Browsing by Author "Davidson, Alan"

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    Blood stream infections in oncology patients at Red Cross War Memorial Children's Hospital, Cape Town
    (2017) Mvalo, Tisungane Knox Titus; Davidson, Alan; Eley, Brian
    Background: Infections cause significant morbidity and mortality in children with cancer, which may be related to the cancer or treatment received. There is paucity of data on the epidemiology of bloodstream infection (BSI) in sub-Saharan Africa. To address this knowledge gap, the present study was conducted at Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town, South Africa. Methods: Structured literature review: From 1 April 2016 to 31 May 2016 a PubMed search was undertaken on BSI in Paediatric Oncology. The search string used was (bacteraemia OR blood stream infection) AND (paediatric OR pediatric) AND (oncology). Studies that did not describe infection patterns, risk factors for infection, morbidity/mortality, articles not in English and those exclusively describing neonatal or ICU patients were excluded from full review. Retrospective cohort study: A retrospective cohort study was conducted at the haematology-oncology unit of RCWMCH. All positive blood cultures from RCWMCH oncology patients taken between 1 January 2012 and 31 December 2014 were retrieved to identify patients who had BSI. Results: Structured literature review: 508 abstracts / articles were initially retrieved and screened. 478 studies were excluded as per the literature review exclusion criteria. Thus, 30 articles were included in full analysis, 17 retrospective studies, 4 prospective multicentre studies, 6 prospective single centre studies, 2 systematic reviews and 1 case report. All were observational studies. This literature review showed that BSI is a frequent and important cause of morbidity and mortality in paediatric oncology. Gram-positive bacteria was noted to be the leading type of pathogen causing BSI. Increased risk of BSI may be from the cancer itself, chemotherapy, hospitalisation, central venous catheter insertion, and oncology patients were at risk of multi-drug resistant infection. Research gaps noted included paucity of studies from Sub-Saharan Africa, limited analysis of the antimicrobial susceptibility of causative microorganisms and limited description of fungal BSI in oncology patients. Retrospective cohort study: From 436 positive blood culture results, 150 BSI episodes were identified amongst 89 patients; 49.1% of the culture isolates were Gram-positive bacteria, 41.6 were Gram-negative bacteria and 9.3% were fungal. Coagulase Negative Staphylococcus and Viridans Group Streptococcus were the most common Gram-positive isolates, and Escherichia coli and Klebsiella species the commonest Gram-negative isolates. The majority of BSI episodes occurred in patients with haematological malignancies (74%), in the presence of severe neutropaenia (76.4%) and whilst on or following chemotherapy (88%). Complications occurred in 14% of the BSI episodes. Fungal infections had the highest prevalence of complications (21.4%). Three children died during BSI as a result of multidrug resistant isolates, giving a case-fatality rate of 2%. Conclusion: The findings of our cohort study show that BSI are mainly caused by Gram-positive bacteria and associated with a low case-fatality rate. The results of this study are consistent with worldwide experience of BSI in paediatric oncology patients. This study provides an understanding of the spectrum of organisms causing BSI and the outcome of BSI in a sub-Saharan African context.
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    Clinical-pathological characterisation of children with B-cell non-Hodgkin lymphoma over a ten year period at a tertiary centre in Cape Town
    (2020) Kriel, Magdalena; Phillips, Lee-Ann; Davidson, Alan; Pillay, K; Hendricks, M
    Background: We characterized B-cell non-Hodgkin lymphoma (NHL) cases over ten years at a tertiary children's hospital to contribute to the body of knowledge on pediatric lymphoma in developing countries with a high human immunodeficiency virus (HIV) burden. Methods: A retrospective cohort study using clinical and laboratory records of children newly diagnosed with B-cell NHL from January 2005 to December 2014. Results: Seventy-five children ≤ 15 years were included. The majority had Burkitt lymphoma (n = 61). Twenty-five percent (n = 19) were HIV positive and 16% (n = 12) had concurrent active tuberculosis. Bulky disease was present in 65.7% (n = 46) and 30.1% (n = 22) were classified as Lymphomes Malins B (LMB) risk group C. The five year survival estimates for HIV-negative and HIV-positive children were similar in our cohort: 81% vs. 79% for eventfree survival and 85% vs. 83.9% for overall survival. Of three children with Burkitt lymphoma, HIV and LMB group C, two died within one year. Conclusions: Irrespective of HIV status, the survival of children in our B-cell NHL cohort compares favorably with cure rates in developed nations, although advanced disease remains associated with a poor prognosis. Characterization of childhood NHL cases contributes to accurate risk stratification and tailored treatment.
