Neuroblastoma and Wilms Tumor: Treating the Two Most Common Abdominal Cancers in Children

In relapsed or refractory leukemia, where prior treatment options offered only a 5 to 10% chance of success, both Western data and four to five years of follow-up on India's own indigenous CAR T-cell programs are now showing 50 to 60% success.

Dr. Danewa explained that CAR T-cell therapy targets surface antigens on the cancer cell itself, such as CD19 or CD22 in ALL: a patient's own T cells are removed, engineered to recognize that antigen, and returned to attack the cancer directly. Because cancer cells can develop antigen escape by losing one target, dual CAR T-cell therapy now targets CD19 and CD22 together, and similar antigen-targeted approaches (anti-GD2) are being developed for neuroblastoma and, increasingly, for brain tumors.

Only about 1% of pediatric tumors are familial or have an identifiable genetic cause. Most arise from spontaneous mutations that the body's own immune checkpoints fail to catch. There is no equivalent of smoking or alcohol as a modifiable risk factor in children, and no established viral cause, so there is currently no basis for a preventive vaccine.

Dr. Danewa recommended Nathan and Oski's Hematology and Oncology of Infancy and Childhood as the primary reference, alongside Lanzkowsky's Manual of Pediatric Hematology and Oncology, and offered to share his own treatment protocols and presentations directly with any doctor who requests them.

For relapsed ALL, inotuzumab and blinatumomab are both available. Inotuzumab is the more affordable option since it only requires day-care admission, roughly 10,000 to 12,000 US dollars per cycle (day 1, 8 and 15), and some manufacturers offer buy-one-get-one support schemes. Blinatumomab is costlier, at 30 to 40 lakh Indian rupees, because it requires 28 days of hospitalization with continuous infusion, so it is used far less often for international patients. Anti-GD2 therapy (dinutuximab) for neuroblastoma runs around 70 to 80 lakh rupees, though the price has been coming down.

Low-risk neuroblastoma needs surgery alone, no chemotherapy or radiation, and the outcome is good. High-risk neuroblastoma requires surgery, chemotherapy, autologous bone marrow transplant, radiation and targeted therapy together, and survival still sits at only 40 to 50%.

Roughly 10 to 20% of neuroblastomas carry an ALK mutation. In that subgroup, an ALK inhibitor can lift survival by 20 to 30 percentage points.

Whichever treatment approach is used, whether surgery first or chemotherapy first, the tumor must come out without rupturing. A rupture during surgery upstages the disease to stage 3 and brings radiation therapy into the treatment plan.

The American approach operates first, then plans chemotherapy based on the histology and grade found at surgery. The European approach gives four to six weeks of chemotherapy first, to shrink the tumor and make it easier to remove, before operating.

Stage 4 Wilms tumor in children still carries a 60 to 70% survival rate, unlike stage 4 in most adult cancers, which typically signals a very different prognosis.