Pleural Effusion in Wilms’ Tumor By U. Betkerur and Philip Lanzkowsky l The association of pleural effusion Wilms’

tumor

is uncommon.

We

three patients who developed were

related

or to its treatment.

pleural effu-

sion as a result of different all of which

and

report INDEX

mechanisms,

to Wilms’

tumor

CASE

WORDS:

Wilms’

tumor;

pleural

effusion.

STUDIES

Case 1 A 4 yr. 8 mo old white male had a left-sided tumor

was ruptured

during

nephrectomy

Wilms’

therapy consisting of 1500 rad to the entire abdomen and paraaortic intervals

lymph nodes. Actinomycin-D

for the first 3 courses,

February,

1975 he developed

tomography.

Intravenous

lungs and mediastinum

diagnosed

and an additional

and Vincristine

and subsequent

a solitary

pyelography

tumor

and because of peritoneal

were also administered

in the right

with 1750 rad as well as an additional

upper lung field, which resulted in radiologic

clearing

650 ml of uniformly

u/L.

The pleural

On cytologic

Roentgenogram

fluid contained

examination

He was treated

and adriamycin

the effusion completely

protein

the aspirate

of the lungs following

in the parenchyma. sisting of DTIC

effusion;

4.9 gm/dl.

intervals.

In

confirmed

by

In July

bloody

cells consistent

and LDH

with

cleared and roentgenogram

Wilms’

lesions

and chemotherapy

of the lungs was normal.

at

2035 tumor.

any infiltrative

at intervals of 3 4 wk. Two weeks after completion

remission without evidence of disease until the time of writing. (January,

1975, he devel-

fluid was obtained

failed to demonstrate

I500 rad to the right hemithorax

Both

400 rad to the right

glucose 97 mg/dl,

had malignant

thoracentesis

with

of the lung fields.

bed

at 6 weekly

lung parenchyma

oped a massive right thoracentesis.

radio-

2000 rad to the tumor

courses were given at 3 monthly

metastasis

1973. The

he received

and liver and spleen scan at the time were normal.

were irradiated sided pleural

in November

spillage

con-

of this therapy

He has remained

in

1977.)

Cor?lrnenl Pleural effusion in this patient was a hemorrhagic the pleura by Wilms’

tumor.

Bannayan

exudate and was due to malignant

et al.’ studied

the site of metastases

Wilms’ tumor at autopsy and found that of these IO had pleural pleural metastases in patients with Wilms’

tumor

are relatively

a result of metastases to the pleura is rare in Wilms’ whom an initial diagnosis

of Wilms’

tumor

tumor.

was established

involvement. uncommon

invasion

in 43 patients Clinically,

and pleural

One patient

however, effusion

has been reported’

on the basis of cytologic

of

with as in

study of the

pleural fluid.

Case 2 A 5 yr, 4 mo old female presented gery a massive left sided Wilms’ phragm. peritoneal

part of the diaphragm

with a left-sided

tumor

was resected.

and posterior

spillage of the Wilms’ tumor occurred.

rad to the entire abdomen

abdominal

mass in October,

Because of invasion

abdominal

musculature

She received radiation

were resected therapy

with the right renal fossa being shielded after

3000 rad to the left renal fossa. Concurrently

1974. At

she was started on repeated

sur-

of the left hemidiaand

some

in a dose of 2000

1200 rad and a total

of

courses of actinomycin-

Front rhe Division of’ Pediatric Hematology-Oncology. Department of Pediatrics. Long Island JeWh-Hillside Medical Center, New HJ3de Park, and the Department of Pediatrics of the School of Medicine oJthe Health Sciences Center qfthe Stare llnir~er.sit,~ of Neua York ar Stony Brook. N. Y. Supported by Long Island Jewish-Hillside Medical Center Granr #3-792. Address for reprint requests: Dr. Philip Lanzowsky. Dept. Pediatrics, Long Island Jewish-Hillside Medical Center, New Hyde Park, N. Y. 11040. o 1977 bv Grune & Stratron. Inc. Journal of Pediatric Surgery, Vol. 12, No. 4 (August), 1977

523

524

BETKERUR

D. In March infection.

1975. she presented

Roentgenogram

tesis revealed mesothelial

cells along

teriologically and LDH

sterile.

with cough and fever and was considered

of the chest showed evidence of a left-sided

80 ml of chylous with

fluid; cytology

debris.