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    How has the OSD affected our state hospitals?
    (2009) Parkes, Jeannette; Abratt, Raymond; Taylor, Allan; Le Feuvre, David; Murray, Elizabeth; Robertson, Barbara; Kotze, Tessa; Marais, David; Khan, Del; Kilborn, Tracy; Wieselthaler, Nicky; Gajjar, Himal; Handler, Lenny; Fagan, Johan; Spitaels, Ariane; Morrison, Adrian; Davidson, Alan; Salie, Shamiel; Urban, Mike; Rajkumar, Ash; Pretorius, Vincent; van Niekerk, Magriet; Ferreira, Germaine; Wolmerans, Marli; Cyster, Lyall; King, Darren; Okwuosa, Sebastian; van Staden, Sanet; van Niekerk, Margarethe; Winckler, Jana; Meissenheimer, Heinrich; Botes, Annie; Tait, Deon; Visagie, Jodine; Swarts, Steve; Klocke, Marina; Lomas, Vanessa; Marais, Ilke; Vijoen, Werner; Perry, Jennie; Nkosi, Nokwazi; Stuve, Katrin
    The long-awaited occupation-specific dispensation (OSD) process for state-employed doctors has now been concluded. The final offer, signed and accepted in the bargaining chamber despite being rejected by 92% of doctors in a SAMA survey, has not received much attention or fanfare. At the conclusion of this process, which has been drawn out over several years, many points have emerged that are extremely worrying for the future of health care in this country.
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    Interim analysis of Acute Myeloid Leukaemia treated on the Red Cross Children's Hospital Rx 2071 (adapted from the MRC AML 15 protocol)
    (2017) Thomas, Karla Mari; Davidson, Alan
    Background: Due to the poor outcomes achieved in acute myeloid leukaemia (AML) treatment, the Red Cross War Memorial Children's Hospital (RCWMCH) Oncology service changed from a BFM-87 based protocol to one based on MRC-AML15 in 2007. Rationale: This study was designed to assess the outcomes and treatment - related toxicity among children treated with RCWMCH protocol Rx 2071. Methods: This was a retrospective review of AML patients treated with Rx2071 between 2007 and 2012 at RCWMCH. Patients with acute promyelocytic leukaemia (APL) and Down Syndrome were excluded. Risk was assigned by cytogenetics. Good risk patients were those with t(8;21), t(16,16) and inv(16). Poor and standard risk included all other cytogenetics according to MRC-AML15. Data pertaining to toxicity was obtained from patient folders. Results: Thirty five children were treated on Rx 2071 during the study period. Males comprised 51.4% (18/35) and females 48.6% (17/35). Age at diagnosis ranged from 0.33 to 12.51 years with the median being 5.68 years. Follow-up from remission in the patients who survived ranged from 1 year 10 months to 9 years 1 month with a median of 62.5 months. Fifteen patients had favourable cytogenetics. Event free survival (EFS) for the good risk group was 85.6%. Twenty patients presented with standard/poor risk cytogenetics. Five patients were deemed poor risk with one having major karyotype abnormalities and four not achieving remission. The remaining fifteen were deemed standard risk by cytogenetics. EFS in this group was 32.4%. Two standard/poor risk patients were transplanted in first complete remission (CR1) and two patients were transplanted in second complete remission. (CR2) Patients had a median of four neutropaenic fevers, and required a median of eight packed cell and eleven platelet transfusions. There were 39 positive blood cultures. There were no chemotherapy related deaths. Discussion: The EFS for good risk patients is excellent but the EFS for standard/poor risk group is not on par with results being achieved in high income countries. The toxicity is not excessive on Rx2071. The results achieved on this protocol were superior to that of the previous BFM- based protocol. Conclusion: The results of this study support the continued use of Rx2071 at RCWMCH.
