Challenges in managing Bilateral Wilms tumor in Tanzania: a case series

Bilateral Wilms tumor (BWT) occurs in up to 10% of children and presents a unique therapeutic challenge that requires balancing the complete removal of cancerous tissue with preserving sufficient renal parenchyma to maintain long-term kidney function. While the overall 5-year survival rates for BWT exceed 86% in high-income countries (HICs), there is little known in low- and middle-income countries (LMICs). We present two cases of 5-year-old black African females diagnosed with BWT. The first patient underwent a two-stage surgery: first, nephron-sparing surgery (NSS) of the left kidney, followed by right nephrectomy 2 months later. After surgery, the patient developed acute kidney injury (AKI). Although the left kidney was functional, it was severely affected by the tumor, so we opted for palliative care at home. The patient died 32 weeks later. The second patient received neoadjuvant chemotherapy. Despite good excretory function in the left kidney, it was severely compromised by the tumor, and the right kidney had no excretory function. Unfortunately, this patient died in the ward from a multitude of complications, including respiratory failure secondary to diaphragmatic compression due to massive ascites, and sepsis. Our cases highlight a number of challenges representative of sub-Saharan Africa: late-stage presentation at diagnosis, surgical delays, limited access to the surgical complexity of nephron-sparing approaches in bilateral disease, and the consequent impact on prognosis and outcomes. These factors contribute to survival rates that are far lower than those reported in high-income settings.