It contained

of 161 u/L.

of the fluid

but no malignant

4.5 gm/dl

of protein

She was treated with antibiotics

intraabdominal

surgery.

(3.3 gm/dl

to an infection.

in 4 cases3 Lymphangiogram

duct although

bac-

80 mg”,, cholesterol,

malignancy

usually will demonstrate

and

was

subsided.

of a respira-

as a result of extensive

in 4, and of uncertain

this may not be evident in certain cases4 Our patient

and within 6 wk the chylothorax

fluid

resulted as a complication lymphatics

Thoracen-

lymphocytes

The

albumin),

In a review of 15 cases of chylothorax. of surgery

effusion.

mature

and the effusion gradually

in this patient who had damage to the abdominal

cause in 7 cases; it was a complication

treatment,

revealed

LANZKOWSKY

to have a respiratory

pleural

cells were identifed.

The pleural effusion was a chylous exudate and probably tory infection

AND

was found to be the etiology,

the defect responded

possibly

due

in the thoracic

well to antibiotic

subsided completely.

Case 3 A 5 yr old female was seen with a huge right sided Wilms’ large she received preoperative on chemotherapy M’/weekly

radiotherapy

to the tumor

I5

consisting of actinomycin-D

in an attempt

to shrink

the tumor

mcg/kg

tumor

in April,

daily for 5 days and vincristine

mass. At

surgery,

encroachment

surface of the liver was noted but the tumor mass was easily separated Histologically

there was no tumor

invasion

of the liver.

therapy consisting of I200 rad to the entire abdomen the tumor bed. Following hematemesis.

Physical examination

centesis revealed

strawcolored

revealed

was pedal

with a protein

cells. Blood chemistry

albumin

3.3 gm/dl.

bilirubin

(control

11.9 set).

and partial

showed

of capillaries. portal

2.3 mg/dl.

marked

Cytologic

findings included:

SCOT

I82 u/L.

thromboplastin centrilobular

made a gradual

recovery

was present.

over a 3 wk period (January,

to and

pleural

content

effusion.

of

Thora-

of 3 gm”,,. glucose

revealed

reactive

serum protein

mesothelial

5.8 gm/dl,

serum

prothrombin

time

time 71.X set (control

25 35 set).

Percutaneous

with

consistent

I I .I set

necrosis of liver cells and dilatation from

the central

veins and mild peri-

with effects of radiation

at the end of which

effusion and ascites cleared and the liver function of disease at the time of writmg.

fever, petechiae.

100 u/L.

congestion

SGPT

A small focus of liver cells necrosis away

fibrous tissue proliferation

radiation

mass consistent with enlargement

examination

cells but no malignant

she received

ascites. and bilateral

of 285 u/L.

content

under-

800 rad were delivered

she developed

fluid, sterile by culture,

of I I2 mg”,, and LDH

liver biopsy

Postoperatively.

a firm epigastric edema,

I .5 mg/

on the

from the liver and removed.

and an additional

the second course of chemotherapy

the left lobe of the liver. There

1975. Because it was

in a dose of 2000 rad and was started

tests returned

therapy.

the liver regressed to normal.

There

She

in sire. the

is no evidence

1977.)

