Renal papillary adenocarcinoma following treatment for Wilms' tumor

Secondary TFE3-Rearranged Renal Cell Carcinoma in a Chinese Girl Treated for Wilms Tumor: Case Report and Literature Review

Background: With the development of modern medicine and the application of multimodal treatment strategies, the survival rate after childhood malignant tumors as well as the incidence of Secondary malignant neoplasm (SMN) have increased. Case report: Patient is a Chinese girl. Initially diagnosed with Wilms tumor affecting her left kidney at the age of 6, she was later found to have TFE3-rearranged renal cell carcinoma (rRCC) affecting her right kidney at the age of 12. Employing NGS technology on specimens obtained from the TFE3-rRCC, we uncovered a significant somatic mutation within PRSS8 gene. This discovery sheds new light on the intricate genetic landscape underlying her condition, paving the way for further exploration and personalized treatment strategies. Conclusion: We consider that the etiology of SMN may be the result of chemoradiotherapy.

Renal cell carcinoma in the contralateral kidney with TFE3 gene translocation following chemotherapy for childhood nephroblastoma: A case report and literature review

Key Clinical Message

Renal cell carcinoma as a secondary malignant neoplasm is relatively rare; however, the possibility of secondary renal cell carcinoma following chemoradiotherapy for childhood nephroblastoma should be considered.

Abstract

The occurrence of secondary renal cell carcinoma (RCC) following chemoradiotherapy for nephroblastoma is relatively rare, especially in microphthalmia transcription factor family translocation renal cell carcinoma. A 13-year-old Japanese male was referred to our department for treatment of a right kidney mass. The patient had undergone open left nephrectomy and adjuvant chemotherapy for nephroblastoma, 12 years before. Diagnostic imaging revealed a tumor in the right kidney and a lesion suspected to be metastasis in the left eighth rib. Chromophobe RCC or translocation RCC was suspected from the imaging pattern. TNM classification was cT1aN0M1, and the clinical stage was IV. Partial nephrectomy by robot-assisted surgery for the right renal tumor and resection of the left eighth rib were performed. Pathologically, the renal tumor was diagnosed as translocation RCC, and the rib lesion demonstrated no evidence of malignancy. We are currently undergoing imaging follow-up and the patient has been recurrence-free for 15 months. In this study, we present a rare case of secondary translocation RCC after successful treatment of nephroblastoma.

Secondary renal neoplasia following chemotherapy or radiation in pediatric patients

Renal neoplasia occurring as a second malignancy following childhood cancer has been most closely associated with neuroblastoma and Wilms tumor. While some cases have been associated with a genetic predisposition, nearly all are thought to result from "late effects" of therapy-related toxicity that involves chemotherapy or radiation. It is unclear if these tumors are enriched for specific molecular or morphologic characteristics. A query of our institutional nephrectomy registry of 8295 patients for renal neoplasia occurring post-treatment for childhood cancer revealed 6 patients with Wilms tumor, 4 with neuroblastoma, and 1 with acute lymphoblastic leukemia (ALL). Three additional cases of MiT family translocation renal cell carcinoma (RCC), from 2 patients, following chemotherapy for neuroblastoma and systemic lupus erythematosus and another of clear cell RCC post-ALL were included. The most common tumor type was clear cell RCC: 9/19 cases (47.4%), followed by metanephric adenoma and MiT family translocation RCC (3/19, 15.8%). There were no characteristic features to indicate a unique renal neoplasia subtype. Potential syndromic renal neoplasia occurred in 2 patients, metanephric adenomas and oncocytoma in a patient with hyperparathyroidism-jaw tumor syndrome post-treatment of Wilms tumor and a fumarate hydratase-deficient RCC in a patient post-treatment for ALL. The mean age at diagnosis of childhood neoplasia or treatment with chemotherapy or radiation was 4.7 years, and the average time to subsequent renal neoplasia was 31 years. Five (of 14) patients developed metastatic RCC, and there were 2 RCC-related deaths. These results indicate the need for extended clinical follow-up of these patients.

