| | Renal function after ifosfamide, carboplatin and etoposide (ICE) chemotherapy, nephrectomy and radiotherapy in children with wilms tumourReceived 4 July 2008; received in revised form 26 August 2008; accepted 25 September 2008. published online 10 November 2008. Abstract We prospectively evaluated tumour response and renal function in 12 newly diagnosed children with high-risk Wilms tumour receiving ifosfamide, carboplatin and etoposide (ICE) chemotherapy. Two cycles of ICE were followed by 5 weeks of vincristine, dactinomycin and doxorubicin (Adriamycin) (VDA), and nephrectomy, radiotherapy, additional VDA, and a third ICE cycle. Carboplatin dosage was based on glomerular filtration rate (GFR) to achieve targeted systemic exposure (6 mg/mlmin). Mean GFR (measured by technetium 99m-DTPA clearance) declined by 7% after 2 cycles of ICE and by 38% after nephrectomy; the mean carboplatin dose was reduced 32% after nephrectomy. Mean GFR remained stable after the third ICE cycle. Although urinary β2-microglobulin excretion increased during therapy, no patient had clinically significant renal tubular dysfunction at the end of treatment. Treatment with ICE, nephrectomy and radiotherapy significantly reduces GFR, largely as the result of nephrectomy. Adjustment of carboplatin dosage on the basis of GFR and careful monitoring of renal function may alleviate nephrotoxicity. 1. Introduction  Over the past three decades, the survival of patients with Wilms tumour has dramatically improved through risk-adapted treatment stratification based on tumour stage and histology.1, 2, 3 Standard therapy for advanced disease consists of nephrectomy, radiotherapy and chemotherapy. Patients with unresectable or metastatic Wilms tumour fare worse than patients with localised and resectable tumours.4, 5 Preoperative chemotherapy, the standard treatment approach in the International Society of Paediatric Oncology trials,6, 7 facilitates surgical resection of large tumours that may involve vital structures.4 Patients with diffuse anaplastic Wilms tumour, particularly stages III and IV, continue to have poor outcomes2, 8, 9, 10 and may benefit from new treatment strategies. Ifosfamide, carboplatin and etoposide, used as single agents or in combination, are active against Wilms tumour.11, 12, 13, 14, 15, 16, 17, 18 The three-agent combination (ICE) has been used effectively to treat recurrent Wilms tumour,19, 20 but its use in frontline therapy has been limited by concern about potential nephrotoxicity in patients who undergo nephrectomy and abdominal radiotherapy. In healthy individuals, the remaining kidney shows compensatory hypertrophy and an increased glomerular filtration rate (GFR) after nephrectomy.21, 22 In children, compensatory hypertrophy allows a post-nephrectomy GFR that is 70–90% of healthy controls.23 There is concern that cancer chemotherapy and irradiation may inhibit compensatory renal hypertrophy after nephrectomy in patients with Wilms tumour.21 However, although long-term renal function has been studied in survivors of Wilms tumour, no data are available about acute changes in GFR during therapy. We evaluated renal function in patients (March 1994–August 1998) with high-risk Wilms tumour receiving chemotherapy that included the ICE regimen given in an ‘up-front window’. Here we report the study results including response rate to ICE, the toxicity of ICE and the longitudinal effect of ICE, nephrectomy, radiotherapy and vincristine, dactinomycin and doxorubicin (Adriamycin) (VDA) on glomerular and renal tubular functions. 2. Patients and methods 2.3. Patient evaluation Physical examination and laboratory studies preceded each cycle of chemotherapy. Before each ICE cycle, a complete blood count and serum electrolytes (including phosphorus and magnesium), blood urea nitrogen, creatinine and bilirubin were obtained. Complete blood counts were performed three times weekly during GCSF treatment, after each ICE cycle. Liver function, blood urea nitrogen and creatinine were assessed every 6 weeks during treatment. Urinalysis was performed before treatment and during ifosfamide administration. Disease evaluations were performed at baseline, after the first 2 cycles of ICE, before nephrectomy, before the third ICE cycle and at the end of treatment. Computed tomography of the chest and abdomen was performed at baseline and after the first 2 cycles of ICE. After completion of treatment, patients were regularly monitored by chest radiography and abdominal ultrasonography for 6 years. A complete response to ICE was defined as complete disappearance of measurable disease. A partial response was defined as greater than 50% and less than 100% regression in the maximum diameters of all measurable lesions in the absence of new lesions. Stable disease was defined as the absence of complete response, partial response and progressive disease. Progressive disease was defined as an increase greater than 25% in the maximum diameter of any lesion or the appearance of new lesion(s). Toxicity was assessed using the National Cancer Institute Common Toxicity Criteria (version 1.0). 