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    Low grade gliomas treated at the University of Cape Town Academic Hospital complex: 2001-2017
    (2021) Kahl, Gisela; Davidson, Alan
    Background: The majority of central nervous system tumours in children are low grade gliomas (LGG). Long-term survival rates are high with a slow, progressive course. Tumour location and extent of resection affect outcome. Adjuvant therapy has an important role. Rationale: This study evaluated the demographic data of our patient population, the characteristics of LGGs in our setting, the time to presentation, and the role of adjuvant therapy including more targeted, novel biologic therapy such as BRAF/MEK inhibitors. The outcome of children with LGGs in our institution was assessed. Methods: A retrospective analysis was performed on all children < 15 years of age diagnosed with a LGG at Red Cross War Memorial Children's Hospital (RCWMCH) between 2001 and 2017. Data were collected from patient hospital folders, as well as paediatric oncology records and Groote Schuur Hospital radiotherapy records. Results: Eighty-six children aged 0.10-13.76 years (median 4.74 years) were diagnosed with LGGs between 2001 and 2017 at RCWMCH. Median time to presentation was 60 days. Sixtyfive patients (76%) were classified as having a WHO Grade I and 21 patients WHO Grade II (24%) tumours. Five patients (6%) had metastatic disease at presentation. The most common sites involved were the cerebellum (27%), hypothalamus (17%) and cerebrum (14%). The most common histology was juvenile pilocytic astrocytoma (JPA) (n=62; 73%). Gross total resection (GTR) was achieved in 21 patients (24%). Twenty-four patients (27%) received chemotherapy of which 11 patients progressed. Twenty-two patients received radiotherapy (26%), of which 3 patients progressed. The estimated 5-year overall survival (OS) was 86.8% and the estimated 5-year progression free survival (PFS) was 42.8%. The presence of a BRAFV600E mutation was checked in 4 patients since 2013, all had JPA histology, and all were negative. Discussion: Our patient demographic differed from published data with respect to younger age at presentation and female predominance. Time to presentation was relatively short. The majority of LGGs were cerebellar, with JPA histology being the most common. GTR was achieved in almost a quarter of patients. WHO Grade II histology did not significantly impact PFS and OS. Children < 3 years had a lower PFS compared to children > 3 years, but OS was similar. OS in this study was comparable to published data in developed countries, however PFS was slightly lower. Conclusion: Our outcomes are similar to those achieved in developed countries. Chemotherapy and radiotherapy are valuable adjuncts to treatment. The presence of a BRAF alterations should be tested in recurrent/progressive disease, to guide use of novel treatments.
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    Management of paediatric immune thrombocytopaenia in a South African centre from 1991-2011
    (2016) Akhalwaya, Shehnaaz; Davidson, Alan
    Three hundred and seventeen patients meeting the diagnostic criteria for immune thrombocytopenia presented to Red Cross War Memorial Children's Hospital between 1991 and 2011. We retrospectively reviewed these patients in order to describe patient demography, the natural history of the disease, and different approaches to diagnosis and management. There were 162 males and 155 female patients. The median age of onset was 3.48 years old (IQR 1.66-6.36). In the 4 weeks preceding presentation, 98 (31%) patients had a viral illness. The median presenting platelet count was 7 x 109/L (IQR 3-14.5). Petechiae were the most common clinical sign at presentation (58%; 184/317). None of the patients presented with intracranial haemorrhages. The majority of patients in the study were admitted (234/317; 74%) with a median stay of 4 days (IQR 0-6). Bone marrow aspirates (BMA) were performed in 188 patients (59%). There was a reduction in BMA from 1991-2000 to 2001-2011 (p<0.001). There was an increase in the percentage of patients treated from 1991-2000 (77/170; 44%) to 2001-2011 (99/147, 67% p< 0.001). Resolution occurred in 75% of patients with a median time to resolution of 31 days (IQR 11-73 days). When we analysed the "survival estimate" from the 2 decades, despite differing rates of BMA, treatment rates and regimens, there was no statistical difference in resolution.
