The last few years have provided dramatic breakthroughs in understanding the genetic factors involved in Wilms' tumorigenesis and normal kidney development. The implications of these findings for the clinical management of children with Wilms' tumor are only now becoming apparent. Over 80% of patients with Wilms' tumor can be cured using contemporary multimodality therapy. As a consequence, the current NWTSG is attempting to intensify treatment for patients with poor prognostic features while decreasing therapy, and thereby adverse late effects, for patients with favorable prognosticators.