• Nephroblastoma (wilms tumor, WT) is the most common
malignant neoplasm in the urinary tract of children
• It is an embryonal renal neoplasm in which blastemal,
stromal and epithelial cell types are present.
• It is thought to arise from the metanephric blasterma in
response to external stimuli during intra and extra-uterine
4. • WT represents about 6% of all childhood malignancies
• Reported incidence = 8 cases per million children/ year
• Here about 20 cases are seen / year
• 75% < 5 years
• Peak incidence = 2-3 years
• There is no sex predilection (F = M )
5. • The exact aetiology is unknown
• Recent studies point to genetic predisposition
• Deletion of Xmosone implicated
• WT is sporadic in 95%; familial in 1-2%; bilateral in
2% of WT associated with syndromes:
1. WAGR (WT, Aniridia, Genitourinary malformation,
2. Beckwith Wiedman syndrome (BWS) (Omphalocele,
macroglossia and visceromegaly)
3. Denys-Drash syndrome (WT, intersex disorder,
4. Perlman syndrome (Overgrowth syndrome with mental
5. Other associated anomalies seen in WT: Isolated
hemihypertrophy, hypospadias, undescended testes.
6. • Children with such syndromes should be screened with ultrasound
every 6 months till 8 years of age.
• GENES involved in WT pathogenesis include:
* WT1 gene. Tumor suppressor gene located on 11p13; required for
normal kidney and gonadal development. Mutation of the gene seen
in WAGR, DDS, bilateral WT & 10% sporadic WT.
* WT2 gene. Located on 11p15; mutation in form of deletion or
overexpression is linked to familial WT and BWS.
* Additional WT loci include 16q, 1p, and p53 (located at 17p13.)
Mutation in these are associated with poor prognosis
7. • MACROSCOPY: WT is sharply demarcated and variably
encapsulated with haemorrhagic areas and cavitations.
Location may be central or polar
• MICROSCOPY: 3 components seen in normal kidney
differentiation--- blastema, tubules and stroma are present.
Based on microscopy, 2 broad variants are known:
1. Unfavorable histology. Presence of anaplasia– cells with
nuclear enlargement, hyperchromatic nuclei and abnormal
ANAPLASIA IS THE SINGLE MOST IMPORTANT INDICATOR
OF POOR PROGNOSIS.
2. Favorable histology. WT without anaplastic features.
8. • STAGES. National Wilms Tumor Study Group NWTSG
staging system is widely used.
Stage I– Tumor limited to kidney and completely resected
II– Tumor extends beyond the kidney but is completely
III– Residual non-haematogenous tumor confined to the
IV– Haematogenous metastases
V– Bilateral tumor
9. History: Commonest is asymptomatic abdominal mass. Others
include abdominal pain, fever, weight loss, haematuria,
anaemia, and varicocele.
WT may rupture and present as acute abdomen
Physical examination: Carefully palpate the abdomen, measure
the blood pressure, look into the eyes; and document
anomalies if present.
Investigations: Should define the nature of abdominal mass;
organ of origin; status of the contralateral kidney; state of the
vena cava; and distant metastases.
* CT scan
* Chest X ray
* Others: S/E/U/C, Full blood count.
10. Involves surgical excision, post operative radiotherapy and chemotherapy.
This can be modified by: stage of disease, age of patient, size of tumor and
clinical state of patient.
Surgery:* serves to excise the tumor and determine intra abdominal stage.
* Important surgical caveats.
* Peculiar situations: IVC involvement, Bilateral tumors
*Complications: Haemorrhage, small bowel obstruction.
Chemotherapy:+ Mostly as adjuvant. Can be used as neoadjuvant in
inoperable tumor; non resectable tumor; bilateral tumor; and IVC
+Agents: Actinomycin D, Vincristine, Adriamycin,
11. Radiotherapy:* Same indication as chemotherapy.
* Renal bed demarcated by titanium clips placed during
Treatment by stage
a. Unfavorable histology. All modalities for all stages
b. Favorable histology. Stages I & II, < 2 years--- SURGERY
> 2 “ -- SURG.+ CHEMO.
Stages III,IV,V– All modalities.
Results: Stage I = 96.5%
II = 92.2%
IV/V/all unfavorable histology =68.1%
Tumor of neural crest origin
- May arise from the adrenal or the sympathetic ganglion from
neck to pelvis
- Most common solid tumor in childhood
- Spontaneous regression and tumor maturation observed in a
- Advances in management have not significantly improved
* Incidence= 1 in 8,000-10,000 children.
* >50% are 2 years or less at diagnosis
* M > F 1.2 : 1.0
13. Sites: 75% -- Retroperitoneal
50% Adrenal medulla
25% Paraspinal ganglia
20% -- Posterior mediastinum
5% -- Neck and Pelvis
Macroscopy: - Purple, highly vascular and friable.
- Becomes nodular as it matures or responds to therapy.