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    Megaloblastic anaemia, diabetes and deafness in a 2-year old child
    (2005) Davidson, Alan; Hartley, Patricia S; Berman, Peter; Shuttleworth, Margaret H G
    Megaloblastic anaemia in childhood usually occurs as a result of dietary folate deficiency or, rarely, congenital disorders of vitamin B12 metabolism. We present a 2-year-old girl with megaloblastic anaemia and insulin-dependent diabetes mellitus, both of which proved responsive to pharmacological doses of thiamine. She was also found to have sensorineural hearing loss. Also known as Rogers’ syndrome, thiamine-responsive megaloblastic anaemia is the result of inactivating mutations in a gene encoding a thiamine transporter. A clinical diagnosis is supported by characteristic bone marrow findings and can be confirmed by demonstrating apoptosis in skin fibroblasts cultured in thiamine-depleted medium. Where available, DNA sequencing is definitive. There is rapid reticulocytosis after thiamine administration. We recommend a trial of therapy for megaloblastic anaemia not responding to folate and vitamin B12, especially in a deaf and/or diabetic child.
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    Megaloblastic anaemia, diabetes and deafness in a two-year old child
    (2005) Davidson, Alan; Hartley, Patricia S; Berman, Peter; Shuttleworth, Margaret H G
    Megaloblastic anaemia in childhood usually occurs as a result of dietary folate deficiency or, rarely, congenital disorders of vitamin B12 metabolism. We present a 2-year-old girl with megaloblastic anaemia and insulin-dependent diabetes mellitus, both of which proved responsive to pharmacological doses of thiamine. She was also found to have sensorineural hearing loss. Also known as Rogers’ syndrome, thiamine-responsive megaloblastic anaemia is the result of inactivating mutations in a gene encoding a thiamine transporter. A clinical diagnosis is supported by characteristic bone marrow findings and can be confirmed by demonstrating apoptosis in skin fibroblasts cultured in thiamine-depleted medium. Where available, DNA sequencing is definitive. There is rapid reticulocytosis after thiamine administration. We recommend a trial of therapy for megaloblastic anaemia not responding to folate and vitamin B12, especially in a deaf and/or diabetic child.
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    Prevalence, Risk Factors and Predictors of Adverse Outcomes of Febrile Neutropenia in Oncology Patients on Chemotherapy at the Red Cross War Memorial Children's Hospital: A Three Year Retrospective Study
    (2022) Adekunle, Motunrayo; Hendricks, Marc; Davidson, Alan
    Background: Febrile neutropenia (FN) is the commonest fatal acute complication of cancer treatment in children. The need for regional clinical decision rules allowing for home-based care in those at low risk for adverse outcomes has been identified. Aims: To evaluate the prevalence and potential risk factors for FN, identify adverse outcomes and validate a tool to identify risk for adverse outcomes in a cohort of children treated for cancer at the Red Cross War Memorial Children's Hospital, Cape-Town, South Africa. Methodology: A retrospective cohort study from 1st January 2017 to 31st December 2019. Results: In all, 179 patients had chemotherapy and 267 FN episodes occurred. Independent predictors of FN were AML (p = 0.039), ALL (p = 0.020) and intensive chemotherapy (p = < 0.001). Mucositis (p = 0.001), CVAD (p = 0.004, haematologic malignancies (p = 0.040), blood transfusion during FN episode (p = 0.001) and severe neutropenia (white cell counts< 0.3 x 109 cells/L) (p = < 0.001) were risk factors for adverse outcomes. The mortality rate from FN was 3.57%. Independent predictors of adverse outcomes were AML (p = 0.001), CVAD in-situ (p = 0.019) and severe neutropenia (p = 0.005). Validation of risk stratification for adverse outcomes using the Swiss Paediatric Oncology Group (SPOG) index with a cut-off value of nine demonstrated a sensitivity and specificity of 52.3% and 62.0%, respectively. Positive and negative predictive values were 56.3% and 58.2%, respectively, with an overall accuracy of 57.4%. In our cohort, coordinates of the curve are best able to predict adverse outcomes with a cut-off value of 7.5. Conclusion: Adverse outcomes from treatment are likely in children with AML, severe neutropenia and those with CVADs in-situ. A lower cut-off of 7.5 using the SPOG FN risk index best predicted adverse outcomes in our cohort.
