Delayed versus upfront surgery: discussion

Pritchard-Jones, J.S. Dome (eds.), Renal tumors of childhood: biology and therapy. Pediatric oncology. Springer-Verlag Berlin Heidelberg (2014)

In the late nineteenth century, several clinicians, including luminary Sir William Osler described renal tumors of childhood. A description from 1872 included a bilateral case (Eberth 1872). In 1886, Hoisholt, a German pathologist living in San Francisco, introduced the name ‘Mischgeschwulst der Niere’ whilst describing a pulmonary metastasised nephroblastoma in an 18-year-old boy and hypothesising its embryonic genesis (Hoisholt 1886). The first comprehensive monograph from the eponym giving surgeon Max Wilms bore the same name (Wilms 1899). Treatment at the beginning of the twentieth century was complete nephrectomy if possible and had an appalling 25% perioperative mortality. As nowadays, the most frequent symptom was painless enlargement of the abdomen though modern imaging modalities were lacking and differential diagnosis was difficult. Nevertheless, several authors in the 1930s were in favour of preoperative irradiation for the purpose of shrinking the tumor. A preand postoperative irradiation concept was developed (Ladd 1938). However every hospital, rather every physician had his own way to treat WT. Patients were seen by multiple doctors and students. In consequence, they underwent repetitive physical examinations possibly contributing to preoperative rupture and hence abdominal dissemination of tumor cells. A remarkable increase of survival was achieved by structuring the perioperative care as reported in a retrospective study by Robert E. Gross and Edward BD Neuhauser about their experience from 1930 to 1950. Restricted and cautious physical exam, sufficient transfusion, intravenous liquids and structured surgery, using a transabdominal approach carried out by experienced surgeons, led to elimination of deaths on the table and increased OS from 15% in the 1914–1930 period to 32% in the 1931–1939 period. Systematic postoperative irradiation with usually 20–40 Gy, starting whilst still sleeping from surgery’s anaesthesia, increased OS to 48% in the 1940–1947 period. Reasoning any delay that puts off nephrectomy would increase the chance of metastasis, and irradiation would cause liquefaction of the tumor mass thus enhancing haematogenous metastasis, the authors favoured upfront surgery (Gross and Neuheuser 1950). However, combined preand postoperative treatment was in use, but nobody had yet done randomised prospective trials of preoperative treatment.


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