In this session from the 12th Annual Update Course in Pediatric Surgery, Dr. Bhargava Mullapudi (Children’s Mercy Kansas City) presents updated strategies in Wilms tumor management, exploring how tumor biology and global guidelines are shaping decisions on surgery vs chemotherapy first.

Key Highlights:

• COG vs SIOP Guidelines: North American centers (COG) typically favor primary surgery, while European protocols (SIOP) begin with chemotherapy—highlighting major global practice differences.
• Impact of Tumor Genetics: Loss of heterozygosity (LOH) at chromosomes 1p and 16q, as well as gain of 1q, influence chemotherapy decisions even in lower-stage disease.
• Staging and Size Aren’t Enough: While age and tumor weight are considered, biological markers ultimately guide treatment, challenging simplified “under 2 years / under 550g” rules.
• Shifting Practice Patterns: Even for Stage I tumors, presence of LOH may justify adding chemotherapy, depending on evolving Children’s Oncology Group recommendations.
• Pathology-Informed Protocols: Surgeons must often pause for biological profiling before placing ports or initiating adjuvant therapy.

This presentation underscores the importance of precision medicine in Wilms tumor care—and how treatment pathways increasingly rely on molecular markers, not just stage and weight.