2.5. Statistical methods Mean GFR and mean estimated Clcr at each time point during therapy were compared with those at baseline by using the paired t-test. The change in GFR and estimated Clcr over time during therapy was modelled by using a linear mixed-effect model accounting for potential within-patient correlation. A Bland–Altman plot was used to assess the agreement between GFR and estimated Clcr.32 3. Results 3.1. Response to ICE and outcome Twelve children (14 months to 14.3 years; median, 4.5 years) were enrolled (Table 1). The three patients with stage III favourable histology Wilms tumour had unresectable tumours at diagnosis. Of the 11 patients with measurable disease before initiation of chemotherapy, 10 had a partial response to ICE and one had stable disease. Patient 9 had no measurable disease and therefore was inevaluable for tumour response evaluation. This patient received ICE and VDA and is alive without evidence of disease. Patient 6 completed the protocol without the third ICE cycle because of lack of response to ICE. Patient 12, who had tumour thrombus that extended into the right atrium, was taken off protocol therapy at week 12 because of persistent thrombus in the inferior vena cava and high-risk of tumour resection. This patient died after a subsequent pulmonary relapse. Eleven of the 12 patients survived without evidence of disease for a median of 11.9 years after diagnosis (Table 1). | | |  | Patient | Age | Race/sex | Disease stage | Tumour histology | Response to ICE | Outcome, survival durationa | |
|---|
| 1a | 5 years | W/F | IV | Favourable | PR | NED, 13.6 years | | | 2 | 9 years 2 months | W/F | III | Favourable | PR | NED, 13.4 years | | | 3 | 1 year 2 months | B/M | III | Favourable | PR | NED, 13.1 years | | | 4 | 2 years 1 month | B/F | IV | Favourable | PR | NED, 12.3 years | | | 5 | 4 years | W/F | IV/V | Focal anaplasia | PR | NED, 12.3 years | | | 6 | 6 years 4 months | Hispanic/F | IV | Favourable | SD | NED, 11.9 years | | | 7 | 5 years 8 months | W/F | IV | Diffuse anaplasia | PR | NED, 11.9 years | | | 8 | 2 years 2 months | W/M | IV | Favourable | PR | NED, 11.8 years | | | 9b | 14 years 3 months | B/F | II | Diffuse anaplasia | NE | NED, 11.3 years | | | 10 | 10 years 1 month | B/F | IV | Favourable | PR | NED, 8 years | | | 11 | 1 year 2 months | B/F | III | Favourable | PR | NED, 10.8 years | | | 12 | 3 years 9 months | B/M | III | Diffuse Anaplasia | PR | DOD, 1.9 years | | | | |
| a Measured from the time of diagnosis. bNephrectomy at diagnosis. |
3.3. Glomerular function All patients, except patients 8 and 12, received radiotherapy to the flank or the whole abdomen on study. In the four patients who received radiotherapy to the whole abdomen, the remaining kidney received 12Gy in three children and 10.5Gy in one. We found no significant difference in glomerular function after nephrectomy between patients who did and did not receive whole-abdomen radiation (P>0.1). Therefore, data for these groups were combined in the analyses because of the limited number of patients. The mean GFR values measured by technetium 99m-DTPA clearance are shown in Table 3. Two patients were excluded because they had nephrectomy at diagnosis before ICE (including one who received whole-abdomen radiation). The linear mixed-effect model showed a significant decrease in mean GFR over the treatment period (P<0.0001). Mean GFR decreased by only 7% after 2 cycles of ICE (P=0.27) but decreased by 38% after nephrectomy (P=0.0018) and did not decrease further after the third ICE cycle. Because of the reduction in GFR, the mean calculated carboplatin dose was reduced from 525mg/m2 for the first 2 cycles of ICE (before nephrectomy) to 359mg/m2 (32% dose reduction) for the third ICE cycle. Table 4 summarises change in the mean estimated Clcr during therapy and follow-up. To allow comparison of the estimated Clcr with GFR data, we excluded the two patients who had nephrectomy at diagnosis and the patient who was taken off protocol therapy at week 12. The linear mixed-effect model showed that estimated Clcr declined significantly over the treatment period (P=0.0003), but remained stable during follow-up. Correlation analysis of GFR values at the same time points (n=35), either measured by technetium 99m-DTPA clearance or estimated from Clcr, showed a Pearson’s correlation coefficient of 0.61 (P<0.0001). However, a Bland–Altman plot revealed wide variation in the difference between the two measures (estimated Clcr–GFR, bias=17.8, confidence interval (CI)=−30.6 to 66.3) (Fig. 2). That is, the estimated Clcr overestimated the GFR by 17.8ml/min per 1.73m2. The mean estimated Clcr at the end of therapy (94±12ml/min per 1.73m2) did not differ significantly from that at last follow-up, 5 years after completion of therapy (92±26ml/min per 1.73m2), in the 11 surviving subjects (P=0.73). However, the estimated Clcr indicated reduced GFR (<90ml/min per 1.73m2) in three of 11 patients (27%) at the end of therapy and in five patients (45%) at one year of follow-up. The estimated Clcr remained consistently below 90ml/min per 1.73m2 during the 5 years of follow-up in these five patients (including the two who underwent up-front nephrectomy). We were unable to perform a parallel comparison