Wilms tumour and renal malignancies: Case

Framing the case

This three-year-old girl has the classic presentation of a Wilms tumour. The painless abdominal mass found by the parent at the bath time, the smooth firm flank mass that does not cross the midline, and the hypertension, together make the renal tumour the working diagnosis, and the first decision is to move the child from the routine workup to the urgent imaging and the specialist referral. The framework that organises the case is the age, the preschool child, and the biology, the favourable-histology Wilms that is cured in around ninety percent. ^[1][4]

Immediate assessment and stabilisation

The assessment begins with the airway, the breathing and the circulation, and the blood pressure, because the hypertension is common and the tumour rupture is the emergency. The child is comfortable and stable, so the focus turns to the imaging. The hypertension, at the ninety-fifth percentile, is noted and the careful antihypertensive is begun if it worsens, but it is not the emergency here. The family is told that the mass is a tumour until the imaging settles it, and the child is kept calm and at rest to avoid the rupture. ^[9]

The diagnostic pathway

The abdominal ultrasound with the Doppler of the renal vein and the inferior vena cava is the first test, and it confirms the solid renal mass and shows no tumour thrombus in the cava. The computed tomography or the magnetic resonance imaging of the abdomen defines the size and the local extension, and the chest computed tomography shows no pulmonary metastases. In the Children's Oncology Group approach, the radiologically typical tumour proceeds to the radical nephrectomy without the biopsy, because the biopsy breaches the capsule and spills the tumour, which upstages the disease to the stage three and commits the child to the radiotherapy. ^[4][9]