A case of renal cell carcinoma after successful treatment of Wilms tumor

This case report documents the eighth reported case of renal cell carcinoma (RCC) occurring after treatment of Wilms tumor. Although secondary malignancies after treatment of Wilms tumors are not infrequent, RCC as the second malignancy is rare. We discuss a 17-year-old girl whose RCC was diagnosed 12.5 years after diagnosis of a Wilms tumor. In addition, we review the literature on the subject. Renal cell carcinoma has been proposed as a consequent of chemoradiation; however, a genetic susceptibility must be considered. Because it is routine to assess the functional status of the remaining solitary kidney by annual ultrasonography, we recommend assessing for the presence of secondary renal malignancies and perhaps continuing routine ultrasounds long-term.

Renal cell carcinoma as second malignancy in patient with previous Wilms tumor

Adult survivors of childhood Wilms tumor are at an increased risk of a second malignancy. Renal cell carcinoma is not thought to be an associated late malignancy. We present a case report of an adult survivor of Wilms tumor who was treated for renal cell carcinoma. The present case, along with the published data, indicates the possibility of such an association. Our findings highlight the need for renal surveillance and to consider nephron-sparing surgery in future Wilms tumor treatment protocols.

Renal cell carcinoma in children under 14 years old: long-term survival

OBJECTIVES

To assess the treatment and long-term survival of children under 14 years old operated upon for renal cell carcinoma (RCC).

PATIENTS AND METHODS

The records of five patients (aged 2, 4, 6, 9 and 13 years) who had been treated for RCC between 1982 and 1993 were reviewed. All had undergone nephrectomy with (two) or without (three) regional lymphadenectomy. After surgery four patients received chemotherapy (vincristine with actinomycin-D, three, vinblastine, one), and two with advanced-stage disease received other agents (interferon alpha, interleukin-2). They were followed for 5 to 15 years.

RESULTS

Three patients with stage I-II RCC were well at 13, 15 and 15 years after treatment. Of the two patients with regional lymph node involvement (stage III), one was well 5 years after surgery while the other developed hepatic, lung and bone metastases, and died 2 years after presentation.

CONCLUSION

The prognosis and long-term survival of children under 14 years old with RCC is very good for those with low-stage tumours. Nephrectomy with complete tumour extirpation is the main mode of treatment. For advanced-stage tumours, the role of adjuvant chemotherapy and/or biological agents must be defined more clearly.

Genitourinary tumors in the families of children with renal tumors

The occurrence of genitourinary tumors in the relatives of a population-based series of 218 children diagnosed with renal tumors was investigated. Family data on 92% (176 of 192) of Wilms' tumor (WT) patients and 77% (20 of 26) of other renal tumor patients were obtained. In all, 21 genitourinary tumors in first-degree relatives in 19 families were ascertained, together with 30 such tumors in second-degree relatives. Ten families were diagnosed with multiple genitourinary tumors, although none of these manifested familial WT. It is proposed that a small proportion of families of children with renal tumors has a genetic predisposition to develop genitourinary tumors and that these tumors may represent further manifestations of the pleiotropic effects of the WT1 gene or of other genes involved in WT predisposition.

Second primary neoplasms in a population-based series of patients diagnosed with renal tumours in childhood

Eight second malignant tumours developed in a population-based series of 218 patients diagnosed with renal tumours in childhood: renal cell carcinoma of the contralateral kidney, hepatocellular carcinoma, Hodgkin's disease, and 4 basal cell and 1 squamous cell carcinomas of skin. Excess risk of developing a second malignancy (excluding skin carcinomas but including a registrable spinal neurofibroma) was 14.7 (95% CI 4.0-37.7, P = 0.0003) for Wilms' tumour patients. Cumulative incidence of second malignant neoplasms (excluding skin carcinoma) was zero at 10 years, 5.0% at 20 years, and 10.2% at 30 years. The most common second neoplasms seen were benign osseous/chondromatous tumours and 4 of the 7 Wilms' tumour patients with malignant tumours had previous or synchronous tumours of this kind. Development of bony exostoses may be a marker for those patients at particularly high risk of subsequent malignancy.

