Overview

Participants are being asked to take part in this clinical trial, a type of research study, because the participants have a Wilms Tumor cancer.

Primary Objectives

To determine whether delivery of proton beam radiation to a conformal reduced target volume in the flank allows normal flank growth compared to the contralateral untreated side and non-irradiated patients.

Secondary Objectives

To deliver proton beam radiation to a conformal reduced target volume (partial kidney proton beam radiation therapy) in the affected kidney(s) for patients with Stage V (bilateral Wilms tumor) and specific involved surgical margins yielding no reduction in the high control rates seen with more traditional flank / whole kidney fields.

Exploratory Objectives

• Study the feasibility of sparing the residual kidney, spine and liver in patients requiring whole abdomen radiation therapy using either a proton beam treatment technique or intensity-modulated radiation therapy ( IMRT) photon based technique.
• Study the feasibility of delivering whole lung radiation therapy with proton beams with the goals of sparing the developing breast tissue, heart structures, thyroid and liver.
• Develop simultaneous xenografts and organoid models from the same starting material to study Wilms tumor biology and compare responses to chemotherapeutic agents.
• Define the evolution of organ specific (kidney, liver, pancreas, etc.) abnormalities (laboratory studies) as an early marker of possible late end organ damage and their relationship to radiation.
• Study and evaluate impact of proton therapy on the musculoskeletal system and physical performance and compare with photon therapy cases treated with classical treatment fields.
• Assess CTC-AE and Pediatric Patient Reported Outcomes during radiation and in follow-up, correlating with disease, treatment and patient variables.
• Correlate quantitative MRI values, including apparent diffusion coefficient (ADC) values, with histopathology findings post-surgery in children with (bilateral) Wilms.
• Assess daily variations in proton range along each treatment beam using standard pre-treatment cone beam CT or on-treatment MR.

Eligibility

Inclusion Criteria:

• Patients are eligible to be enrolled on this trial at the time of initial (or presumptive) diagnosis of Wilms tumor, at the time of surgery or at the time of radiation treatment.
• Patients that are determined to be stage I or II will be eligible for the surgical and biologic aspects of this trial but will otherwise be followed per institutional standards and be "off therapy" at the time of stage determination (followed only for survival).
• Patients identified to have an anaplastic or other unfavorable tissue component (non-Wilms histology) to their tumor may have tissue assessed for the biology objective but will be removed from the therapeutic portion of the study at the time of identification of this pathologic finding.

        Performance Level • The Karnofsky performance status must be ≥50 for patients >16 years of
        age and the Lansky performance status must be ≥ 50 for patients ≤ 16 years of age.
        Prior Therapy
          -  Only prior therapy with the initial chemotherapy regimen defined in section 5.1 and
             Appendix III are allowed for patients that are treated with neoadjuvant chemotherapy.
             These patients may change to an alternate regime based on response or biologic
             features and noted in section 5.1. Prior biopsy or surgery is allowed.
          -  Prior radiation therapy is not allowed if directed at the abdomen. Emergent RT to
             other sites of disease is acceptable.
        Organ Function Requirements:
          -  None - As per institutional standard of care. Diagnosis / Stage
          -  Presumed diagnosis of Wilms tumor (continued management on trial will depend on stage
             and histology)
          -  Resected upfront stage III, IV or V favorable histology Wilms tumor. Stage III
             includes any one or multiples of the following:
               -  Lymph nodes within the abdomen or pelvis are involved by tumor. (Lymph node
                  involvement in the thorax, or other extra-abdominal sites is a criterion for
                  Stage IV)
               -  The tumor has penetrated through the peritoneal surface
               -  Tumor implants are found on the peritoneal surface
               -  Gross or microscopic tumor remains post-operatively (e.g., tumor cells are found
                  at the margin of surgical resection on microscopic examination - in the post
                  chemotherapy setting only specific types of viable tumor at the surgical margin
                  are considered stage III AND require adjuvant radiation - see surgery / pathology
                  / radiation section for additional details)
               -  The tumor is not completely resectable because of local infiltration into vital
                  structures
               -  Tumor spillage occurring either before or during surgery
               -  A trans abdominal biopsy (regardless of type- tru-cut, open or fine needle
                  aspiration) was performed prior to resection or chemotherapy. Retroperitoneal
                  biopsies DO NOT require radiotherapeutic management like stage III
               -  Tumor is removed in greater than one piece (e.g. tumor cells are found in a
                  separately excised adrenal gland; a tumor thrombus within the renal vein is
                  removed separately from the nephrectomy specimen). Extension of the primary tumor
                  within vena cava into thoracic vena cava and heart is considered Stage III,
                  rather than Stage IV even though outside the abdomen.
          -  Stage IV - Hematogenous metastases (lung, liver, bone, brain, etc.), or lymph node
             metastases outside the abdomino-pelvic region are present. (The presence of tumor
             within the adrenal gland is not interpreted as metastasis and staging depends on all
             other staging parameters present). Patients with lung involvement and local abdominal
             stage I or II are eligible to remain on trial for whole lung irradiation objective.
          -  Stage V - Bilateral renal involvement by tumor is present at diagnosis. An attempt
             should be made to stage each side according to the above criteria on the basis of the
             extent of disease
          -  Patients that have or will receive neoadjuvant chemotherapy for unresected unilateral
             or bilateral Wilms tumor without a biopsy are not assumed to be require adjuvant
             radiation on this study. That determination will be based on surgical findings and the
             approach to treatment detailed in the protocol.
        Timing
          -  Patients undergoing upfront surgery must start RT, if indicated, within 28 days of
             definitive surgery with a goal of starting RT by day 21.
          -  Patients receiving neoadjuvant chemotherapy will be enrolled either at diagnosis (if
             at St. Jude) or at the time of RT.
        Other Criteria
        • Female patients of childbearing potential (age ≥10 years old or post-menarche) must have
        a negative pregnancy test prior to enrollment.
        Exclusion Criteria:
          -  Inability or unwillingness to provide written informed consent
          -  Prior radiation therapy to a site to be treated with proton / photon radiation as part
             of this trial. Emergent radiation is allowed.