Evidence
There is minimal evidence specifically addressing the utility of PRE in this clinical setting. However, the evidence previously discussed regarding primary surgery supports the position that PRE is frequently not justified. In the SIOP MMT trial, chemotherapy was commonly used after initial biopsy instead of primary surgery or PRE, and conservative surgery and/or brachytherapy was utilized for patients who failed to achieve CR. This treatment paradigm resulted in excellent outcomes with a 5-year overall survival rate of 91% and a local failure rate of 18%.4, 7