DISCUSSION
A clinician panel used the GRADE approach to produce evidence-based recommendations for the surgical management of pediatric WT. Nineteen recommendations were formulated to address preoperative, operative, and postoperative concerns identified by surgeons practicing in limited-resource settings. The guidelines address key questions prioritized by the panel in the three phases of patient care. The panel included multidisciplinary WT experts and maintained geographic and gender balance. It produced recommendations based on the available evidence and the identified priority outcomes and goals relevant in limited-resource settings.
A few themes were identified throughout panel deliberations. In a limited-resource setting, childhood tumor treatment is often effective only if the patient presents early; therefore, access to timely therapy is of paramount importance. In addition, a multidisciplinary childhood cancer team incorporating radiologists, pathologists, oncologists, radiation oncologists, and surgical specialists who discuss the case prior to any surgical intervention is essential to ensure high quality of care. Establishing a multidisciplinary team discussion or tumor boards is a cornerstone of building capacity for pediatric oncology care. One of the key limitations identified by the panel was a paucity of evidence to address the selected questions. When evidence exists, it is frequently of low quality. Well-designed, randomized controlled trials and cost-effectiveness analyses are needed to examine the impact of the included preoperative, operative, and postoperative interventions on the outcome of WT.
Diagnostic capacity is limited in LMICs, and this continues to pose a significant challenge to improving the outcomes of children with WT. When there is no access to cross-sectional images, ultrasound and x-ray images may guide therapy. The availability of pathologic analyses of frozen sections may also be limited in LMICs. However, there is no evidence to support the utility or cost-effectiveness of frozen sections in WT surgery. The therapeutic interventions recommended by the panel are affordable; most are considered standard of care across settings with various resources and are not associated with increased risk to patients. These recommendations are, therefore, practical and can serve as a reference for practice standardization that may improve the surgical outcomes of WT globally.