Significance and management of computed tomography detected pulmonary nodules: A report from the National Wilms Tumor Study Group

Purpose: To define the optimal treatment for children with Wilms tumor who have pulmonary nodules identified on chest computed tomography (CT) scan, b ut have a negative chest radiograph, we evaluated the outcome of all such p atients randomized or followed on National Wilms Tumor Study (NWTS)-3 and - 4, Patients and Methods: We estimated the event-free and overall survival perc entages of 53 patients with favorable histology tumors and pulmonary densit ies identified only by CT scan (CT-only) who were treated as Stage IV with intensive doxorubicin-containing chemotherapy and whole-lung irradiation, a nd compared these to the event-free and overall survival percentages of 37 CT-only patients who were treated less aggressively based on the extent of locoregional disease with 2 or 3 drugs, and without whole-lung irradiation. Results: The 4-year event-free and overall survival percentages of the 53 p atients with CT-only nodules and favorable histology Wilms tumor who were t reated as Stage IV were 89% and 91%, respectively. The 4-year event-free an d overall survival percentages for the 37 patients with CT-only nodules and favorable histology who were treated according to the extent of locoregion al disease were 80% and 85%, respectively. The differences observed between the 2 groups were not statistically significant. Among the patients who re ceived whole-lung irradiation, there were fewer pulmonary relapses, but mor e deaths attributable to lung toxicity. Conclusions: The current data raise the possibility that children with Wilm s tumor and CT-only pulmonary nodules who receive whole lung irradiation ha ve fewer pulmonary relapses, but a greater number of deaths due to treatmen t toxicity. The role of whole lung irradiation in the treatment of this gro up of patients cannot be definitively determined based on the present data. Prolonged follow-up of this group of patients is necessary to accurately e stimate the frequency of late, treatment-related mortality. (C) 1999 Elsevi er Science Inc.