Bilateral Partial Nephrectomies for Large Bilateral Wilms’ Tumors By Eugene
S. Wiener
B
ILATERALITY occurs in 3%-10% of children with Wilms’ tumor (nephroblastoma).‘-4 The majority present in a synchronous fashion, usually one side being the dominant lesion while contralateral involvement is small, surgically accessible, noted incidentally. Occasionally both tumors are large, creating a dilemma when attempting to preserve adequate renal tissue while extirpating tumor. Recent experience demonstrates the feasibility of staged bilateral nephrectomies in such a patient. CASE REPORT An II-mo He appeared
old male presented with a 2-wk acutely ill with a BP 160/105.
history of poor feeding and abdominal There were large bilateral flank masses
distention. measuring
15 x 13 cm on the left and 12.5 x 9 cm on the right. There was penile hypospadius. IVP and selective renal arteriography confirmed bilateral Wilms’ tumors with upper pole involvement on the left and central involvement on the right (Fig. 1). The hemoglobin was 8.9 g/l00 ml and the creatinine was 0.6 mg/lOO ml. Chest x-rays and other studies were normal. Vincristine sulfate was administered in two doses, 7 days apart, with definite decrease in size of both masses. The hypertension was controlled with Apresoline. A left subtotal nephrectomy was performed first, preserving a small lower pole remnant. Fortunately this remnant was supplied and drained by a separate artery and vein. Postoperatively the patient received actinomycin D and vincristine. Renal function determinations were normal and IVP showed prompt function of the remaining left kidney and further shrinkage on the right. Six weeks later a similar but more extensive procedure was performed on the right which required major renal pelvis repair. The initial postoperative period was marked by temporary leakage of urine and temporary moderate decrease in renal function. Cyclic courses of chemotherapy were continued for 15 mo, and 1950 rads were delivered to the abdomen, shielding renal tissue. Pathologic examination of the tumors showed apparent complete removal of tumor. There was microscopic evidence of significant maturation of the tumor comparing the second to the first specimen, presumably due to chemotherapy. Almost 2 yr following treatment, the patient exhibits normal growth and development (weight 75th and height 25th percentile), BP 92/60, creatinine (serum) I.1 mg/lOO ml and C,, 50 ml/mm. Selective renal arteriogram I yr postoperatively and recent IVP show functional bilateral renal remnants, the right side much larger than the left (Fig. 2).
DISCUSSION
Several reports concerning bilateral Wilms’ tumors indicate a variety of therapeutic approaches including: (1) one sided radical nephrectomy with contralateral partial nephrectomy, (2) one sided radical nephrectomy with contraFrom the Children’s Hospital of Pittsburgh and the Universitv of Pittsburgh School of Medicine, Pittsburgh. Pa. Presented before the 7th Annual Meeting of the American Pediatric Surgiral Association. Boca Raton. Fla.. April 29-Ma-v I. 1976. Address for reprint requests: Eugene S. Wiener, M.D., 3500 Fifth Avenue, Pittsburgh, Pa. 157i3. I
S. Wiener
B
ILATERALITY occurs in 3%-10% of children with Wilms’ tumor (nephroblastoma).‘-4 The majority present in a synchronous fashion, usually one side being the dominant lesion while contralateral involvement is small, surgically accessible, noted incidentally. Occasionally both tumors are large, creating a dilemma when attempting to preserve adequate renal tissue while extirpating tumor. Recent experience demonstrates the feasibility of staged bilateral nephrectomies in such a patient. CASE REPORT An II-mo He appeared
old male presented with a 2-wk acutely ill with a BP 160/105.
history of poor feeding and abdominal There were large bilateral flank masses
distention. measuring
15 x 13 cm on the left and 12.5 x 9 cm on the right. There was penile hypospadius. IVP and selective renal arteriography confirmed bilateral Wilms’ tumors with upper pole involvement on the left and central involvement on the right (Fig. 1). The hemoglobin was 8.9 g/l00 ml and the creatinine was 0.6 mg/lOO ml. Chest x-rays and other studies were normal. Vincristine sulfate was administered in two doses, 7 days apart, with definite decrease in size of both masses. The hypertension was controlled with Apresoline. A left subtotal nephrectomy was performed first, preserving a small lower pole remnant. Fortunately this remnant was supplied and drained by a separate artery and vein. Postoperatively the patient received actinomycin D and vincristine. Renal function determinations were normal and IVP showed prompt function of the remaining left kidney and further shrinkage on the right. Six weeks later a similar but more extensive procedure was performed on the right which required major renal pelvis repair. The initial postoperative period was marked by temporary leakage of urine and temporary moderate decrease in renal function. Cyclic courses of chemotherapy were continued for 15 mo, and 1950 rads were delivered to the abdomen, shielding renal tissue. Pathologic examination of the tumors showed apparent complete removal of tumor. There was microscopic evidence of significant maturation of the tumor comparing the second to the first specimen, presumably due to chemotherapy. Almost 2 yr following treatment, the patient exhibits normal growth and development (weight 75th and height 25th percentile), BP 92/60, creatinine (serum) I.1 mg/lOO ml and C,, 50 ml/mm. Selective renal arteriogram I yr postoperatively and recent IVP show functional bilateral renal remnants, the right side much larger than the left (Fig. 2).
DISCUSSION
Several reports concerning bilateral Wilms’ tumors indicate a variety of therapeutic approaches including: (1) one sided radical nephrectomy with contralateral partial nephrectomy, (2) one sided radical nephrectomy with contraFrom the Children’s Hospital of Pittsburgh and the Universitv of Pittsburgh School of Medicine, Pittsburgh. Pa. Presented before the 7th Annual Meeting of the American Pediatric Surgiral Association. Boca Raton. Fla.. April 29-Ma-v I. 1976. Address for reprint requests: Eugene S. Wiener, M.D., 3500 Fifth Avenue, Pittsburgh, Pa. 157i3. I
