Treatment of Wilms' tumor and factors affecting prognosis

Pitfalls of Liver Scan in Wilms’ Tumors

Twenty-five patients suffering from nephroblastoma were investigated with a liver scan. The scan results were compared with surgical and pathological findings. This study suggests that different factors (i.e., primary tumor compression, local recurrence and effects of radiotherapy) may determine identical pathological patterns of the scan. Anamnestic information is very important for a correct diagnosis.

Sarcomatous Variant of Wilms’ Tumor. A Light and Immunohistochemical Study of Four Cases

Four cases of infantile sarcomatous renal tumors are reported. Rhabdomyoblastic differentiation was investigated in these tumors by the immunoperoxidase method using antimyoglobin sera. Rhabdomyoblastic cells were found in 2 cases and in a metastasis of one case in which the primary tumor was composed by undifferentiated cells negative for myoglobin stain. The histogenesis of these neoplasias is discussed, and it is suggested that they are a sarcomatous variant of Wilms’ tumor.

Fetal rhabdomyomatous nephroblastoma: a tumour of good prognosis but resistant to chemotherapy

Fetal rhabdomyomatous nephroblastoma (FRN) is a rare variant of Wilms' tumour. The tumour chiefly consists of fetal striated muscle with particularly distinct striations and central nuclei. To determine the effect of (preoperative) chemotherapy in the treatment of this subtype of nephroblastoma, a retrospective analysis was performed. By 1 November 1991, SIOP 9 had registered 852 patients (pts) from 55 centres. We report on 13 children diagnosed with FRN between 1988 and 1992 with a median age of 2 years and 1 month (range 1 month-8 years 6 months). There were 7 boys and 6 girls. 9 patients were classified as stage I, 2 as stage II, 1 as stage III and 1 as stage V. 12 patients received preoperative chemotheraphy with actinomycin-D and vincristine for 2 weeks (1 pt), 4 weeks (5 pts) and 8 weeks (6 pts) respectively. The average tumour volume at registration (determined by ultrasonography) in 12/13 patients was 965 cm3 (range 17.3-2520 cm3). 3/7 of the FRN patients showed no tumour regression after 4 weeks preoperative CT and 4/8 after 8 weeks preoperative chemotheraphy (compared with only 28 and 34%, after 4 and 8 weeks CT, of all trial patients). Of 13 patients, 10% are alive and free of disease with a mean follow up of 4 years. This variant of Wilms' tumour is a poor responder to preoperative chemotherapy and is associated with a generally favourable outcome in most of all unilateral cases when treated by surgery.

Triple therapy for adult Wilms tumor

Adult Wilms tumor is still considered a rarity. Approximately 170 adult Wilms tumors have been reported. The final diagnosis is usually established with surgery. There is no specific radiologic diagnosis of adult Wilms tumor. We report on a case of Wilms tumor in a twenty-two-year-old black man. The tumor was removed with radical nephrectomy and classified as Stage II. Radiation of the renal fossa (4,000 rad) and chemotherapy with actinomycin D and vincristine were administered after surgery. Six years after surgery the patient is disease free. A review of published cases of adult Wilms tumor is presented, and a plea is made for triple therapy.

Successful treatment of renal vein and vena caval extension of nephroblastoma by preoperative chemotherapy

Intravascular nephroblastoma involving the renal veins or inferior vena cava, occurring in 6 to 10 per cent of the cases, dramatically complicates the treatment course for those individuals. Heroic surgical procedures, including sternal splitting and cardiopulmonary bypass, have been used to treat these tumors, often with an added morbidity and increased mortality. We have detailed the dramatic responses to preoperative chemotherapy in 3 patients with intravascular nephroblastoma, which resulted in either complete eradication or marked shrinkage of the intravascular tumor, greatly simplifying the ensuing surgical procedure. These observations strongly indicate that preoperative chemotherapy should be used as the primary treatment in patients with this condition.

Angioma-like pseudometamorphosis in Wilms' tumors subjected to preoperative radio- and chemotherapy

Six Wilms' tumors (stage III-V), which had undergone preoperative irradiation and chemotherapy, were examined histologically. While mesenchymal and differentiated epithelial tumor elements were preserved to a large extent, blastemic tumor structures were almost completely lacking. Instead, pseudoangioma-like structures similar to cavernous hemangioma prevailed. As demonstrated by transitional pictures, the pseudoangioma-like pattern is a result of the fact that blastemic tumor elements are replaced by blood after therapy-induced necrosis and lysis. The clinical advantages of preoperative treatment are briefly discussed, especially for patients with advanced tumors.

