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  • Vincristine, Dactinomycin, and Doxorubicin With or Without Radiation Therapy or Observation Only in Treating Younger Patients Who Are Undergoing Surgery for Newly Diagnosed Stage I, Stage II, or Stage III Wilms' Tumor (AREN0532)

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This collection contains data from the Children’s Oncology Group (COG) Clinical Trial NCT00352534, “Vincristine, Dactinomycin, and Doxorubicin With or Without Radiation Therapy or Observation Only in Treating Younger Patients Who Are Undergoing Surgery for Newly Diagnosed Stage I, Stage II, or Stage III Wilms' Tumor". Principal Investigator: Conrad Fernandez, MD in Halifax, NS.  It was sponsored by NCI and performed by the Children's Oncology Group under study number AREN0532. This phase III trial is studying vincristine, dactinomycin, and doxorubicin with or without radiation therapy or observation only to see how well they work in treating patients undergoing surgery for newly diagnosed stage I, stage II, or stage III Wilms' tumor. Select patient-level clinical data from this trial is available via the following link:

Trial Description           

COG AREN0532 is a treatment study of kidney tumors which have not spread to other parts of the body. 544 very low and standard risk favorable histology Wilms Tumor patients entered the trial. At accrual all patients were Stage I-III and had not received any prior therapy. Dates of therapy were from 2006 to 2013.

The National Wilms Tumor Study (NWTS) approach to treating stage III favorable-histology Wilms tumor (FHWT) is Regimen DD4A (vincristine, dactinomycin, and doxorubicin) and radiation therapy. Further risk stratification is desired to improve outcomes and reduce late effects. In a 2018 JCO paper, the trial evaluated clinical and biologic variables for patients with stage III FHWT without combined loss of heterozygosity (LOH) at chromosomes 1p and 16q. This paper included 535 patients with stage III disease. Relapse after stage III treatment is associated with an overall survivsal survival (OS) of only 50% despite intensive salvage chemotherapy and/or autologous bone marrow transplantation. It is thus highly desirable to identify patients who need augmentation of initial therapy with the hope of preventing relapse.

A novel finding in this study was the remarkably strong predictive value of combining LOH and lymph node status. The relapse rate was exceptionally low among patients with tumors that were LOH - and lymph node – negative. However, this trial demonstrated that those with combined lymph node involvement and LOH 1p or 16q had a significantly worse 4-year EFS outcome of 74%. There is a trend toward a poorer 4-year OS in this comparison; however, it is not statistically different.

Approximately two thirds of patients had delayed-nephrectomy tissue submitted for central pathology review. Most patients with blastemal-type Wilms tumor but none of seven patients with low-risk/ completely necrotic Wilms tumor experienced relapse, consistent withthe with the findings of the International Society of Pediatric Oncology (SIOP) that histologic response to preoperative chemotherapy plays an important role in predicting outcome.

The results of this trial described the overall good outcome of patients with stage III FHWT using DD4A with radiation therapy and identified an association of combined lymph node and LOH status, as well as postchemotherapy, delayed nephrectomy histology, with EFS.

Data from the 2018 J Clin Oncol. paper, cited below: A total of 535 patients with stage III disease were studied. Median follow-up was 5.2 years (range, 0.2 to 9.5). Four-year event-free survival (EFS) and overall survival estimates were 88% (95% CI,85% to 91%) and 97% (95% CI, 95% to 99%), respectively. A total of 58 of 66 relapses occurred in the first 2 years, predominantly pulmonary (n = 36). Eighteen patients died, 14 secondary to disease.

A better EFS was associated with negative lymph node status (P less than .01) and absence of LOH 1p or 16q (P less than .01), but not with gross residual disease or peritoneal implants. In contrast, the 4-year EFS was only 74% in patients with combined positive lymph node status and LOH 1p or 16q. A total of 123 patients (23%) had delayed nephrectomy. Submitted delayed nephrectomy histology showed anaplasia (n = 8; excluded from survival analysis); low risk/completely necrotic (n = 7; zero relapses), intermediate risk (n = 63; six relapses), and high-risk/blastemal type (n=7; five relapses).

Trial Outcomes

Results of the trial have been reported in the following publications:

  • Fernandez CV, Mullen EA, Chi YY, Ehrlich PF, Perlman EJ, Kalapurakal JA, Khanna G, Paulino AC, Hamilton TE, Gow KW, Tochner Z, Hoffer FA, Withycombe JS, Shamberger RC, Kim Y, Geller JI, Anderson JR, Grundy PE, Dome JS. Outcome and Prognostic Factors in Stage III Favorable-Histology Wilms Tumor: A Report From the Children's Oncology Group Study AREN0532. J Clin Oncol. 2018 Jan 20;36(3):254-261. doi: 10.1200/JCO.2017.73.7999. Epub 2017 Dec 6. Erratum in: J Clin Oncol. 2019 Oct 10;37(29):2710. PMID: 29211618; PMCID: PMC5773840.
  • Dix DB, Fernandez CV, Chi YY, Mullen EA, Geller JI, Gratias EJ, Khanna G, Kalapurakal JA, Perlman EJ, Seibel NL, Ehrlich PF, Malogolowkin M, Anderson J, Gastier-Foster J, Shamberger RC, Kim Y, Grundy PE, Dome JS; AREN0532 and AREN0533 study committees. Augmentation of Therapy for Combined Loss of Heterozygosity 1p and 16q in Favorable Histology Wilms Tumor: A Children's Oncology Group AREN0532 and AREN0533 Study Report. J Clin Oncol. 2019 Oct 20;37(30):2769-2777. doi: 10.1200/JCO.18.01972. Epub 2019 Aug 26. PMID: 31449468; PMCID: PMC7001789.