The management of bilateral Wilms tumor

Synchronous bilateral Wilms' tumor with liver metastasis

Background

Wilms’ tumor (nephroblastoma) is mostly unilateral; however, bilateral Wilms’ tumors are seen in about 5–8% of patients. This can be synchronous or metachronous. It is uncommon to get liver metastasis from bilateral Wilms’ tumor.

Case presentation

An 8-year-old male Ugandan presented with a history of abdominal swelling and flank pains for 1 year. There was no history of hematuria. Both ultrasound and computed tomography of the abdomen demonstrated multiple solid lesions in both kidneys and a huge solid mass in segments V, VI, VII and VIII of the liver. Histological examination of renal biopsy specimen was favorable for chemotherapeutic regimens. However, following a multidisciplinary tumor board consensus, a nephron-sparing surgery was deemed unsuitable, and he was managed conservatively with chemotherapy (adriamycin and vincristine) with a palliative intent.

Conclusions

Metastatic bilateral Wilms’ tumor has a particularly poor prognosis. There are no clear evidence-based guidelines for the management of this rare presentation. This patient benefited from early palliative care and symptom management.

Management of bilateral Wilms' tumour: A case report

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Wilms’ tumor is the most prevalent kidney tumor, accounting for 6% of all pediatric malignancies, 5–7% being bilateral case.

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Cases about a 19-month-old boy diagnosed as stage V Wilms tumor based on SIOP and NWTSG classification.

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Neoadjuvant chemotherapy regimen followed by the right partial, left radical nephrectomy, and adjuvant radiotherapy.

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No specific guideline on follow-up and imaging timing; we do regular follow-up every 12 months and periodic MRI imaging.

Introduction

Wilms’ tumour remains the most common renal tumour in children (6% of all pediatric malignancies) and present as one of the most challenging tasks for paediatric urologists as its management requires an advanced procedure. The ultimate goal in these cases is to preserve as much renal parenchyma as possible whilst still achieving complete tumour resection.

Presentation of case

Here we present a six year follow up report of a bilateral Wilms’ tumour case in a 19-months old boy. This patient underwent neoadjuvant chemotherapy regimen, followed by right partial nephrectomy and left radical nephrectomy. Adjuvant radiotherapy was performed following the surgery. Follow-up imaging 5 months afterward revealed a firmly heterogeneous cystic lesion consist of fat and calcification at the upper pole of the right kidney, none of which created any problem for the patient. MRI was later performed on the 19^th month after the surgery, showing marked decrease in the size of the cyst.

Discussion

According to SIOP and NWTSG classification, the patient presented as stage V of the disease. The patient was on neoadjuvant chemotherapy (Regimen I) as recommended by NWTSG. This strategy was shown to be effective, as the tumour on the left kidney was reduced to less than 70% of the initial size. A routine follow-up using chest x-ray, abdominal ultrasonography (USG), and contrast studies such as MRI and MSCT scan, was performed in our reports.

Conclusion

From our experience, the combination of neo-adjuvant chemotherapy, renal salvage surgery and adjuvant radiotherapy is a feasible, safe and effective option for bilateral Wilms’ tumour cases.

Wilms tumor in patients with osteopathia striata with cranial sclerosis

Germline pathogenic variants in AMER1 cause osteopathia striata with cranial sclerosis (OSCS: OMIM 300373), an X-linked sclerosing bone disorder. Female heterozygotes exhibit metaphyseal striations in long bones, macrocephaly, cleft palate, and, occasionally, learning disability. Male hemizygotes typically manifest the condition as fetal or neonatal death. Somatically acquired variants in AMER1 are found in neoplastic tissue in 15-30% of patients with Wilms tumor; however, to date, only one individual with OSCS has been reported with a Wilms tumor. Here we present four cases of Wilms tumor in unrelated individuals with OSCS, including the single previously published case. We also report the first case of bilateral Wilms tumor in a patient with OSCS. Tumor tissue analysis showed no clear pattern of histological subtypes. In Beckwith-Wiedemann syndrome, which has a known predisposition to Wilms tumor development, clinical protocols have been developed for tumor surveillance. In the absence of further evidence, we propose a similar protocol for patients with OSCS to be instituted as an initial precautionary approach to tumor surveillance. Further evidence is needed to refine this protocol and to evaluate the possibility of development of other neoplasms later in life, in patients with OSCS.

Synchronous Bilateral Wilms Tumor: Five-Year Single-Center Experience with Assessment of Quality of Life

Context:

Synchronous Bilateral Wilms tumor (sBWT).

Aims:

This study aimed to assess the outcome of patients with sBWT treated on SIOP protocol.

Settings and Design:

Retrospective and prospective randomized study.

Subjects and Methods:

SIOP 93-01 protocol was used to study nine patients of sBWT in a single center and followed up over a period from 2 to 5 years.

Statistical Analysis Used:

Unpaired t-test and Mann–Whitney U-test were used for analysis.

Results:

Of nine patients, six were included in the study as three patients lost to follow-up. Among the six patients, there were four girls and two boys with a median age of 2 years. Mean regression in the size of tumor was 87% in four out of six patients. Tumor with unfavorable histology showed 32% response (ratio of favorable: unfavorable histology 2:1). Event-free survival rate was 81.3% and overall survival was 90% over 2–5 years. Recurrence was seen in two patients of whom one had Denys–Drash syndrome. Mean DTPA glomerular filtration rate was 91.4/ml/min/1.73 m² preoperatively and that of 3 months after completion of treatment was 84/ml/min/1.73 m². Health-related quality of life (HRQOL) using Pediatric Quality of Life Inventory and Lansky Play Performance Scale revealed significant improvement results of all functioning domains such as physical, social, emotional, and school subscales with P < 0.05 and performance scale (P < 0.04).

Conclusions:

We suggest SIOP protocol for sBWT and bilateral nephron-sparing surgery in two stages. However, long-term follow-up is required to assess the ultimate renal function outcome. HRQOL is an essential guide in improving the conditions of pediatric cancer survivors.

Nephron Sparing Surgery for Synchronous Bilateral Wilms-Operative Steps

Approximately 5% of children with Wilms tumor present with bilateral disease. The treatment challenge is to achieve a high cure rate while maintaining adequate long-term renal function. We report the feasibility and outcome of nephron sparing surgery in a child with bilateral Wilms tumor who was treated at our institution.

NECROTURIA WITH ACUTE URINARY RETENTION: A RARE PRESENTATION OF BILATERAL WILMS' TUMOUR

BACKGROUND

Wilms' tumour is one of the most common solid abdominal tumours in children in sub-Saharan Africa. Most cases present with an asymptomatic abdominal mass. We report a 2 year old male child who presented with acute urinary retention of 6 hours duration. He had a left flank mass and ascites, with a piece of necrotic tissue protruding from the urethral meatus. The urinary retention was relieved by manual removal of the necrotic tissue and passage of a Foley's urethral catheter. Abdominal ultrasound and computed tomographic scan revealed bilateral Wilms' tumour.The child commenced neoadjuvant chemotherapy and he has made significant improvement.

CONCLUSION

This is a rare mode of presentation of bilateral Wilms' tumour which presented with a diagnostic dilemma. The need to palpate the abdomen of children who come to the hospital, cannot be over-emphasized.