The advent of CT imaging of the chest as part of the work up of Wilm's tumor has created substantial controversy. It is natural to assume that lesions of the lung found on CT scan,in the setting of a known primary tumor, represent metastatic disease. False. A study by Ehrlich et al, from the National Wilms' Tumor Study 5 showed that up to a third of lung lesions found on CT only (negative CXR) were not malignant (by pathology). This raises the question of how CT-only lesions should change the management.
Based on COG recommendations, patients who are local stage I or II FH Wilms' tumor should undergo biopsy of CT-only lung lesions to gauge therapy. Patients with Stage III or IV disease, who are enrolled in AREN0533 trial (evaluating response of lung lesions to 3 drug therapy after 6 weeks) are not treated differently in the presence of lung lesions unless these lesions persist after 6 weeks, at which time they would be treated with additional lung radiation, preferably after confirming their malignant nature with biopsy.
Erlich PF. The value of surgery in directing therapy for patients with Wilms’ tumor with pulmonary disease. J Ped Surg (2006) 41, 162-167
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