T-cell lymphoma and mature nephroblastoma after synchronous bilateral Wilms' tumor

Fatal ischemic enteritis with hemorrhage--a late complication of treated Wilms tumor

A 35-year-old man with a history of childhood Wilms tumor successfully treated with radiotherapy, chemotherapy, and surgery, collapsed and died unexpectedly in hospital following admission for abdominal pain. At autopsy, there was ischemic necrosis of the small intestine with altered blood within the stomach and small intestine. Within the upper abdominal aorta, there was patchy confluent calcific atherosclerosis with extension into the proximal superior mesenteric artery which was occluded by thrombus. Death was attributed to ischemic enteritis of the small intestine caused by mesenteric artery thrombosis complicated by gastrointestinal hemorrhage with aspiration. Localization of atherosclerosis to the radiation field with no significant atherosclerosis elsewhere and the young age of the decedent were supportive of radiation-induced atherogenesis. Geographically, localized atherosclerosis at autopsy in a tumor survivor should raise the possibility of a treatment-related side effect that may directly contribute to death many years after the original therapeutic intervention.

Unilateral tonsillar enlargement and tonsillar lymphoma in children

The clinical presentation and surgical and pathological findings of 46 children with unilateral tonsillar enlargement (UTE; age range 2 to 13 years, mean age 6.5) who underwent tonsillectomy for biopsy purposes between 1975 and 1995 were compared with those of 7 children who received treatment for tonsillar lymphoma (TL; age range 2 to 9 years, mean age 4.8) during the same period. There was no history of rapid tonsillar enlargement in children in the UTE group, and only 20 (43%) were symptomatic. Symptoms included recurrent sore throats in 10 patients (22%), snoring in 5 (11%), nasal obstruction in 4 (9%), and dysphagia in 1 (2%). No children had systemic symptoms or significant cervical lymphadenopathy. In contrast, tonsillar enlargement was observed to occur within a 6-week period in all children with TL, and 6 (86%) children had symptoms at presentation that included dysphagia in 5 (71%), snoring in 3 (43%), night sweats in 2 (29%), and fever and rigors in 2 (29%). Cervical lymphadenopathy greater than 3 cm was present in 6 (86%) children, while 1 child (14%) had hepatosplenomegaly. There was no histopathologic evidence of neoplasia in the UTE group, and a true discrepancy in size between the two tonsils was confirmed in only 21 of 44 (48%) cases. All 7 patients in the TL group had non-Hodgkin's lymphoma. All received chemotherapy, with 5 of the 7 cured and 2 dying of disease. The data suggest that tonsillectomy should be performed for biopsy purposes in UTE where there is a history of progressive enlargement, significant upper aerodigestive tract symptoms, systemic symptoms, suspicious appearance of the tonsil, cervical lymphadenopathy, or hepatosplenomegaly. The diagnosis of TL should also be considered when UTE is present in an immunocompromised child or one with a previous malignancy, when acute tonsillitis is asymmetric and unresponsive to medical treatment, or when rapid bilateral tonsil enlargement occurs. Observation is appropriate management for other cases of UTE.

Leukemia, lymphoma, and related disorders in families of children diagnosed with Wilms' tumor

Leukemias and lymphomas occurring in a series of families with Wilms' tumor (WT) are described. One surviving case developed a large cell anaplastic Ki-1 lymphoma at age 20 years, and 23 second- and higher degree relatives were affected. In two instances leukemia/lymphoma occurred in the context of Li-Fraumeni syndrome (LFS) and two other families showed striking clusters of unusual and early-onset malignancies. In several cases, children had genitourinary abnormalities of the type associated with the WT1 gene on chromosome 11p13. Some of these families may provide important subjects for study of WT genes in hematologic disease and lymphomas and for investigation of interaction between different tumor-suppressor genes, e.g., WT1 and other candidate WT genes, and p53.