of GFR values during follow-up, because the technetium 99m-DTPA clearance test was done only during therapy. Three patients were treated for hypertension: one during therapy and two after completion of therapy. One of these patients showed diminished Clcr and marked proteinuria as a result of focal segmental glomerulosclerosis (FSGS), detected through retrospective histological study of non-tumour involved sections of the removed kidney. Extended follow-up at a median of 11.2 years (range, 7.3–12.8 years) after completion of therapy revealed that six of the 11 long-term survivors (aged 12–25.6 years; median, 18.6 years) had an estimated Clcr<90ml/min per 1.73m2. The median estimated Clcr was 86ml/min per 1.73m2 (range, 10–169ml/min per 1.73m2). Two patients had hypertension, two had trace proteinuria, and one (the patient with FSGS) had undergone renal transplantation. 3.4. Renal tubular function Urinary magnesium wasting was not observed (Fig. 3a); urinary magnesium-to-creatinine ratios were within the age-adjusted normal range,33 and no magnesium supplementation was required. Mean urinary TMP/GFR values were obtained prior to chemotherapy cycles and nephrectomy, and remained within the normal range throughout therapy (Fig. 3b).31, 34 Transient hypophosphataemia was observed after ICE therapy, but resolved before the next cycle. Five patients required phosphate supplementation (two of 12 after the first ICE cycle and three of 10 after the third ICE cycle) for a median duration of 10 days (range, 1–38 days) after their serum phosphorus concentration reached 2.7–3.1mg/dl. No child required chronic supplementation. Five children required potassium supplementation (one after the first ICE cycle, three after the second cycle, and two after the third cycle) for a median duration of 9.5 days (range, 1–14 days). One child required potassium supplementation after both the second and third ICE cycles. One child required phosphate, potassium and bicarbonate supplementation after the third ICE cycle; only this patient required bicarbonate supplementation. No child required chronic potassium supplementation. Mean β2-microglobulin excretion increased during therapy, peaking after nephrectomy and remaining elevated at the end of treatment (Fig. 3c). At the time of extended follow-up (median of 11.2 years after completion of therapy), no patient had evidence of tubular dysfunction based on serum levels of electrolytes and phosphorus or required electrolyte or mineral supplementation. 4. Discussion To our knowledge, this is the first longitudinal study of GFR during therapy for Wilms tumour. Our patients’ mean GFR did not decline significantly after 2 cycles of ICE. GFR was substantially reduced after nephrectomy, but did not decline further after the third ICE cycle. Most studies of renal function in Wilms tumour survivors were performed months to years after nephrectomy and completion of therapy. One study reported no statistically significant difference in GFR (measured by inulin clearance) between children who underwent nephrectomy for Wilms tumour or neuroblastoma (median post-nephrectomy follow-up, 12 months and 9 months, respectively) and children of comparable age who underwent nephrectomy for non-malignant disease (median post-nephrectomy follow-up, 23 months).35 At least 50% of the children in that study had chronic renal insufficiency (defined as GFR<90ml/min per 1.73m2). In another study, Wilms tumour patients were stratified according to whether treatment had included radiotherapy, GFR (measured a median of 13 months post-nephrectomy) was lower in irradiated (73% of normal) versus non-irradiated (95% of normal) patients.36 In that study, 34% of all subjects were considered to have chronic renal insufficiency (GFR 1.5 SD or more below the mean for age-matched controls). In a study that examined GFR and renal compensatory growth 5 or more years after nephrectomy, 22 children with Wilms tumour who had received abdominal radiation were compared to 15 children who had undergone nephrectomy for congenital hydronephrosis.23 Kidney size increased by 25–29% in the Wilms tumour group, but by 42% in the hydronephrosis group. In addition, mean GFR as measured by inulin clearance was significantly lower in the Wilms tumour group (82% versus 92%, respectively, of the healthy control mean), of which 73% had chronic renal insufficiency. The authors concluded that renal compensatory growth was retarded by chemotherapeutic agents and/or radiotherapy in children with Wilms tumour. In another long-term follow-up study, 10 of 53 survivors of Wilms tumour had a GFR<80ml/min per 1.73m2.37 Low GFR was associated with higher doses of radiation and less renal hypertrophy as measured by ultrasonography.37 Our study was not designed to evaluate renal hypertrophy and lacked the statistical power to discern whether radiation contributed to the decrease in glomerular function after nephrectomy. We were surprised by the low incidence of chronic renal tubular dysfunction in our patients although the regimen included only 3 cycles of ICE. Ifosfamide-induced renal injury is characterised by tubular wasting of glucose, potassium, bicarbonate, phosphate, amino