Late effects of treatment for Wilms' tumor

Twenty-six out of a total of 49 patients who were treated for Wilms' tumor at the Mallinckrodt Institute of Radiology between January 1960 and December 1975 have survived at least five years. The median follow-up time is 153 months (12 years, 9 months). One girl, who received pelvic irradiation, has not reached puberty at age 14, but the other 25 patients are currently in good health and have no major complaints or functional impairments at present. Twenty-one patients have, however, developed some complication at some time since treatment. Serious side-effects requiring hospitalization included one case of pericarditis and one of esophageal varices secondary to portal hypertension. Both these patients, however, had advanced tumors requiring aggressive treatment and their complications should be seen in perspective. There has also been one case of temporary low grade renal failure and one of transient hypertension. More common complications were 14 instances of scoliosis (only three have had any symptoms, however), five of osseous hypoplasia, three of soft tissue hypoplasia, three of liver damage and three of lung damage. There was one case of osteochondroma within a radiotherapy field. The factors pertaining to these complications and the anticancer therapy which preceded them are discussed in detail. We conclude that, whereas structural changes following modern radiotherapy for Wilms' tumor are very common, severe dysfunctions are infrequent. Even more extended periods of observation will be required before the total number of abnormalities is ascertained. However, the striking observation from this study is the lack of late functional effects.

Preoperative chemotherapy for Wilms tumor

Preoperative chemotherapy was administered to 19 children with Wilms tumor judged clinically to be unresectable at M. D. Anderson Hospital between January 1, 1962, and September 1, 1980. After 2 to 4 doses of vincristine, marked reduction in tumor size occurred in 16 patients. After chemotherapy 16 tumors could be resected completely, another required irradiation to reduce the tumor, and only 2 tumors could not be excised. Pathologically the most dramatic changes occurred in the undifferentiated interstitial stroma, followed next by changes in the nodular blastema. Differentiated elements were apparently not affected. No serious complications were attributed to the preoperative drug treatment. This experience suggests that in selected instances preoperative chemotherapy can affectively facilitate the therapy of Wilms tumor.

A study of childhood renal tumours using xenogeneic antiserum

Fifty-six primary childhood renal tumours, 14 normal and 12 fetal kidneys were examined for their staining reaction with xenogeneic anti-Wilms' antiserum. The antiserum was raised by injecting Wilms' tumour extracts into 6-month-old rabbits which had been rendered tolerant in utero with pooled normal kidney extracts. Renal carcinomas, mesoblastic nephroma and a large proportion of tubular wilms' tumours were stained by the antiserum. In contrast, 6 of 7 bone-metastasising renal tumours of childhood (BMRTC) failed to fluoresce when treated with the antiserum, suggesting that the BMRTC has a different origin from the other childhood renal tumours studied.

Renal venography: anatomy, technique, applications, analysis of 132 venograms, and a review of the literature

Selective renal venography is a simple but important diagnostic procedure which has few complications. A thorough knowledge of renal venous anatomy is essential for its proper performance and clinical application. This is particularly true because renal venous variations are frequent and may interfere with the successful appraoch to retroperitoneal surgery. The method is widely accepted for the evaluation of the renal venous bed in patients with suspected renal vein thrombosis or hematuria of unknown etiology. It depicts the extent of renal venous involvement in renal carcinoma and clarifies the diagnosis in some patients with avascular tumors, renal pelvic carcinoma, and retroperitoneal tumors. It may also be useful in defining the morphologic abnormality when the kidney fails to visualize on urography, in delineating the extent and nature of renal parenchymal disease, and in enhancing the precision of renal vein renin collection.

