Early multimodal therapy in adult Wilms' tumor: case report

Breaking down tumor thrombus: Current strategies for medical management

Tumor thrombus, the intravascular extension of tumor into adjacent blood vessels, is frequently encountered in patients with renal cell carcinoma and hepatocellular carcinoma, and often involves the abdominal vasculature including the renal vein, portal vein, and the inferior vena cava. While a bland thrombus is composed of platelets and fibrin, in contrast, a tumor thrombus refers to an organized collection of tumor cells. Though oftentimes detected incidentally on imaging, tumor thrombus may have significant clinical implications and can be challenging to differentiate from bland thrombus. Additionally, the optimal management of tumor thrombus, including the use of anticoagulation, remains poorly described. This review summarizes common causes of tumor thrombus, as well as its impact on staging, prognosis, and treatment.

Adult Wilms’ tumor: Review of literature

Background. The most common renal tumors in adults is renal cell carcinoma. Wilms’ tumor in subjects older than 16 years is rare; only 3% of Wilms’ tumors are reported in adults, which explain the difficulties in diagnosis and treatment of this tumor entity in this age group.

Methods. Patient with stage IV adult nephroblastoma with favorable histology was described, current treatment modalities were discussed, and the literature was reviewed.

Results. Nineteen year old female patient is presented with renal mass, abdominal lymphadenopathy, and bilateral pulmonary deposits. Sonar guided biopsy from the renal mass was taken and pathology revealed nephroblastoma. Right nephrectomy was performed and the pathological examination revealed classic histology of nephroblastoma. The case diagnosed as stage IV adult Wilms’ tumor with favorable histology. According to National Wilms’ Tumor Study Group (NWTS-3), multimodal therapy was initiated immediately after surgery. The patient failed to respond to the first line therapy and died due to disease progression.

Conclusion. Adult Wilms’ tumor has no specific guidelines and this may lead to improper or incorrect treatment.

A case of mixed adult Wilms' tumour and angiosarcoma responsive to carboplatin, etoposide and vincristine (CEO)

Here we report an unusual case of mixed Wilms' tumour and angiosarcoma in a 38-year-old female patient who presented with haematuria and right lower back pain. A computed tomographic (CT) scan confirmed a massive renal tumour associated with extensive retroperitoneal lymph node involvement, bony metastases and a right hip fracture. She was initially managed with palliative nephrectomy, which was followed by rapid postoperative deterioration. Histopathology revealed differentiated adult Wilms' tumour with renal angiosarcoma, whereas the pathology of the para-aortic lymph node and bone metastasis revealed angiosarcoma only. In view of her cachexia and cytopaenia, emergency chemotherapy was initiated using a modified regimen of carboplatin, etoposide and vincristine (CEO) in preference to the more traditional but less well-tolerated VAC (vincristine, actinomycin D, cyclophosphamide). Four cycles of this protocol yielded a dramatic response on re-staging CT scan. This case suggests that highly angiogenic tumours such as angiosarcoma may be effectively palliated using agents usually reserved for refractory Wilms' tumour, and supports the view that adult Wilms' tumour is more sensitive to such agents.

Wilms' tumor arising within a mediastinal teratoma

The majority of Wilms' tumors present in young children as an intraabdominal mass of renal origin. The use of multimodal treatment protocols according to internationally recognized treatment guidelines has resulted in extremely high cure rates even in the setting of advanced disease. By comparison, Wilms' tumors in older patients or Wilms' tumors located entirely outside the kidney are extremely rare. Because of the rarity of these tumors and the lack of established treatment guidelines specific to these lesions, older patients with atypical Wilms' tumors are at risk for under treatment and poorer outcomes. We report the case of an 18-year-old man with a Wilms' tumor arising within a mediastinal teratoma and discuss the management of this extremely rare lesion.

[Adult Wilms' tumor]

Wilms' tumor is a malignant embryonic renal neoplasm that is exceptional in adults. There are not clinical data or radiographic investigations that can distinguish it from renal cell carcinoma. So the diagnostic is based in the pathological evaluation. It may be cystic and must be consider in the differential diagnosis of cystic lesions of the kidney. The prognosis of Wilms' tumor in adults is worse than in children because of the high recurrence, the lower response rate to chemotherapy regimens and the advanced stage at the time of clinical presentation, like an asymptomatic abdominal mass in 75% of the cases. We report a new case of nephroblastoma in a 29 years old woman presenting like a renal colic, with a cystic configuration by abdominal ultrasound initially, that changed into a solid renal mass later. There is not a definitive treatment protocol currently but some authors suggest a combination chemotherapy with carboplatin and etoposide because it is very effective in recurrent or refractory adult Wilms' tumor. Our patient remains asymptomatic and without evidence of recurrence 18 months after the surgery.

Adult Wilms' tumor: A monoinstitutional experience and a review of the literature

BACKGROUND

The authors reviewed their institutional experience regarding adult patients with Wilms' tumor (WT) to assess their clinical characteristics and compliance with respect to children's treatment guidelines.

METHODS

A total of 17 adult patients (median age at the time of diagnosis of 17.5 years; range, 16-29 years) were referred to the study institute between 1983 and 2001 and were followed for a median of 131 months. The treatment modality was planned according to the two consecutive Italian protocols for WT that were active during the referral years. The patients were staged according to the National Wilms Tumor Study-4 (NWTS) staging system as follows: eight patients had Stage II disease, four patients had Stage III disease, and five patients had Stage IV disease.

RESULTS

All the patients but one underwent nephrectomy, with three incomplete surgeries performed. Two patients with Stage II disease were treated elsewhere with nephrectomy only and they were admitted to the study institution at the time of disease recurrence. Anaplasia was found to be present in only one patient with Stage IV disease. The authors noted 9 cases of disease recurrence or progression occurring during treatment and 6 of these 9 patients died of their disease, with an overall survival rate of 62.4% at 5 years.

CONCLUSIONS

Compared with children, adults with WT are reported to have a worse prognosis. In the current study, the authors found that poor compliance with specific therapeutic guidelines may contribute to this poorer outcome. Because of the rarity of this disease, adults with WT are at a risk of either undertreatment or incorrect treatment.