Hypernephroma in children

Renal cell carcinoma in children and young adults

Renal cell carcinoma (RCC) is a relatively uncommon tumor in childhood. Its biologic behavior and prognostic factors have rarely been documented. We report treatment and survival of 4 children (aged 8, 9, 11, and 14 years) who had RCC, along with a review of the literature to analyze the frequency of major symptoms, clinical stage, and prognostic factors based on 130 published cases of RCC in individuals younger than 20 years of age. Two of our cases had renal tumors detected by ultrasound screening, and all 4 cases were followed for a considerable length of time and were alive and free of disease after treatment. An analysis of these 130 published cases of pediatric RCC showed tumor staging and cell type to be the factors that affected patient survival. Tumors composed of granular cells or mixed cells, or at advanced stages, had a poor prognosis. Age, sex, tumor size, symptom duration, and cellular pattern were not related to patient prognosis. Children older than 10 years of age, who have an abdominal mass, flank pain, and/or hematuria should alert clinicians to consider the possibility of RCC. The importance of early diagnosis of renal tumors, using ultrasound as a tool of screening, is emphasized, since surgical treatment leads to a favorable prognosis only in the early stage of RCC.

Local lymph node involvement does not predict poor outcome in pediatric renal cell carcinoma

BACKGROUND

Local lymph node involvement in adults with renal cell carcinoma (RCC) is associated with poor outcome. The prognostic significance of local lymph node involvement in children with RCC has not been studied systematically.

METHODS

A retrospective review of patients treated at St Jude Children's Research Hospital (Memphis, TN) and an extensive review of the medical literature were undertaken to evaluate the prognostic significance of local lymph node involvement in pediatric RCC.

RESULTS

Thirteen patients with the diagnosis of RCC were treated at St. Jude since the hospital's inception in 1962. Four patients presented with lymph node-positive, distant metastasis-negative (N + M0) disease, and all 4 remain disease free after resection without adjuvant therapy (follow-up duration, 2-9 years). A systematic review of the literature including 243 pediatric patients with RCC revealed stage-specific survival rates of 92.5%, 84.6%, 72.7%, and 12.7% for Stage I-IV disease, respectively. Of 58 children with N + M0 RCC for whom outcome data were available, 42 (72.4%) were alive without disease at last follow-up. Among patients whose therapy could be discerned, those who received no adjuvant therapy fared as well (15 of 16 alive) as those who received various adjuvant treatments (22 of 31 alive).

CONCLUSIONS

Children with lymph node-positive RCC in the absence of distant metastatic disease had a relatively favorable long-term prognosis, with survival rate nearly triple those of adult historical controls. Until highly effective therapies for RCC are identified, these children should not be exposed to adjuvant treatment. Further investigation of the biologic differences between adult and pediatric RCC is warranted.

Meta analysis of the relationship between tuberous sclerosis complex and renal cell carcinoma

The association of angiomyolipoma with tuberous sclerosis complex (TSC) patients is well recognised. Some literature has suggested that patients with TSC are at increased risk of renal neoplasm, particularly since angiomyolipomas can be locally invasive and demonstrate tumor like neovascularity on angiography. In an attempt to place in context one case of metastatic renal cell carcinoma in a patient with TSC a meta analysis of the literature was performed. One pediatric patient with TSC and metastatic renal cell carcinoma was evaluated. Reviews and case reports of TSC and renal cell carcinoma and related imaging findings were identified by searching the MEDLINE database, the 'bibliography of reviews' in Index Medicus, personal files and the reference lists from all identified reviews. Individual cases suitable for review in the available literature from 1922 through 1993 comprised the data base. The data base was analysed with the method of proportions and unpaired two-tailed Student's t-test for different populations. A cumulative summary of the literature amassed 107 additional cases from 62 reports over 71 years. Our case is the 17th case, to our knowledge, of renal cell carcinoma in TSC. Analysis of the distribution of characteristics and incidence of; renal cysts, renal cell carcinoma, and lymph node involvement demonstrate no increased risk of renal cell carcinoma in patients with TSC (P = NS). Though anecdotal evidence has suggested a relationship between TSC and renal cell carcinoma, meta analysis of cases of coincident TSC renal complex, cystic changes, angiomyolipoma and renal cell carcinoma implies an identical, though small, risk of malignancy in TSC patients as compared with the normal population.

Spectrum of differentiation in pediatric epithelial tumors of kidney: report of two cases

Two unusual presentations of childhood renal cell epithelial tumors including one whose unique clinical manifestation was polycythemia are described. One was a renal cell carcinoma which was so poorly differentiated that ancillary histopathologic techniques were necessary to arrive at the correct diagnosis. The other case represented the opposite extreme being so well-differentiated as to raise the differential diagnosis of renal cell carcinoma versus renal cell adenoma with blastemal areas. These case studies exemplify the practical role for specialized histopathologic techniques in diagnosing pediatric renal tumors, which may not be feasibly or even accurately categorized into known renal tumor types using routine diagnostic methods.