Rhabdomyosarcoma of the kidney in children

Among 227 consecutive renal tumors examined from the Hospital de Niños de Buenos Aires, seven examples of a distinctive clinicopathological entity occurred. These renal neoplasms were all unilateral, grossly infiltrative without a definitive capsule. Microscopically, the lesion was characterized by a sarcomatous pattern with a rhabdomyoblastic differentiation. Four of them had regional lymph node involvement at surgery. Four developed bone metastases and none had lung metastases. In three instances, the bone metastases were histologically similar to the original neoplasm. The age of the patients ranged from 11 months to 5 1/2 years. A male predominance was observed. Two patients died; one is alive 5 years after surgery; three are alive with metastases; one has been followed for less than a year. In this study, it is proposed that another group of tumors be removed from the Wilms' tumor classification. The neoplasm has been described previously in the literature under several names. It is not clearly related clinicopathologically to nephroblastoma. The term rhabdomyosarcoma is proposed in view of its entirely different biological behavior.

Nephroblastoma and neuroblastoma--histology and prognosis

Statistically evaluating the influence of a histological grading, respectively of morphological differences on prognosis of nephroblastomas and neuroblastomas, better chances for survival become evident not only for earlier clinical stages, but also for nephroblastomas with high differentiation, or neuroblastomas with signs for differentiation. Only for neuroblastomas a relevant predeliction of tumors with signs of differentiation for the early clinical stage I is present. Combined subclassification according to clinical stages and histological grades results in 3 risk groups with different chances for survival. These 3 groups may play a role for specific therapeutic considerations.

Slow growth of an untreated Wilms's tumour in the adolescent

Retrospective radiological documentation of a growing Wilms's tumour in rare. Considered to be a relatively rapidly growing tumour, we present a case where there was adequate radiological evidence of a Wilms's tumour 4 years before the clinical metastatic presentation.

Undifferentiated sarcoma of the kidney: a tumor of childhood with histopathologic and clinical characteristics distinct from Wilms' tumor

The pathological and clinical features of 123 patients with Wilms' tumor diagnosed between 1961 and 1977 were analyzed. A subgroup of nine patients with distinctive histology characterized by the presence of exclusively sarcomatous elements was identified. These patients were indistinguishable clinically from the other patients with Wilms' tumor and were treated as Wilms' tumor. The rate of recurrence in this group of sarcomatous Wilms' tumor was very high (7/9) and long-term disease-free survival correspondingly low )3/9 free of disease from 15 months to nine years) when compared to the patients with classical Wilms' tumor (50% recurrence rate and 71% currently free of disease). In addition, patients with metastases (seven of seven patients with recurrence had skeletal involvement as contrasted to one of 50 patients with metastatic classical Wilms' tumor). We conclude that the "sarcomatous Wilms' tumor" represents a distinct clinicopathological entity identifiable morphologically at diagnosis, best described as renal sarcoma and that in the future optimal treatment of this disease may vary somewhat from the treatment of classical Wilms' tumor.

Wilms' tumor--model of a curable pediatric malignant solid tumor

Wilms' tumor is the model of the treatment of a pediatric solid tumor. Initially it appeared that multi-modality therapy, consisting of transabodominal nephrectomy, post-operative radiation therapy to the tumor bed and adjuvant, single agent chemotherapy provided the highest likelihood of disease-free survival. The identification of important prognostic factors, such as histology, tumor weight, lymph node involvement and age at diagnosis has led to a re-examination of the treatment of Wilms' tumor. Future therapeutic developments will include the administration of less therapy to some well defined groups of patients, and the exploration of new programs for patients who have been demonstrated to have a poor prognosis using currently accepted treatment techniques.

Histopathology and prognosis of Wilms tumors: results from the First National Wilms' Tumor Study

Detailed histological analysis of 427 cases entered on the first National Wilms' Tumor Study revealed that lesions with foci of marked cytological atypism (anaplasia), and those composed predominantly of sarcomatous stroma, were associated with unfavorable outcome. Twenty-five patients had anaplasia, and 24 had sarcomatous lesions of which a total of 28 (57.1%) died of tumor. Three hundred and seventy-eight patients had tumors which showed neither of these features, and only 26 (6.9%) died of tumor. Seven of ten deaths due to tumor in patients diagnosed before two years of age were associated with sarcomatous lesions. Three sarcomatous patterns were recognized, of which one, designated "clear cell" sarcoma, had a predilection for bony metastases. Using criteria defined and illustrated in this paper it is possible to identify in advance those patients likely to do poorly using current therapeutic approaches.

