An eHealth Decision-Support Tool to Prioritize Referral Practices for Genetic Evaluation of Patients with Wilms Tumour.

Cullinan N1, Villani A1, Mourad S2, Somers GR3, Reichman L4, van Engelen K5, Stephens D6, Weksberg R5, Foulkes WD7, Malkin D1, Grant R1, Goudie C2.

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Abstract

Over 10% of children with Wilms tumour (WT) have an underlying cancer predisposition syndrome (CPS). Cognizant of increasing demand for genetic evaluation and limited resources across healthcare settings, there is an urgent need to rationalize genetic referrals for this population. The MIPOGG study, a Canadian multi-institutional initiative, aims to develop an eHealth tool to assist physicians in identifying children at elevated risk of having a CPS. As part of this project, a decisional algorithm specific to WT consisting of five tumour-specific criteria (age <2 years, bilaterality/multifocality, stromal-predominant histology, nephrogenic rests, overgrowth features) and two universal criteria (family history suspicious for CPS, congenital anomalies) was developed. Application of the algorithm generates a binary recommendation - for or against genetic referral for CPS evaluation. To evaluate the algorithm's sensitivity for CPS identification, we retrospectively applied the tool in consecutive paediatric patients (n=180) with WT, diagnosed and/or treated at The Hospital for Sick Children (1997-2016). Odds ratios were calculated to evaluate the strengths of associations between each criterion and specific CPS subtypes. Application of the algorithm identified 100% of children with WT and a confirmed CPS (n=27). Age <2 years, bilaterality/multifocality and congenital anomalies were strongly associated with pathogenic variants in WT1. Presence of >1 overgrowth feature was strongly associated with Beckwith-Wiedemann syndrome. Stromal-predominant histology did not contribute to CPS identification. We recommend the incorporation of the WT algorithm in the routine assessment of children with WT to facilitate prioritization of genetic referrals in a sustainable manner. This article is protected by copyright. All rights reserved.