Acute hemorrhage into Wilms tumor: a cause of rapidly developing abdominal mass with hypertension, anemia, and fever

Successful management of Wilms tumor accompanied by traumatic renal injury: a case report

When a tumor and trauma coexist, the treatment strategy must be established while considering their interaction. We herein report a 5-month-old girl with Wilms tumor complicated by blunt renal trauma. She was involved in a traffic accident and had hemorrhagic shock due to renal bleeding. We performed hemostasis by transcatheter arterial embolization. Ten days later, we extirpated the potential malignant tumor and left kidney. We were able to complete the surgery without rupture or major bleeding. Postoperative histopathology confirmed Wilms tumor. In the year since she received postoperative chemotherapy, there has been no recurrence. When we were deciding the treatment strategy, we first had to determine how much the renal trauma had affected the tumor staging. The second issue was when to extirpate the tumor after managing the trauma. There are no standard criteria for such situations at present, so we referred to the criteria concerning the bed rest period in cases of traumatic kidney injury and previous case reports and decided to wait over a week from the injury treatment to perform surgery. As a result, we were able to remove the tumor completely without any rupture or major bleeding.

Perirenal hemorrhage as first presentation of Wilms tumor

Wilms tumor typically presents as an abdominal mass, though occasionally patients present with other manifestations. We report a case of a child presenting with a perirenal hemorrhage and an initially occult Wilms tumor, found only on subsequent renal arteriography. Symptoms in this patient were caused by the presence of perirenal and subcapsular hemorrhage rather than the tumor itself. Despite an unusual presentation, we need to consider underlying neoplasia in children with renal hemorrhage and the absence of a history of trauma. Follow-up studies might help clarify initial negative imaging results.

Current treatment and prognosis of Wilms' tumor

Thanks to the nationally and internationally organized efforts refinements in the therapy of Wilms' tumor have allowed restructuring and reduction of therapeutic strategies. A decrease in tumor relapse and long term sequelae are the immediate goals which will no doubt be the result of tailoring chemotherapy and radiation therapy exposure together with improved surgical techniques and outstanding supportive care.

Wilms' tumor

In the last 2 decades, important advances in the treatment of Wilms' tumor have been made. The remarkable improvement in survival in these patients has been the product of new surgical techniques, classification of the tumors into prognostic stages upon initial presentation and the tailoring of chemotherapy and radiation therapy thus permitted. A brief historical perspective is presented with a review of the current treatment and ongoing studies.

Demonstration of both primary and secondary reninism in renal tumors in children

Two infants with renal tumors and associated hypertension are presented. By using an antibody to purified human renal renin, the sites of renin production were localized immunohistochemically in each tumor. The first case was a 9-month-old girl with Beckwith-Wiedemann syndrome. She presented with bilateral renal masses and hypertension (140/90 mm Hg). Following a left nephrectomy and chemotherapy and radiotherapy, her BP returned to normal. Her tumor was a Wilms' tumor of favorable histology, composed predominantly of glomeruloid structures. Renin was localized within a part of these neoplastic glomeruloid bodies. We therefore designated this as a Wilms' tumor with glomeruloid differentiation having primary reninism. The second case was a 24-day-old girl with hypertension (140/70 mm Hg). A renal tumor was found and successfully removed. Her BP returned to normal. The tumor was histologically confirmed as a congenital mesoblastic nephroma. By indirect immunoperoxidase staining, renin was localized only in the hypertrophied juxtaglomerular cells adjacent to the residual glomeruli entrapped by the tumor. None was seen in the tumor cells. We concluded that this was a case of secondary reninism--a case of hypertension secondary to the local ischemia at the entrapped glomeruli.

The diagnosis and management of Wilms' tumor

Wilms' tumor is the most frequent malignant tumor of the kidney in infants and children. Effective treatment requires abdominal exploration with nephrectomy and administration of postoperative combination chemotherapy, with abdominal irradiation employed only for the treatment of microscopic or gross residual abdominal disease. Current therapeutic research is focused on improving therapy for certain patient groups, such as those with sarcomatous tumors, who continue to have a poor prognosis, and designing less toxic treatment programs for those patients who currently have a favorable prognosis.

Wilms' tumor with intracranial metastases presenting with intracranial hemorrhage

Intracranial metastasis of Wilms' tumor is very rare. Furthermore, intracerebral hemorrhage is an unusual presentation of metastases. We report the case of a 4-year-old girl who had multiple intracranial metastatic lesions, initially presenting as an intracranial hemorrhage. Removal of the tumors and hematoma was followed by radiation therapy and chemotherapy. Thereafter, complete remission occurred. It is thought that this malignant tumor with metastases may be curable through combined therapy.

Paravertebral widening in a case of recurrent Wilms' tumour

In infants and children the association of paravertebral widening and abdominal tumour has been regarded as typical of neuroblastoma. However, a paraspinal mass may develop in other malignant tumours too, but seems to be extremely rare in nephroblastoma. The fourth case so far on record is reported. Microscopically the tumour was of the sarcomatous clear cell variant.

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.

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.