Roentgen Therapy of Wilms' Tumor

Abstract

Wilms' tumor, adenomyosarcoma, or embryonal mixed tumor of the kidney, is the most common renal neoplasm occurring in infancy and childhood. Some examples, however, have been reported in adults. The prognosis in a majority of cases is generally unfavorable, and the course of the disease is usually rapid. Symptomatology The familiar triad of symptoms for renal neoplasms—hematuria, pain, and a mass—is not found in all cases of Wilms' tumor. The usual finding in these cases is a rapidly growing mass. In 2 of the cases to be reported here, hematuria was the initial symptom pointing toward a disturbance in the urinary tract. Persistent pain was not reported in any of the cases; but in 2, vague abdominal pain associated with gastric disturbances was noted over a period of several months. These vague abdominal pains were generally associated with meals. The blood pressure was not elevated in any of the cases to be presented. Hypertension may occur, however, in some instances, as observed by Bradley and Pincoffs in their series of cases (1). Trauma may be associated with the onset of the more severe symptoms, as occurred in Case III, reported below. Physical Findings The patient is usually a child averaging three to five years of age, fairly well nourished and in apparent good health. A mass in either flank, of varying size, smooth contour, and firm consistency, that moves on deep inspiration, is found. As metastases from Wilms' tumor are generally bloodborne, care should be taken in examining these patients not to palpate the tumor more than is absolutely necessary. Diagnosis Other abdominal tumors that may be encountered in children and lead to some confusion in differential diagnosis are medulloblastoma of the adrenals, retroperitoneal sarcoma, lymphosarcoma of the bowel, congenital abnormalities of the kidney, mesenteric and pancreatic cysts, and splenomegalia associated with leukemia or lymphoblastoma. Complete radiographic and urologic examination of the urinary tract in these patients is definitely indicated. As they are generally young, a cystoscopy with retrograde pyelography is not always feasible. There are also cases in which the intravenous route for visualization of the renal pelves and calices is not technically possible. In these cases, differential diagnosis of Wilms' tumor may be carried out by intramuscular urography, using a 35 per cent solution of diodrast intragluteally, as described by Adams and Hunt (2). Even though we are generally desirous of knowing the histology of the tumor with which we are dealing, biopsy either by the aspiration method or exposure of the tumor is to be condemned because of the danger of spreading this anaplastic growth. Reliability of diagnosis should be dependent upon the clinical history, physical examination, and roentgenographic study. Preliminary roentgenographic examination of the urinary tract will reveal a tumor of varying size, overlying one or the other kidney area.