Paraneoplastic erythrocytosis in a young adult with an erythropoietin-producing Wilms' tumor

Wilms' Tumor in Adults-Conventional and Unconventional Presentations of a Rare Entity with a Review of Literature

Wilms' tumor (WT) in adults is a rare neoplasm. Only a few reports are available in the literature. The tumor often masquerades as renal cell carcinoma (RCC). For accurate reporting, histopathological examination (HPE) plays a vital role in early diagnosis and prompt administration of multimodality treatment helps to improve the prognosis. We comprehensively analyzed five cases of adult WT presenting in the third to fifth decade with flank pain, hematuria, fever, and palpable lump. After complete clinical, biochemical, radiological, and HPE evaluation, tumor was staged and treatment was planned accordingly. Patients with low-stage WT were treated with open radical nephrectomy and chemotherapy. One of the patients diagnosed with inferior vena cava (IVC) thrombus apart from the above treatment also underwent IVC thrombectomy. Another young male presenting with distant metastasis (stage IV) and focal anaplasia on histology received preoperative chemotherapy and then planned for surgery. Unfortunately, the tumor being unresectable, second-line chemotherapy was given but he ultimately succumbed to death. All other patients are on regular follow-up and disease-free. Adult nephroblastoma is a rare clinical entity with hostile behavior. The presence of IVC thrombus is not a contraindication to surgery. Although the management strategy as per pediatric protocol by the inclusion of multimodality approach improves survival, still the overall prognosis in adults is dismal. There is a need for a standardized treatment protocol to encourage a homogenous approach for this rare disease and thereby improve survival.

Cushing syndrome secondary to CRH-producing Wilms tumor in a 6 year old

Abstract Cushing syndrome is caused by prolonged exposure to elevated serum cortisol. It is uncommon in children, and etiology includes pituitary adenoma, adrenal tumor, and exogenous glucocorticoid administration. Rarely, it is paraneoplastic in origin. We present a case of paraneoplastic Cushing syndrome due to Wilms tumor that secreted corticotropin-releasing hormone (CRH). A 6-year-old male presented with polyphagia and weight gain. He showed Cushingoid appearance, hypertension, and palpable left flank mass. Serum cortisol and adrenocorticotropic hormone (ACTH) levels were elevated. Computed tomography showed a neoplasm originating from the left kidney. Pathologic diagnosis of Wilms tumor was made upon nephroureterectomy. Immunohistochemical staining was positive for CRH and negative for ACTH. All features of Cushing syndrome disappeared after surgery. This represents a rare case of Cushing syndrome secondary to Wilms tumor in which CRH production has been demonstrated.

Production of erythropoietin and multiple cytokines by metanephric adenoma results in erythrocytosis

This is the first report of direct evidence that metanephric adenoma cells produce erythropoietin and other types of cytokines, which may be the cause of the high incidence of erythrocytosis in patients with this tumor. The purpose of the study was to establish a metanephric adenoma cell line in vitro from nephrectomized tumor tissue in order to investigate the ability of metanephric adenoma cells to produce erythropoietin and other types of cytokines. The tumor tissue was obtained from a 16-year-old boy who had developed metanephric adenoma with erythrocytosis and was served for cell culture. Significantly high concentrations of erythropoietin, granulocyte-macrophage colony-stimulating factor (GM-CSF), granulocyte-colony-stimulating factor (G-CSF), interleukin-6 (IL-6), and IL-8 were detected in the cell culture supernatant. Southern hybridization showed specific positive signals for GM-CSF, G-CSF, IL-6, IL-8 and erythropoietin. The number of chromosomes was 46-XY without any structural abnormalities in cytogenetic analysis of the cultured cells.

Neuroblastoma with expression of erythropoietin resulting in erythrocytosis

We report the detection of erythropoietin mRNA in the tumor from a patient with neuroblastoma and erythrocytosis. A 2-year-old girl with neuroblastoma presented with hemoglobin 21.3 g/dL, red blood cells 8.03 x 1012/L, and hematocrit 0.641. The serum erythropoietin level was 26.54 mU/mL. The hemoglobin, hematocrit, and serum erythropoietin level were within normal ranges 3 months after surgical excision of the tumor. RT-PCR analysis showed that erythropoietin mRNA expression in the tumor tissue was as high as that of normal renal tissue. These results conclusively demonstrated that the tumor was the site of the ectopic erythropoietin production.

Wilms tumor associated with polycythemia: case report and review of the literature

PURPOSE AND METHODS

A case of polycythemia with a normal serum erythropoietin is described, which led to the diagnosis of Wilms tumor. The clinical features of the reported cases of Wilms tumor associated with polycythemia are reviewed.

RESULTS

An asymptomatic 6-year-old boy with polycythemia, a normal serum erythropoietin, and no evidence of erythroid colony forming activity in his serum was found to have a Wilms tumor. After resection and chemotherapy, he has had no recurrence of either the polycythemia or the Wilms tumor. There have now been 10 cases of Wilms tumor reported: 7 patients were more than 16 years of age, 8 were boys, and 9 were clinical stage I with a favorable histology.

CONCLUSIONS

Polycythemia is a rare manifestation of Wilms tumor that can occur in the absence of an elevated serum erythropoietin and has an association with male gender, older patient age, and low clinical stage. Children with unexplained polycythemia should be investigated for Wilms tumor, even if the serum erythropoietin level is normal.

Paraneoplastic manifestations in children

Paraneoplastic manifestations are signs and symptoms observed in patients with cancer, distant from the tumour or its metastases and not caused by invasion, obstruction or bulk mass. In children with cancer, paraneoplastic manifestations are rare and distinct from those observed in adults. Knowledge about paraneoplastic manifestations can be of great clinical importance because they may be the presenting sign of a tumour or its recurrence and hence facilitate early diagnosis. In contrast, they sometimes mask the symptoms of a tumour and cause diagnostic delay. In this review, paraneoplastic manifestations in children are described, including hypercalcaemia, Cushing syndrome, precocious puberty, opsoclonus/myoclonus, acquired von Willebrand disease, watery diarrhoea syndrome, and hypertension. The mechanisms causing these manifestations are also discussed.