Bilateral Wilms tumors

Metachronous bilateral Wilms tumor. Report of longest-known survivor and guidelines for conservative management

In a one-year-old black male patient a classic Wilms tumor of the left kidney was treated with left nephrectomy, chemotherapy, and irradiation to the entire abdomen. Two years later a mature Wilms tumor, consisting predominantly of rhabdomyomatous elements, was discovered in the right kidney. Although a second course of chemotherapy was given and 2,000 rad were delivered to the right flank, the mass continued to enlarge with progressive deterioration of renal function. A nephron-sparing procedure was performed, in which a 3,400-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. Currently, he is disease-free with normal renal function more than twenty years after diagnosis of the metachronous bilateral Wilms tumor. We believe he is the longest known surviving metachronous Wilms tumor patient and emphasizes the importance of conservative, meticulous surgery in the management of both unilateral and bilateral Wilms tumors. The role of multimodal therapy (chemotherapy, irradiation, and surgery) as well as the current guidelines for the management of bilateral Wilms tumors as proposed by the National Wilms Tumor Study are reviewed.

The association of Wilms' tumor, male pseudohermaphroditism and diffuse glomerular disease (Drash syndrome): report of eight cases with clinical and morphologic findings and review of the literature

In 8 children (6 males) at least 2 of 3 disorders were found--male pseudohermaphroditism (MPH), Wilm's tumor, and glomerular disease. MPH was present in the 6 males; they had abdominal cryptorchidism (6/6), ambiguous genitalia (6/6), negative sex chromatin (5/5), and 46XY karyotype (2/2). The gonads examined microscopically in 3 patients were dysgenetic testes. The renal tumor present in 7 was nephroblastoma (NB) of the classical type without anaplasia or nephroblastomatosis, bilateral in 1, and unilateral but multinodular in 2. Five underwent nephrectomy for a renal mass, and in 2 NB was found at open biopsy or at autopsy. The mean age at diagnosis was 10 months. Glomerular disease in 6 patients began with onset of the nephrotic syndrome between 20 days and 39 months of age; it was resistant to steroid therapy and led to death from renal failure. Microscopically the glomerular process was a diffuse mesangial sclerosis (DMS). The 2 children with NB and MPH, but without DMS are healthy 2 1/2 and 9 years postnephrectomy. Neither familial incidence nor parental consanguinity was found. This syndrome has complete and partial forms, and its early recognition is important both for patient management and for assessment of prognosis.

The current management of bilateral Wilms tumor

The good prognosis of synchronous bilateral Wilms tumor seems inappropriate for the magnitude of the disease process. Our experience with 11 cases demonstrates the unusual tumor response to chemotherapy and limited preservative surgery. Although 2 patients died 2 with metastatic disease have responded to chemotherapy and are alive at 5 and 8 years after treatment. In addition, 1 patient has survived with biopsy only and no definitive surgery. Although all surgical options have been used, ranging from biopsy alone to bench surgery with autotransplantation to bilateral nephrectomy, our experience demonstrates the effectiveness of a conservative approach with initial biopsy, chemotherapy and subsequent partial nephrectomy if needed. Our survival data and the histological examination of the tumors after chemotherapy suggest a strong relationship of bilateral Wilms tumor to the nodular renal blastema-nephroblastomatosis complex, and a mechanism to explain the excellent tumor response to chemotherapy.

Partial nephrectomy for Wilms tumor

We report a case of a left Wilms tumor that was treated successfully by partial nephrectomy. The advantages and disadvantages of this approach are discussed.

Abdominal masses

The more common abdominal masses of the pediatric age group are discussed along with current thoughts regarding preoperative imaging modalities. A careful physical examination is indispensable, and masses should be evaluated with consideration given to mobility, location, consistency, contour, and site. A rectal examination is essential. The more unusual clinical presentations are discussed in appropriate sections.

Prognostic factors and outcome in bilateral Wilms' tumor

Twenty-one patients with bilateral Wilms' tumor are reviewed and the details of diagnosis, therapy, and survival presented. All patients had an abdominal mass at the time of diagnosis. Associated findings included hypertension, aniridia, and genitourinary anomalies. Favorable histologic features were found in all simultaneously occurring tumors and in the initial tumor in nonsimultaneous tumors. Eleven of the 18 patients with simultaneously occurring tumors survived for at least 2 years, for an overall 2-year survival rate of 61%, which was similar to the 2-year survival rate of 60% found in a review of 61 other simultaneously occurring bilateral Wilms' tumors reported in the literature since 1971. Two "front-end" factors that affected prognosis were the patient's age and the stage of the most advanced tumor at the time of diagnosis. A significantly better survival was found in children whose tumor was diagnosed before the age of 2 years and in patients who had Stage I or II disease in the most advanced tumor, as compared with those who had Stage III or IV disease. The overall survival rate in this series and in the literature review is much poorer than that reported for bilateral Wilms' tumor in the National Wilm's Tumor Study; some possible reasons for this are given. The authors' current approach to diagnosis and therapy is reviewed.

The role of computerized tomography in the diagnosis and management of patients with bilateral Wilms tumor

We report 2 cases of bilateral Wilms tumor. In both cases computerized tomography provided accurate data for the diagnosis of bilateral tumors and predicted surgical resectability, without nephrectomy, of the smaller tumor. In 1 patient computerized tomography demonstrated tumor growth while on chemotherapy and radiotherapy. The role of angiography in the management of these patients is discussed.

Survival in bilateral metachronous (asynchronous) Wilms tumors

The survival of patients with Wilms tumors has improved dramatically during the last few decades. In contrast, the bilateral form of the disease, especially when the tumors are not concurrent, is still considered by many to hold a much worse prognosis. A review of 50 cases reported during the last 20 years reveals that the survival of patients with metachronous Wilms tumors has improved in parallel with survival of patients with unilateral disease and, when matched for extent of tumor spread, survivals for the last decade are almost identical to those of bilateral synchronous disease and unilateral Wilms tumors.

Bilateral Wilms' tumor and secondary malignancies

A series of six patients with bilateral Wilms' tumor (nephroblastoma) is presented. Multimodal therapy yielded a survival rate of 83% at 2 yr of follow-up. However, at the end of a later follow-up period only two patients (33%) were alive. of the 4 patients who died. Only 1 died of Wilms' tumor. One died of complications of aggressive chemotherapy and two patients died after 12 and 16 yr following treatment of secondary malignant tumors arising in the irradiated region. Patients with bilateral tumor should be followed at regular intervals for the duration of life for the occurrence of secondary malignant tumors.

Renal transplantation for Wilms tumor: report of 20 cases

Renal transplantation as part of the treatment for Wilms tumor was done on 20 patients. In 80 per cent the neoplasms were bilateral. Transplantation is indicated in individuals whose renal function is severely impaired or absent because of the malignancy, treatment or both. Patients who received homografts less than a year after treatment of the tumors had a 47 per cent incidence of recurrence or metastases compared to a zero incidence of these problems in those whose transplants were delayed for longer periods. Survival for 2 years or more was obtained in 75 per cent of the recipients with unilateral neoplasms and in 38 per cent of the patients with bilateral tumors.