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    Sequential improvement in paediatric medulloblastoma outcomes in a low-and-middle-income country setting over three decades
    (2021) Riedemann, Johann; Parkes, Jeannette; Davidson, Alan; Figaji, Anthony
    Background: Medulloblastoma (MB) is the commonest malignant brain tumour of childhood. Accurate clinical data for paediatric MB in the LMIC setting is lacking. Sequential improvements in outcome seen in high income countries are yet to be reflected in LMIC. Aim: Quantification of paediatric MB outcomes in the LMIC setting over three decades of advances in multidisciplinary intervention. Setting: Cape Town, South Africa Methods: This was a retrospective study of 136 children with MB diagnosed between 1985 and 2015. Modified Chang criteria were used for risk stratification. The primary study objective was overall survival (OS), quantified by analysis of epidemiological, clinical and pathological data. Results: OS improved significantly during the most recent decade (2005-2015) when compared with the preceding two decades (1985-1995 and 1995-2005). Despite reduced dose craniospinal irradiation for standard risk cases, OS was significantly greater than during the preceding two decades. High-risk disease was identified in 71.4% of cases and was associated with significantly inferior OS compared with standard risk cases. Improved OS was positively correlated with therapeutic era, 3-D conformal radiotherapy technique, older age at diagnosis, classic and desmoplastic histology, extent of resection and absence of leptomeningeal spread on imaging. Conclusion: Advances in multidisciplinary management of MB in our combined service are associated with improved survival. Access to improved imaging modalities, advances in surgical techniques, increased number of patients receiving risk-adapted combination chemo- and/or radiotherapy as well as craniospinal irradiation using a linear accelerator with 3D planning, are considered as contributing factors.
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    The evolving management of Burkitt's lymphoma at Red CrossChildren's Hospital
    (2006) Davidson, Alan; Desai, Farieda; Hendricks, Marc; Hartley, Patricia; Millar, Alastair; Numanoglu, Alp; Rode, Heinz
    Background. Treatment for Burkitt’s lymphoma at Red Cross Children’s Hospital has evolved from the use of aggressive surgery and less intensive chemotherapy to a conservative surgical approach with more intensive chemotherapy. Methods. The study was a retrospective folder review of patients diagnosed with Burkitt’s lymphoma at RCCH between 1984 and 2004. Results. Ninety-two children were treated for Burkitt’s lymphoma at RCCH between 1984 and 2004. There were 10 patients with group A or fully resected disease, 52 with group B or extensive localised disease, and 30 with dissemination to the bone marrow and/or central nervous system or group C disease. Protocol 1 (less intensive chemotherapy based on the COMP regimen) was used from 1984, with protocol 2 (more intensive chemotherapy based on the LMB regimen) introduced in 1988 for group C disease, 1991 for group B disease and 1996 for group A disease. Overall 5-year survival increased from 20% with protocol 1 to 66% with protocol 2 for group C disease, and from 76.5% with protocol 1 to 88.2% with protocol 2 for group B disease. There were more admissions for neutropenic fever in patients on protocol 2 and more episodes of mucositis, and these patients required more red cell and platelet transfusions. With a more conservative surgical approach, biopsy largely replaced attempts to partially resect the tumour at primary surgery, and there was a consequent decline in surgical complications. Conclusions. Intensive chemotherapy with protocol 2 has resulted in improved survival for group C and group B patients, but with more morbidity. Protocol 1, which is less intensive with less morbidity, remains a viable strategy for group A and group B disease in resource-poor settings.
