The modern management of pediatric genitourinary malignancies has resulted in survival rates that are dramatically better than figures from just a few decades ago. This is largely due to advances in multimodal treatment, collaborative efforts, and multidisciplinary management. Nevertheless, issues related to long-term side effects, treatment-related morbidity, and progression or recurrences remain important and pressing in terms of research directions and areas for improvement. In this Editorial Comment the author attempts to employ the current state of the art, masterfully summarized in the accompanying review by Drs Grimsby and Ritchey, to provide a view of trends that are likely to become increasingly important in the future, highlighting common patterns in treatment philosophy seen in other areas of oncology: more selective or patient-tailored treatment strategies, refined protocols and —whenever possible— tissue sparing and minimally invasive surgical interventions.
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Many pediatric genitourinary malignant conditions have experienced favorable improvements in survival.
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As children affected by these conditions live longer and become young adults, long-term consequences of the malignant process and its treatment become more prominent.
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Balancing under and over-treatment is likely to become an important future goal, with the judicious introduction more selective strategies along with minimally invasive and tissue-sparing procedures.
The current state of the art, a culmination of collaborative efforts by many scientists, health care providers, patients, and families, has been clearly and masterfully summarized in this issue of the Pediatric Clinics of North America . Years of clinical and basic science innovation have translated into better prognosis, albeit often achieved with aggressive therapeutic strategies that have important side effects and long-term consequences that are yet to be fully characterized. In many circumstances, improved survival has come at a cost, and we are becoming increasingly aware of the impact on survivors of childhood neoplasms. Thus, it is important to pick up on new trends and common denominators in the recent advances described by Drs Grimsby and Ritchey, in the article elsewhere in this issue: a movement toward tissue-sparing procedures, tailored chemotherapy, selective and more accurately delivered radiation therapy, protocols generated by collaborative study groups, and extended long-term monitoring. These advances should allow for the shared goal of decreasing morbidity from the condition itself as well as the treatment, function preservation, and better quality and quantity of life.
From a surgical point of view, the preservation of grossly normal-appearing or unaffected parts of the organ during resection has become increasingly appealing. In some situations, such as renal neoplasms or prepubertal testicular teratomas, experience has shown that some tumors tend to splay out the surrounding parenchyma, creating an optical illusion on imaging studies and intraoperative evaluation that there is little tissue to be saved by performing a selective versus radical resection ( Fig. 1 ). For chemosensitive neoplasms, the introduction of neoadjuvant therapy for the purpose of decreasing the size of the primary tumor and allowing less radical resection has also gained momentum based on experience with bilateral renal involvement or inoperable tumors (notably Wilms tumors ). Regardless of the tissue of origin, we should ask ourselves if it is fair to remove the whole organ to embrace the concept of radical resection, so often the default when it comes to solid tumors. Selective surgical resection of the tumor from the whole organ has already gained acceptance (even becoming standard of care) in the treatment of many other conditions, such as breast, kidney, penile, and urothelial cancers. Although more technically challenging, the investment may pay off down the road, particularly for patients who are at risk for further functional decline with age or from acute events related to metachronous neoplasms or injury to the contralateral organ. If this rationale is acceptable for older patients with multiple comorbidities and shorter overall life expectancy, it stands to reason that an even stronger case can be made for children and adolescents. Particularly for this patient population, who should be offered hope for life expectancies in the order of decades, slight early increases in morbidity trends can translate into exponential worsening over time, with a detrimental impact on quantity and quality of life. Ultimately, the careful balance between the potential benefits of organ preservation compared with the risk of local recurrence and subsequent need for intensified multimodal treatment protocols need to be frequently assessed. These are some of the fundamental questions likely to be addressed in future trials as survival outlooks aim way past the traditional 5-year and 10-year curve cutoffs.
