Wilms Tumor Management: A Systematic Review Comparing SIOP and NWTS/COG Protocols in Diagnosis, Treatment, and Outcome.
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INTRODUCTION: Wilms tumor is the most common pediatric renal malignancy, with two predominant management approaches creating clinical decision-making challenges. SIOP advocates preoperative chemotherapy to reduce tumor burden, while NWTS/COG prioritizes immediate surgery for histopathological analysis. Evidence-based comparison is essential, particularly in resource-limited settings. OBJECTIVE: To systematically compare preoperative chemotherapy (SIOP) versus upfront nephrectomy (NWTS/COG) protocols in Wilms tumor management by analyzing diagnostic accuracy, treatment efficacy, and surgical outcomes through direct comparative studies. METHODS: A PRISMA 2020-guided systematic review was conducted, searching PubMed, ScienceDirect, SpringerLink, and Google Scholar for comparative studies (2015-2024) that directly compared SIOP and NWTS/COG protocols in pediatric Wilms tumor patients. Quality assessment was performed using the ROBINS-I tool. RESULTS: Four comparative studies encompassing 226 patients from developing countries (India, Pakistan, Iraq, Vietnam) were included. Diagnostic accuracy varied significantly, with SIOP protocols showing misdiagnosis rates of 17.4-21.7% in resource-limited settings, while NWTS protocols achieved 100% accuracy in the single study reporting this outcome. Surgical outcomes were heterogeneously reported: one Indian study found no intraoperative spillage in SIOP patients (0/23) versus 22.2% in NWTS patients (2/9), though this finding cannot be generalized due to single-center limitations. Postoperative complications varied by setting, with one Pakistani study reporting higher rates in SIOP patients (21% vs. 9.5%). Survival outcomes ranged from 80.9-96.7% across protocols and countries, with no consistent pattern favoring either approach. CONCLUSION: Neither protocol demonstrates consistent superiority across all outcomes. Protocol selection should be individualized based on disease stage, diagnostic capabilities, and healthcare infrastructure. The limited number of comparative studies and heterogeneous reporting highlight the need for standardized outcome measures and larger multicenter trials.