Aggressive inflammatory pseudotumor of the abdomen 9 years after therapy for Wilms tumor. A complication, coincidence, or association?

BACKGROUND

Inflammatory pseudotumor (IPT) is a benign lesion that occurs in various organs and tissues. It is usually sharply demarcated from the surrounding tissue and surgery is considered to be the best treatment.

METHODS

This article discusses a 15-year-old boy with an aggressive IPT of the abdomen occurring 9 years after therapy for Wilms tumor.

RESULTS

IPT widely involved the esophagus, stomach, and liver, producing severe dysphagia. Histologically, it showed classic features of IPT and, also, areas of metaplastic bone, a new feature recently described in the same lesion of the kidney. It mimicked malignant tumor clinically and led to extensive surgery, but early follow-up has shown no recurrence.

CONCLUSION

Although many complications of surgery and chemotherapy are well known, the authors believe that it is unlikely to be the cause of IPT in the case presented. Therefore, the possibility of coincidence or association of Wilms tumor and IPT remains open.

Infections in the compromised child

Children receiving chemotherapy for malignant diseases show different patterns of infection depending on their underlying disease and its therapy. Granulocytopenia carries the risk of bacterial infection, and also, if prolonged, of fungal infection. Impairment of cell-mediated immunity predisposes to infections with Pneumocystis carinii and is thought to be responsible for severe primary infections with varicella and measles, as well as the severe cytomegalovirus infections seen after allogeneic bone marrow transplantation. Absence or impairment of splenic function predisposes to overwhelming septicaemia with encapsulated organisms, while defects in the normal mechanical barriers to infection provide routes for bacterial and fungal invasion. Despite the lack of physical signs of a normal inflammatory response, clinical evaluation may be critical to the localization of infection in the immunocompromised child. Blood culture and biopsy remain pivotal investigations in the achievement of a microbiological diagnosis. Empirical treatment with a combination of antibiotics has been shown in comparative studies to be effective in initial management of the febrile neutropenic patient: continuing studies are evaluating the role of monotherapy and of different antibiotic combinations, particularly in the light of changing patterns of bacterial infections. Empirical antifungal therapy has been shown to be necessary for persistent or recurrent fever, particularly as persistent fungal infection may compromise the outcome of continuing cytotoxic therapy. Continuing uncertainties over many aspects of management of the infected immunocompromised child provide scope for clinical trials in parallel with trials evaluating new anticancer regimens. The use of new diagnostic methods, the role of prophylaxis, the most appropriate empirical regimen, the evaluation of new antimicrobial agents, all require careful evaluation for efficacy and safety. Perhaps the greatest dilemma of all is how far results from trials in adults can be extrapolated to paediatric practice.

Recurrent renal cell carcinoma arising in Wilms' tumor

A 19-month-old black girl had a radical nephrectomy for a Wilms' tumor that contained areas of epithelium indistinguishable from renal cell carcinoma. She was treated with chemotherapy but subsequently had pulmonary metastases develop and massive abdominal recurrence. The recurrent tumor was histologically renal cell carcinoma with no identifiable Wilms' tumor elements. The child died with recurrent and metastatic tumor 13 months after nephrectomy. Pathologic, immunoperoxidase, and flow cytometric studies of this unusual case are presented.

