Is antenatal detection of Wilms tumor a bad prognostic marker.

Sir,

We thank the reader for their interest and comments on our paper. However we would like to submit the following in response to their observations.

Radiotherapy can be planned in patients who are already stage III preoperatively. In patients who become stage III after surgery (due to spillage, incomplete resection, or positive lymph node), the radiotherapy that needs to be administered in some other institute cannot be planned in advance. We are responsible clinicians and do not hide behind excuses. The degree to which delay in radiotherapy affects the prognosis is in itself questionable.[2]

The word “advanced stage” has not been used by us as has been assumed. In fact if there had been no spill this patient would have been Stage I.

We have described the mass as predominantly cystic. The solid areas were not very accessible for FNAC. Even during the short stay of 3-4 days while the child was being evaluated the mass had significantly increased in size so as to start causing respiratory compromise. In retrospect our decision to go in for surgery stood vindicated as we were able to remove the tumor in to without any injury to surrounding structures. Tumor spill was the only adverse event which occurred during surgery and has been reported in up to 24% cases.[1]

The personal opinion of the author is duly noted. Rapid progress of the tumor mass did not allow for nutritional build up. Tumor recurrence within 3 weeks of three-drug chemotherapy supported our decision of not giving upfront chemotherapy in a predominantly cystic neoplasm. In retrospect, we are even more confident of our plan as this tumor recurred within 3 weeks despite three drug chemotherapy, so a good response to preoperative chemotherapy was unlikely if it had been administered.

We have not asserted the antenatal Wilms but only suggested that this subgroup may have poor survival. We have mentioned the data available in literature. It is appalling to know that references have been mentioned without even going through them. The fourth reference quoted in this letter to editor is an editorial written for an article (Applegate KE, Ghei M, Perez-Atayde AR. Prenatal detection of a Wilms’ tumor. Pediatr radiol 1999;29:65-7) which had already been quoted in our paper. Furthermore, in that editorial, early surgery for this subset of tumors is recommended. The fifth reference the author has quoted describes Wilms tumor in a prenatally detected multicystic kidney at the age of 18 months which is different from prenatally detected Wilms tumor.