Cormlent Bilateral

pleural effusion

secondary to transient Liver dysfunction

in this patient

liver dysfunction,

is a known complication

chemotherapy.5

’ The acute enlargement

tests developing

after radiation

therapy right

suggested that radiation

lobe of liver.

generalized

which

anasarca

was confirmed

therapy

was a serous transudate

due to irradiation

of right sided Wilms’

from chemotherapy

liver function

hypertrophy

by liver biopsy. The subsequent

of the liver to normal

damage

treated

to the liver.

with radiation

and

liver function

to the right renal fossa and the second course of chemo-

in abnormal

and compensatory

tumor

of the left lobe of the liver and abnormal

injury and toxicity

resulted

as a result of hypoproteinemia

and chemotherapy

hypoalbuminemia

of the left lobe of the liver.

course with rapid return

size and return of liver function

resulted in injury

tests with

The

of the enlarged

to the and

diagnosis left lobe

tests to normal,

proved this to be a tran-

and Wilms’ tumor had Wilms’ tumor

is uncommon. The and pleural effusion

sient complication. SUMMARY

The association of pleural effusion three patients reported in this article

PLEURAL

525

EFFUSION

as a result of different mechanisms: pleural metastases, chylous exudate due to postsurgical lymphatic damage with associated infection and due to hypoproteinemia secondary to transient liver dysfunction as a result of irradiation, and chemotherapy damage to the liver. Pleural effusion in Wilms’ tumor may, therefore, result from metastases, complications of therapy, or unrelated causes. Aspiration of the pleural fluid with cytologic, chemical, and bacteriologic examination determines the significance of the pleural effusion. Since this paper was submitted

Note added in prooj. Tumor

with pleural effusion

left-sided Wilms’ of the tumor.

Tumor

was admitted

renal fossa being shielded

after

with

Four mild

oped abnormalities sudatr

months

of liver

and alternating

mesothelial

of radiation etfusion.

Thoracentrsis crlls

but

pulmonary

fact that it coincided with

with abdominal

in origin.

no

in

hvcr

function

pleura and chcmothrrapy

tiatcd by cytotoxic

agents.

spillage

rad. In

addi-

and Adriamycin and chemotherapy,

I50

thereafter ml

cells

devel-

of clear tranwere

identified.

in the left lower lobe of the The

pulmonary

of the pleural

and renal

due to the combination

the diaphragmatic

therapy

malignant

Because of the nature

abnormalitics

pleural effusion

after 2400

revealed

infiltrate

case of Wilms’

abdomen wjith the right

and shortly

of the lung did not rcvcal any mrtastascs.

considered to bc inflammatory it to be a sympathetic

surgery

being shielded

pleural

function.

of the chest revealed a small

lung and tomography

during

a fourth

a I3 yr old female. had a

courses of Actinomycin-D

after the initiation

and renal revealed

patient.

in a dose of 3600 rad to the entire

fever. cough, a bilateral

and the cytology

Rocntgenogram

This

1600 rad and the liver

tion. she was treated with vincristine at 6 weekly intervals.

for publication,

unit.

which was rrsccted but ruptured

She received radiation

she presented

to our

function,

of abdominal

and a manifestation

infiltrate fluid

was

and the

w’e considered

irradiation

of radiation

involving

toxicity

potcn-

REFERENCES I. Effect

Bannayan GA. of

Wilms‘tumor.

AG.

on

the

Cancer27:XIZ

2. Jaffe N. Jockin tumor:

Huvoh

irradiation

Diagnosis

H.

D’Angio

GJ:

maturation

of

818. 1971

Tefft

Chest

64:

3. McFarlane

R. Holman

Am Rev Resp Dis

105:2X7

chylothorax.

KA,

P, Ekert

Chylothorax

291. 1972

Branscom

Chest 65:316

5. McVeagh

CW:

JJ:

Spontaneous

347. 1974 H:

Hepatotoxicity

following

therapy

6. Tefft

Wilms’

and ratumor.

62X. 1975

M. Mitua A. Jaffe N:

Irradiation

of

Acute effects enhanced by

chemotherapeutic

Am J Roentgen01 Ther

Nucl

administration’!

Med I I I :165~ 173.

1971 7. Jayabose Hepatotoxicity

S.

Shende

Wilms’

tumor.

A,

Lanrkowsky

of chemotherapy

phrectomy and radiation of

nephrectomy

for right-sided

the liver in children: concomitant

130 132. 1973

4. Herrog

diation

J Pediatr X7:627

M et al: Wilms’

by thoracentesis.

chemotherapy

following

P: ne-

therapy for right-sided

J Pediatr 88:89X,

1976