Wilms' tumor: prognostic factors for patients without metastases at diagnosis: results of the National Wilms' Tumor Study

Multivariate statistical analyses are used to evaluate a wide range of factors in predicting relapse and survival for 429 children enrolled in the National Wilms' Tumor Study. Anaplastic or sarcomatous histology, specimen weight over 250 grams, positive regional lymph nodes, treatment with only a single drug and age over two years are the most important predictors of relapse. The first three factors also predict mortality. Laterality, capsular penetration, intrarenal vascular invasion, direct regional extension and operative spillage have lesser effects which do not contribute significantly to the multivariate prediction equations, while sex, race and the presence of a tumor thrombus in the renal vein have essentially no effect. Treatment with combination chemotherapy is confirmed to be efficacious regardless of what prognostic factors are operating. A statistical model allows prediction of relapse and death for each of 24 patient subgroups, with the estimates of percentage relapsed ranging from 3% to 100%.

Histologic grading of Wilms' tumor as potential prognostic factor: results of a retrospective study of 26 patients

A histologic grading system based on tumor differentiation was applied in a retrospective study of 26 patients with Wilms' tumor to determine if it might provide an index to prognosis. The results were compared to those obtained by applying a histologic classification based on the presence or absence of individual histologic structures to the same tumors. Low grade tumors with predominance of differentiated structures--glomeruli and tubules--were associated with a better cure rate than high grade tumors composed mainly of undifferentiated spindle elements. The presence of undifferentiated large cells correlated with poor cure rate. The findings suggest that histologic grading may be valid as a prognostic factor in Wilms' tumor.

Nephroblastoma (Wilms tumor): tubule density and prognosis

Relative differences in tubules density of the primary tumors have been suggested to be prognostically useful in nephroblastoma (Wilms tumor). Forty cases from our institution were retrospectively graded according to tubule density. There were significant differences in disease-free survivals between histologic grades. When compared to other clinical and pathologic staging criteria, tubule density was not more useful prognostically than the staging systems tested. However, when used in conjunction with clinical or pathologic stage, tumor grade improved prognostic sensitivity. Regardless of grade or stage, patients less than 24-months-old at diagnosis had better disease-free survival.

Histopathological study of the first Medical Research Council Nephroblastoma Trial

A histological analysis of the tumors from the first Medical Research Council (M.R.C.) Nephroblastoma Trial was carried out. Material from 104 out of the 111 concluded cases was suitable for assessment. The degree of tubular differentiation and the presence or absence of glomeruli, cysts and papillary structures were correlated with clinical stage and survival. A significant association was found with regard to tubular differentiation. Papillary structures appeared to be important, but the number of cases was small. The presence of either glomeruli or cysts was not a statistically significant feature as regards prognosis.

The increasing importance of radiation therapy in the improved prognosis of children with Wilms' tumor

Treatment results for 32 children with Wilms' tumor seen at the JCRT, CHMC and SFCI from January 1, 1971, through December 31, 1975, are presented. Indications for and technical details of irridation are discussed. The uniform efficacy of irradiation in preventing local relapse in all patients presenting with unilateral disease despite tumor spill in nine is stressed. Actuarial survival of nearly 80% of all patients seen and followed for more than 2 years has been achieved. Eight of 14 patients with documented pulmonary relapse have been controlled with irradiation, chemotherapy and surgery. The importance of an aggressive multidisciplinary approach to this tumor is stressed.

Fetal rhabdomyomatous nephroblastoma-a variant of Wilms' tumor

The fetal rhabdomyomatous nephroblastoma is considered to be a predominantly monophasic mesenchymal variant of Wilms' tumor, which has not been seen in patients older than four years. It acts less aggressively than a Wilms tumor despite its much larger size. Its better prognosis appears to be related to either the absence of or the insignificant amounts of neoplastic epithelium. The bilaterality of this tumor in one-third of the cases, however, may negatively affect the overall prognosis, because complete resection may be impossible or because renal failure ensues.