acids and low-molecular weight proteins such as β2-microglobulin.38 None of our patients experienced significant chronic tubular wasting or required long-term supplementation of potassium, phosphorus or bicarbonate. The rate of chronic renal insufficiency was within the range (40–73%) reported in patients with Wilms tumour who did not receive nephrotoxic drugs.23, 36, 37 Ifosfamide nephrotoxicity appears to be dose dependent and more likely to occur in younger children or those who have undergone nephrectomy.39, 40 Previous or subsequent administration of other nephrotoxic agents, most notably cisplatin, increases the likelihood of renal toxicity with ifosfamide treatment.38, 39 A subset of patients will experience not only the acute effects of ifosfamide but also chronic renal dysfunction manifested by tubular wasting syndromes or reduced GFR. The low incidence of chronic renal tubular dysfunction in our study could be partially explained by the relatively low cumulative dose of ifosfamide (<20g/m2). If serum creatinine or Clcr is used to identify patients with decreased GFR, the incidence of glomerular dysfunction will be underestimated. Ashraf et al.41 reported that seven of 20 patients (35%) had abnormal GFR values determined by using radiolabelled chromium-EDTA (an exogenous substrate), yet none had an abnormal Clcr rate based on plasma creatinine values. In our study, estimated Clcr overestimated measured GFR by 17.8ml/min per 1.73m2. We observed no progressive decline in mean estimated Clcr after completion of therapy, but the number of our patients with abnormally low estimated Clcr increased over time. Adjustment of the carboplatin dosage according to the measured GFR may have prevented severe renal tubular toxicity, particularly in the cycle of ICE administered after nephrectomy. Although treatment with ICE resulted in transient tubulopathy and evidence of subclinical tubular damage (increased urinary β2-microglobulin), no clinically significant tubular dysfunction was noted at the end of treatment. However, a subset of survivors experienced chronic renal insufficiency, which may have been related to sub-optimal compensatory hypertrophy after nephrectomy. Our study showed ICE chemotherapy to be highly active against Wilms tumour, with non-renal toxicity consisting primarily of moderate myelosuppression. The NWTS-5 trial (1995–2002) used VDA to treat children with stages III and IV Wilms tumour with favourable histology or focal anaplasia, and the combination of vincristine, cyclophosphamide, doxorubicin and etoposide (Regimen I) to treat children with stages II–IV diffuse anaplastic Wilms tumour.2 Although outcomes of patients with diffuse anaplastic Wilms tumour treated with Regimen I were superior to those of historical controls, disease recurrence remained problematic. Because the combination of cyclophosphamide, carboplatin and etoposide may have activity similar to that of ICE and may be less nephrotoxic, the Children’s Oncology Group is currently investigating this combination in frontline treatment of high-risk renal tumours. Our study was limited by the small number of patients and the lack of GFR assessment by technetium 99m-DTPA clearance at follow-up. However, our data suggest that ICE can be safely used in patients with high-risk renal tumours by adjusting the carboplatin dosage to the GFR and carefully monitoring renal function, especially after nephrectomy. Importantly, our findings document the feasibility of designing protocols that incorporate carboplatin, ifosfamide or both for the treatment of renal tumours. Conflict of interest statement None declared. Acknowledgements We thank Sharon Naron, ELS, and Donald Samulack, PhD, for editorial review. Supported in part by United States Public Health Service Cancer Center Support Grant CA21765, Program Project Grant CA23099, and by the American Lebanese Syrian Associated Charities (ALSAC). Presented in part at the Thirty-fifth Annual Meeting of the American Society of Clinical Oncology, May 15–18, 1999. References 1. 1Green DM. The treatment of stages I–IV favorable histology Wilms’ tumor. J Clin Oncol. 2004;22(8):1366–1372.
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42. 42Schwartz GJ. Clinical assessment of renal function. In: Kher KK, Schnapper HW, Makker SP editor. Clinical pediatric nephrology. 2nd ed.. Boca Raton, FL: Taylor and Francis; 2007;p. 71–93. a Department of Oncology, Mail Stop 260, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee, TN 38105-3678, USA b Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA c Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA d Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA e Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA f Department of Pathology and Laboratory Medicine, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA g Children’s Foundation Research Center at LeBonheur Children’s Medical Center, Memphis, Tennessee, USA  Corresponding author: Address: Department of Oncology, Mail Stop 260, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee, TN 38105-3678, USA. Tel.: +1 901 595 2573; fax: +1 901 521 9005.
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