Renal cell carcinoma in children: histology, immunohistochemistry, and follow-up of 10 cases

Ten renal cell carcinomas in children under 15 years were investigated. The average age was 122.5 months and the girls predominated in our cases (7 girls, 3 boys). By using the classification of Thoenes et al., Pathol Res Pract 181: 125-143, 1986 a predominance of clear cell-eosinophilic tumor cell type and of the tubulopapillary growth pattern was found. Immunohistochemistry revealed a heterogeneity of cytokeratin expression. By using the monoclonal antibodies Cam 5.2 and KL 1, cytokeratins were found in 7 cases each. The other 4 cytokeratin antibodies used were less sensitive. The expression of cytokeratin 13 in 3 cases suggested a more complex histogenesis than assumed. Vimentin was found in 3 tumors, but an association to a higher grade (G) of malignancy was not found in these cases. One tumor expressed the Tamm-Horsfall-protein, which is predominantly found in the distal tubule of the normal kidney. In summary the results of immunohistochemistry characterized the great heterogeneity of these tumors. Follow-up information was available in 9 cases. All patients with G I- and G II-tumors were free of disease after an average time of 39.6 months (mean 27 months). Two of the 3 cases with G III-tumors died after 9 and 15 months, despite additional chemo- or radiotherapy. Therefore tumors of grade I and II of the Thoenes classification seem to have a good prognosis.

Long-term follow-up of children with renal carcinoma

Renal carcinoma is a rare tumour in children. The clinical, histological and follow-up details of 6 patients are presented. Haematuria is confirmed as an important indicator of renal pathology. Long-term follow-up suggests that chemotherapy and radiotherapy have little effect on the prognosis in advanced disease.

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.

Undifferentiated renal cell carcinoma in infancy: report of a case and review of literature

A case of rapidly progressed undifferentiated renal cell carcinoma in a 2 2/12-month-old boy is reported. The histology is characterized by sarcomalike spindle and pleomorphic cells and bizarre giant cells, thus creating many difficulties in the differential diagnosis. The diagnosis of renal cell carcinoma was established on the basis of tubular formation by clear and granular cells observed in a few discrete areas. The literature on renal cell carcinoma occurring under 10 years of age was reviewed, with special attention given to histological typing. It is generally believed that renal cell carcinoma in children is well differentiated, but 2 of 39 cases reviewed were undifferentiated. We conclude that renal cell carcinoma in infants or young children may have an undifferentiated, atypical histological appearance and can progress rapidly. The differential diagnosis from anaplastic Wilms' tumor and sarcomatous tumors of the kidney in children is discussed.

Adenocarcinoma of kidney in seven-year-old child. Eight-year follow-up

A seven-year-old child with regionally advanced adenocarcinoma of the left kidney is described. It is now eight years since surgery and irradiation, and there is no evidence of disease. Follow-up and review of the literature is presented.

Renal cell carcinoma in children

Data from four pediatric hospitals concerning 20 children treated for renal cell carcinoma (RCC) from 1964-1978 were reviewed. Median age of the patients (pts) was 11.8 years (range, 14 months-19 years). Twelve were male and eight female; 17 were white and three black. Most patients presented with pain and hematuria with or without a palpable mass. An intrarenal tumor was detected at IV urography (17 pts), arteriography (2 pts), or at surgery (1 pt). Treatment consisted of nephrectomy in 15 pts, renal biopsy (4 pts), or no surgery (1 pt), followed by chemotherapy (5 pts), radiation therapy (1 pt), or both (7 pts). Ten pts died of distant metastases at a median of one year (range, 0.2 to two years) after diagnosis. The other 10 pts (50%) survive free of relapse at a median of 4 years (range, two to ten years) from diagnosis. Proportions surviving free of recurrent disease two or more years by National Wilms' Tumor Study (NWTS) Group were 5/5 in Group I, 3/7 in Group II, 1/3 in Group III, and 1/5 in Group IV; by age at diagnosis, 6/6 in those under 11 years old and 4/14 in those 11 or older; and by type of surgery, 10/15 who had nephrectomy and 0/5 with limited or no surgery. The data indicate that radiation and chemotherapy had only minor if any influences on relapse-free survival. We conclude that (1) RCC in children is similar to its counterpart in adults; (2) RCC has a worse prognosis than Wilms' tumor except for the earliest stage; (3) nephrectomy alone is adequate treatment for Group I RCC, and (4) young age (less than 11 years old) may be prognostically favorable.

Rupture of a renal cell carcinoma in a child: five-year tumor-free survival and literature review

The third case of presumably spontaneous rupture of a hypernephroma in a child is reported. This patient remains free of disease more than 5 years following radical nephrectomy, radiation and chemotherapy. Although renal adenocarcinoma in children remains a rare disease, more than 80 cases have appeared in the literature, making it necessary now to consider this tumor in the differential diagnosis of all childhood abdominal masses. Equally significant is the observation that presentation as an acute abdominal crisis in a child can occur, making it important that diagnostic considerations in such situations include hypernephroma, as well as Wilms' tumor. Review of the literature shows that occasional cures from spontaneous retroperitoneal rupture of hypernephromas have been reported in adults, but not in children, although this child has survived in spite of tumor spillage in the free peritoneal cavity.