (C) 1998 by W.B. Saunders Company.