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    Use of palliative chemotherapy in South Africa: National survey of paediatric oncologists and experience in a single unit
    (University of Cape Town, 2020) Büchner, Ané; Meiring, Michelle; Davidson, Alan
    BACKGROUND: Palliative chemotherapy is cancer-directed therapy, which aims at stopping or slowing down the progression of the malignancy even though it may not have any potential for remission or cure. In South Africa, delayed diagnosis of childhood cancer is a common problem for a variety of reasons including lack of health care facilities, transport, information about the disease and delayed presentation due to traditional healer visits or other cultural issues. In patients who present with advanced cancer, or in patients with relapsed cancer without realistic hope of cure, palliative chemotherapy can be offered in an attempt to manage symptoms, improve quality of life and prolong meaningful survival. OBJECTIVES: This research study evaluated South African paediatric oncologists' perspectives and practices regarding the use of chemotherapy in patients with cancer with no realistic hope of cure. The second part of the study described the use of palliative chemotherapy in patients who received treatment at the Steve Biko Academic Hospital Paediatric oncology unit. DESIGN & METHOD: An online survey was conducted among paediatric oncologists in South Africa. The main aims of the questionnaire were to assess paediatric oncologists' considerations around the use of palliative chemotherapy, and then focus on the most recent patients treated with palliative chemotherapy. For the second part of the study, a file review was done of deceased patients who died in the period from January 2012 to December 2018 and who had received palliative chemotherapy as part of their cancer management. We reviewed diagnoses, palliative chemotherapy regimens, timing of initiation and stopping palliative chemotherapy, and whether end of life decisions and discussions were documented. RESULTS: A total of 41 participants completed the survey, giving a response rate of 89%. The majority of the paediatric oncologists were either neutral or agreed that palliative chemotherapy should be considered. The most important treatment aim was to improve quality of life of the patient (92.7% of respondents). The most important considerations when prescribing palliative chemotherapy was to minimise toxicity of the chemotherapy regimen (4.56 mean, SD=0.5 utilising a 5 point scale where 1=not important to 5=very important), and the effectiveness of the chemotherapy (4.37; SD=0.48). Only 19.5% of patients received treatment primarily because parents requested it. According to the oncologists polled, the key considerations were largely achieved in the most recent patient treated with palliative chemotherapy. Individual opinions and preferences concerning recommending palliative chemotherapy differ between paediatric oncologists. Of the 305 patient deaths recorded in the study period, a total of 74 patients had received palliative chemotherapy and were included in the file review. The most common diagnoses were neuroblastoma (18.2%), retinoblastoma (15.6%) and osteosarcoma (14.3%). At the time of diagnosis, the median age of the patients was 6.0 years (range 0.3 to 17.6 years). In 47 patients (63.5%) the disease was deemed incurable at first diagnosis and palliative chemotherapy given from the onset of treatment, while 27 patients (36.5%) were given palliative chemotherapy at relapse. The median time from last palliative chemotherapy to death was 30 days (range 0-742 days). The main documented aim of palliative chemotherapy was to improve symptom control (97.3%) while parents' opinion played an important role in 32.9% of cases. About half of the patients (41 of 74, 55.4%) had documentation of symptomatic improvement. CONCLUSION: Although the overall attitude towards the use of palliative chemotherapy is positive, there is great inter-individual variation between oncologists in opinions and experience. The lack of empirical data to justify recommendations about palliative chemotherapy remains a problem, and the researcher hopes that this study will spark productive discussion and planning towards more structured use of palliative chemotherapy in children with cancer in South Africa. This study shows that many decisions around end of life care and decision-making could be better researched using a quantitative, prospective, interview-based approach. Repeated measurements of the child and family's quality of life and its associations with palliative chemotherapy should be a research priority in future.
