Postoperative phase
The panel suggests postoperative abdominal radiation therapy within 14
days of surgery for patients with WT who require adjuvant radiation
therapy. (Weak recommendation; Quality of evidence: Very Low)
Panel deliberation. Postoperatively, patients who need
radiation therapy, especially those with high-risk WT, should be
referred to a radiation oncologist within 1 week of surgery to receive
abdominal radiation within 14 days. A radiation oncologist should be
part of the multi-disciplinary team discussion of all patients at
diagnosis, so referral and need for radiation therapy can be
anticipated. Delayed radiation therapy of the abdominal primary tumor in
non-metastatic patients is associated with suboptimal local
control.64-66 In contrast, for patients with
metastatic disease, radiation of the abdominal primary within 14 days
post nephrectomy is of no clear significance. Therefore, in these
patients, abdominal irradiation can be performed at the same time as
lung irradiation (when indicated). Suboptimal nutritional status of
patients should be considered when combining whole-lung radiation
therapy with flank versus whole-abdomen radiation therapy.
The panel suggests that resection of residual pulmonary
oligometastasis after completion of chemotherapy (when feasible) be
considered in a setting of local protocols that allow the omission of
whole-lung irradiation in patients with favorable histology, stage IV
WT with pulmonary metastasis. (Weak recommendation; Quality of
evidence: Very Low)
Panel deliberation. The decision to omit whole-lung
irradiation is based on tumor biology, histological risk group of the
abdominal primary, and chemosensitivity; and can be applied in the
context of local treatment protocols. Lung irradiation can be avoided
for patients with non-anaplastic histology who are complete responders
(i.e., those who have no residual pulmonary metastases on a chest CT
after chemotherapy). In patients with residual post-chemotherapy
oligometastasis that are amenable to resection, radiation therapy can be
omitted if there was no residual viable tumor in the surgically cleared
nodules.60-62,67,68 Resection of residual nodules may
be helpful when institutional protocols/guidelines allow the omission of
whole-lung radiotherapy in patients with non-anaplastic histology and no
viable tumor in respected lesions.