Anaplastic sarcoma arising in a mature metachronous bilateral Wilms' tumor after irradiation and chemotherapy. Spontaneous versus induced malignant change

A 1-year-old male infant developed a classic Wilms' tumor of the left kidney. Treatment consisted of a left nephrectomy, chemotherapy, and irradiation to the left flank and associated abdomen. Two years later, a mass in the right kidney was discovered; open renal biopsy demonstrated a mature Wilms' tumor consisting entirely of rhabdomyomatous elements in the biopsy specimen. The patient was given a second course of chemotherapy and 2000 rad to the right flank. Over the next 8 years, the mass continued to grow without evidence of metastatic spread. Renal function deteriorated secondary to compression of the surrounding normal renal parenchyma by the enlarging tumor; creatinine clearance from the solitary kidney decreased from 120 ml/min to 40 ml/min during the 12 months prior to removal of the lesion. Via a nephron-sparing procedure, the 3400 g tumor measuring 19 cm X 16 cm X 9 cm was enucleated from the right kidney without compromise to the remaining normal tissue. Pathologic examination of the surgical specimen revealed a mature Wilms' tumor with a malignant anaplastic sarcoma arising in the central portion. Postoperatively, the patient received a third course of chemotherapy with no irradiation to the tumor bed. Currently, he is disease-free with normal renal function more than 20 years after diagnosis of the metachronous bilateral Wilms' tumor. This is the first reported case of an anaplastic sarcoma arising within a Wilms' tumor; this individual also is the longest surviving patient with metachronous Wilms' tumor. The various possibilities regarding the development of the anaplastic sarcoma within the Wilms' tumor of the right kidney are discussed, including the possible role of chemotherapy and irradiation in the development of a second malignancy.

Renal parenchymal carcinoma in children

A series of 14 cases of renal parenchymal carcinoma in patients under 20 years of age is presented and reviewed with the best documented case reports from the literature. Unlike its adult counterpart the tumour has an equal sex ratio and minor trauma frequently precipitates presentation, otherwise its behaviour is similar. The treatment of choice is nephrectomy but, unlike adults, there is evidence to support the value of adjunctive radiotherapy and chemotherapy in the treatment of local spread. Prognosis is particularly worsened by cellular granularity, and vascular or direct extrarenal spread. The 5 year survival rate is 52 per cent.

Papillary Wilms' tumour with carcinoma-like foci and renal cell carcinoma in childhood

Five cases of Wilms' tumour with prominent papillary formation and focal carcinoma-like epithelium are described. The morphology of these tumours is compared with a group of six renal cell carcinomas in childhood. A link between this type of nephroblastoma and renal carcinoma is suggested but pure renal carcinomas are considered to be a separate category. The biological behaviour of the papillary Wilms' tumours was found to be more aggressive than is generally believed. The course of the disease may be influenced by carcinoma-like structures although this fact is not definitely established. Staging seems to be more helpful in such patients as is the case with renal cell carcinomas. Further studies on this type of Wilms' tumour are needed to establish more consistent data.

Lectin histochemistry of kidney tumours and its pathomorphological relevance

Thirty kidney tumours of various histological type were histochemically investigated under the light microscope by means of the ABC-method. We used four biotinylated lectins which are known to bind also to normal renal tubular epithelial cells of different nephron segments. The nuclear grade, the histological growth pattern, the cell type and the histogenesis of the tumours were studied. The lectin of Lotus tetragonolobus bound to nine out of ten renal cell carcinomas with low nuclear grade, but in contrast no binding was seen in eight poorly differentiated ones. Four carcinomas mimicking collecting duct epithelium were also negative after treatment with this lectin, but showed strong staining after treatment with peanut agglutinin, Dolichos biflorus agglutinin and soybean agglutinin. Five oncocytomas showed a high affinity only for Dolichos biflorus agglutinin and only one case was positive with Lotus tetragonolobus agglutinin; three tubulo-papillary adenomas of the renal cortex without any oncocytes were negative with all of the lectins used. The value of lectin histochemistry in tumour pathology and its significance in routine pathological examination of kidney tumours are discussed.