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    Wilms' tumour outcomes at Red Cross Children's Hospital 1979-2003
    (2007) Davidson, Alan; Hartley, Paddy
    BACKGROUND: In Africa Wilms' tumour frequently presents with advanced disease. This study reports our results over 25 years using the National Wilms' Tumor Study Group approach of primary surgery, in the form of nephrectomy, followed by chemotherapy. A small number of these tumours are bilateral and here surgery has evolved from simple nephrectomy into the use of nephron-sparing techniques. METHODS: A retrospective analysis was performed on all patients diagnosed with Wilms' tumour between January 1979 and December 2003. Treatment was according to National Wilms' Tumor Study Group protocols. For unilateral Wilms' tumour primary surgery, where possible, was followed by adjuvant chemotherapy with vincristine and dactinomycin. Doxorubicin was added for stage III and IV tumours. Other drugs were used for unfavourable histology, and radiotherapy was reserved for local stage III tumours and pulmonary metastases. Patients with bilateral Wilms' tumours underwent initial bilateral biopsy, neoadjuvant chemotherapy and tumourectomy. Where indicated, nephrectomy (partial or complete) involved using ice dam topical cooling and vascular control, and in one case bench surgery and extensive renal reconstruction with orthotopic autotransplantation. Revision tumourectomy was utilized on three occasions for recurrence in areas of nephroblastomatosis. Radiotherapy was reserved for pulmonary metastases and palliation. RESULTS: There were 188 children with unilateral Wilms' tumour and 20 with bilateral Wilms' tumour. Among those with unilateral Wilms' tumour fifty seven (30.3%) were stage I, 33 (17.6%) were stage II, 60 (31.9%) were stage III and 38 (20.2%) were stage IV. Twenty-four patients (12.8%) had unfavourable histology. Fifteen of the bilateral Wilms' tumours had a synchronous presentation, one with liver metastases at diagnosis, and five were metachronous. Nephroblastomatosis was identified in 18 of the 20 patients (90%) with bilateral Wilms' tumour. One hundred and forty five patients are alive and disease free, 23 to 318 months from diagnosis. The estimated 5-year overall survival for all unilateral Wilms' tumours was 78.3%; 82.8% for favourable histology and 47.3% for unfavourable histology. Among those with favourable histology, estimated 5-year overall survival was 94.6% for stage I, 96.2% for stage II, 78.4% for stage III and 54.2% for stage IV. There was no difference in overall survival between those favourable histology stage III tumours that were operable and those deemed inoperable. Intra-operative spillage was uncommon (8%), and did not increase local relapse rate. Survival of stage IV disease has not improved over the last decade. mong those with bilateral Wilms' tumours, 11 are alive free of disease one to fifteen years after completing treatment, all with well-preserved renal function. Nine have died (two of unrelated disease), including six of the seven with spread outside the kidney. All three with unfavourable histology are alive, as are four of the five with a metachronous presentation. Survival for bilateral Wilms' tumour has improved markedly in the last decade. CONCLUSIONS AND RECOMMENDATIONS" National Wilms' Tumor Study Group protocols employed in a South African setting with highly competent and experienced surgical care, produced results for non-metastatic favourable histology unilateral Wilms' tumour comparable to those of the National Wilms' Tumor Study Group. For bilateral Wilms' tumours appropriate chemotherapy together with conservative (nephron-sparing) and innovative surgery produced good results with preservation of adequate renal function in nearly all cases. We can seek to improve outcomes via better risk stratification with molecular markers, new adjuvant chemotherapy regimes for high risk tumours and novel surgical approaches to improve nephron-sparing in bilateral Wilms' tumour. Improving results in Stage IV patients may depend as much on earlier diagnosis, as on advances in therapeutics.