Adjuvant Treatment of Bilateral Wilms Tumor in Children After VAD Neoadjuvant Chemotherapy
Children with metastatic bilateral renal tumors and favorable histology Wilms tumor — with or without a predisposing condition — require a staged treatment approach. This protocol defines the risk-adapted adjuvant phase that follows neoadjuvant therapy and surgical resection.
After the VAD Neoadjuvant Regimen
Initial management uses the VAD regimen (vincristine, dactinomycin, doxorubicin), with the goals of achieving tumor response and resectability, assessed at 6 weeks. Nephron-sparing surgery is performed when tumors become operable. When complete tumor response or resectability is not achieved at 6 weeks, neoadjuvant therapy continues through 12 weeks before surgery. This adjuvant protocol is the defined next step once surgical resection has been completed.
Adjuvant Approach
Following surgery, adjuvant chemotherapy is selected by risk, based on histological findings — specifically whether blastemal predominant histology is present — and on the degree of tumor response achieved during neoadjuvant therapy. Radiation therapy, including to metastatic sites, may also be part of the plan depending on local staging and the response at 6 weeks. The complete regimen selection criteria, radiation indications, and treatment algorithm are in the structured protocol.
References
DOI: 10.6004/jnccn.2021.0037
- Neoadjuvant therapy with the VAD regimen is recommended for children with metastatic bilateral renal tumors with or without a predisposing condition.
- Switching to regimen DD4A is recommended for patients without blastemal predominant histology or those with a complete response at 6 weeks of neoadjuvant chemotherapy.
- Augmented therapy with regimen I is recommended for patients with blastemal predominant histology, because they are at greater risk.
- Patients with a complete response at 6 weeks of neoadjuvant chemotherapy do not need RT.
- Whole lung irradiation is administered in patients with lung metastases, and extrapulmonary metastatic sites may also require radiation.