Wilms' tumor: natural history and prognostic factors: a retrospective study of 248 cases treated at the Institut Gustave-Roussy 1952-1967

A statistical analysis of 248 histologically proven cases of Wilms' tumor treated at the Institut Gustave-Roussy, Villejuif, France, from 1952 to 1967, is presented. Two years recurrence-free survival and five years survival have been selected as prognostic criteria. Patients under two years of age have significantly fewer metastases and a better five-year survival rate than those over two. Stage is stronly correlated with recurrences and survival. Influence of tumor size, number of tumor nodules, tumor rupture, adhesions, regional lymph node involvement, and renal vein infiltration is shown. Detailed analysis of histopathologic features indicates that a favorable clinical course is significantly related to the number of different varieties of epithelial differentiation (tubular, glomerular, microcystic) found in any tumor, whatever the abundance of each of them. Presence of striated muscular cells, however abundant, does not influence survival or metastatic rates. Cases where irradiation given prior to surgery resulted in complete destruction of tumor cells, form a distinctive group of very unfavorable prognosis. Relapse of tumor occurs in 54% of cases, 10% presenting with metastases. Involved sites are listed. No correlation is found between date of metastases and other parameters. The three major prognostic factors of age, stage, histologic pattern, bear prognostic value separately. Stage and age are linked, as well as histology and age. Stage and histology are not linked. Age in itself therefore seems less important. It is concluded that these well-defining treatment for each individual case.

Bench surgery and renal autotransplantation in the pediatric patient

A new operative procedure in renal surgery has evolved from the extensive recent experience in kidney transplantation. Bench surgery and autotransplantation have not been, as yet, fully exploited by surgeons caring for children. This approach to reconstruction of renal substance and renal vessels has as its greatest dividend conservation of kidney tissue. The operation has specific applicability for selected cases of: (1) renovascular hypertension; (2) congenital obstructive uropathy; (3) bilateral Wilms' tumor, and; (4) renal trauma in children.

Capsular and vascular invasion: important prognostic factors in Wilms' tumor

The influence of capsular and vascular invasion on prognosis was determined retrospectively in 52 children with Wilms' tumor. Local recurrence was more prevalent (0.26) in patients with rupture or capsular invasion than in any other group. Inadequate postnephrectomy irradiation or infiltration of the liver by nephroblastoma cells appeared to be predisposing factors in the development of these reccurrences. Of the 26 patients with gross or microscopic vascular invasion, 13 developed metastasis. This proportion was significantly higher than in patients without vascular involvement (p less than 0.05). These observations emphasize the importance of microscopic detection of capsular and vascular invasion in staging of Wilm's tumor.

The incipient Wilms' tumor

The diagnosis of Wilms' tumor is usually made by excretory urography after the patient presents with an abdominal mass. A diagnosis prior to the appearance of an obvious mass might result in an improved cure rate and less morbid therapy. The three cases described illustrate the difficulty in making an earlier diagnosis since pyelograms were "normal" prior to detection of the abdominal mass.

Renal tumours in children

A ten-year series of renal tumours in children up to 14 years of age was collected from the files of the Finnish Cancer Register. After histological evaluation of the material, 74 cases were accepted as primary renal tumours. Fifty-eight of these were typical Wilms' tumours, three rhabdomyosarcomas, six foetal hamartomas and seven unclassified malignant tumours. Wilms' tumours were classified into three types on the basis of the histological differentiation. The total five year survival in the Wilms group was 50 per cent with no difference between patients over and under the age of one year. Of the subtypes of Wilms' tumours the sarcomatous type showed worse prognosis than average; only three out of 16 patients were alive after a five-year follow-up time. None of the patients with foetal hamartoma died of tumour, although two fatalities, connected with the surgery, were recorded. The value of histological classification of Wilms' tumours and the importance of the recognition of the foetal hamartoma is emphasized.

Bone metastases in Wilms' tumour

In a series of 81 patients with a diagnosis of Wilms' tumour seen at the Hospital for Sick Children, Great Ormond Street, between 1960-1972, two patients developed histologically proven bone metastases. In one patient a lump on the head was the presenting symptom of his Wilms' tumour. In the second patient an isolated metastasis developed in the iliac bone 2 3/4 years after complete removal of an encapsulated Wilms' tumour. The bone lesion was outside the previously irradiated volume. Response to treatment was poor and both patients died with further widespread disease. A review of other series confirms the low incidence of bone metastases from Wilms' tumour and the poor prognosis of this complication. This contrasts with a high incidence of pulmonary metastases in which the response to treatment and subsequent survival is good. The value of skeletal surveys and scans in detecting this relatively rare site of metastases from Wilms' tumour is discussed.