This 4-year-old boy was referred in February 1962 with a large mass in the right abdomen. While sledding, he noted abdominal pain and was seen by his pediatrician, who felt the tender mass. Intravenous pyelogram showed a large Wilms’ tumor; chest roentgenogram showed multiple small metastatic nodules in both lungs. Decision was made to proceed with radical nephrectomy, after overnight bowel prep, anticipating probable rupture of the tumor into the right mesocolon.
A long, 9th interspace right thoracoabdominal incision was made disclosing a large tumor with blood in the serosa and mesentery of the overlying right colon in continuity.
The tumor was mobilized superiorly together with the right adrenal and all paracaval lymph nodes. The ureter was divided deep in the pelvis. The ileum was divided 4 inches (10.16 cm) proximal to the cecum. The hepatic flexure of the colon was divided taking all right colon mesentery with the specimen. Although large, the tumor had not invaded the adjacent duodenum, diaphragm, or retroperitoneal muscles.
An end to end Ileocolic anastamosis was performed. A drain was left in the renal fossa and a tube in the right chest. During the operation he received Actinomycin D intravenously. Postoperatively, he received chemotherapy and radiation therapy of the right abdomen and both lung fields.
Fig. 1. Wilms Tumor Patient at 4 Years (Select Image for High-quality Version). Age 4 years. Large Wilms’ tumor right side, noted on abdominal exam after tenderness from sledding.
Fig. 2. Thoracoabdominal exposure of another large right Wilms tumor (Select Image for High-quality Version). Note easy access to all sides of the mass. Right lung, lower lobe is visible; right lobe of liver is seen between lung and tumor; right colon displaced medially by the tumor. Intestines not in field. Note that there are no intra-abdominal retractors on tumor itself.
Fig. 3. Surgical Specimen After Hemisection (Select Image for High-quality Version). Right colon removed in continuity with tumor because trauma from sledding the previous day had caused rupture and bleeding from the tumor which was contained by the right colon mesentery.
Fig. 4. Chest Film Pre- and Postoperative (Select Image for High-quality Version). (Top) Preoperative chest film with multiple small metastases visible, most evident in right lower lobe. (Bottom) Chest film 2 months after postoperative chemotherapy with Actinomycin D and Vincristine, and radiation of both lungs and right abdomen. Metastases no longer visible.
His childhood was unremarkable. He later married, had three children, and worked for the U.S. Postal Service.
In February 2009, the patient was operated on elsewhere for carcinoma of the left colon. The surgeon felt the entire gross tumor was removed. Chemotherapy was given prophylactically. The tumor proved to be mucinous adrenocarcinoma of the colon.
In July 2010, jaundice appeared. Laparoscopy disclosed diffuse carcinomatosis. He declined and died in December 2010, at age 52, 48 years after removal of the Wilms’ tumor.
As his original surgeon who had followed him until age 24 years, I felt remiss about not continuing, to emphasize to him that a second cancer can appear many years later. Perhaps life-long monitoring should be considered for all of our pediatric cancer survivors as they transition to care of physicians who see them beyond childhood.