Microscopy: - Composed of neuroblasts– small round cell with prominent nucleus
and small cytoplasm.
- Immature tumor has no special arrangement of cells
- More mature tumor show rosette formation; some may resemble
normal ganglion cells.
Electron microscopy shows neurofibrils and electron dense granules; this rules out
rhabdomyosarcoma and Ewing’s tumor
14. Evans staging is commonly used.
Stage I - Tumor confined to the organ of origin
II - Tumor extends beyond the organ of origin but not crossing midline.
Ipsilateral nodes may be involved
III - Tumor extends beyond midline. Bilateral nodes may be involved
IV - Distant metastases
IVS- Same as I or II with presence of disease in the liver, skin or bone
Hereditary factors important
Cytogenetics/ Molecular biology: Alterations seen in NB are
1. Mutation at 1p36 – associated with poor outcome
2. Mutation at 14q
3. Amplification of N-myc protooncogene– poor prognosis
4. Expression of Multidrug resistant related protein gene and
bcl-2 gene activity--- poor outcome.
5. Expression of Nerve growth factor recceptors– good
16. Presentation: Related to the site of primary tumor; Metastases; and Metabolic
Common presentations include abdominal mass; weight loss; FTT; and anaemia.
Others: Respiratory distress, dysphagia, paraplegia, Horners syndrome,
hypertension, flushing & iritability, urinary sympyoms, constipation, skin
nodules, ‘panda eye’, watery diarrhea, dancing-eye syndrome etc.
Investigations: 1. Plain Xray
5. Bone scan with MIBG
6. Urine chemistry: HMA= Undifferentiated NB; VMA= More
7.Blood chemistry: NSE, LDH, Ferritin
8. Immunohistochemistry: Neurofilament, NSE etc
9. Biopsy & Bone marrow aspiration
Others: LFT, FBC.
PRESENTATION & DIAGNOSIS
18. • Depends the stage at diagnosis
• Localized tumors are best managed with surgery
• Partially resected or unresectable tumors need CHEMO. & or RADIO.
• Surgery: Operative principles.
• Chemotherapy: Adjuvant or Neoadjuvant
Agents: Cyclophosphamide, Doxorubicin, Vincristine, Cisplatin.
Radiotherapy: For > 1 year olds. MIBG can be used.
Immunotherapy: IL-2 has been tried.
Treatment by stages
Stage I- SURG.
II- SURG + CHEMO
III- High CHEMO. then SURG.
IV- < 5 months- CHEMO then SURG
> 5 “ - High CHEMO or RAD. Then SURG, & High CHEMO
IVS- Supportive care
19. Outcome: Stage I – 90%
Stage II --80%
Stage III --60%
Stage IV --10%
Stage IVS --70%
Future THINKING: 1. Early diagnosis. Mass screening for VMA & HVA at 6
2. Use of differentiating agents e.g.13 cis – retinoic acid
3.Targetted Immunotherapy with anti ganglioside GD2 antibodies
for advanced NB.
20. CENTRAL NERVOUS SYSTEM TUMOURS
Generally, clinical features may be insidious onset and include
1. Deteriorating school performance
2. Hand preference
3. Changing handwriting
4. Changing personality & child`s behaviour
5. Convulsion due to pressure effects/invasion of vital area
6. Features of raised intracranial pressure
7. May paradoxically presents with weight gain/obesity due to
8. Visual/Hearing impairment
9. May present with Diabetes insipidous/DBM
10. May present with syndrome of inappropriate ADH synthesis
11. May present with stroke
Two broad groups are recognised
A. INFRATENTORIAL/POSTERIOR CRANIAL FOSSA TUMOURS
They are located within the posterior cranial fossa
Or have relationships with it examples include
1. Cerebellar Astrocytoma
3. Brain Stem glioma
4. Ependymoma of the 4th ventricle = Most malignant of them
5. Acoustic neuroma & Meningioma: They are rare in kids
B. SUPRATENTORIAL TUMOURS
22. INVESTIGATIONS IN CNS TUMOURS
1. CT scan: Delienate the lesion
3. CSF Analysis
4. Contrast studies
5. SKULL X-RAY
a. May show calcification/enlargement of sellartursica craniopharyngioma
b. Calcification of 4th ventricle in Ependymoma
c. Evidence of raised intracranial pressure
6. OPTHMOLOGICAL EXAMINATION: Fundoscopy
7. OTHER STUDIES
a. Serum electrlyte = SIADH
b. Urinalysis & Electrolyte = SIADH
c. Other biochemical & blood assays
d. Cerebral angiography
23. SALIENT FEATURES OF SOME CNS TUMOURS
1. Highest icidence is between 2- 8years
2. Signs of raised ICP
3. Signs of cerebellar lesions:Nystagmus,Tremor,Ataxia,
5. Usually there is lateralising signs
TREATMENT: Surgery + Chemo + Irradiation
1. Midline in location
2. Fastest growing intracranial tumour
3. Boys more affected than girls
4. Clinical features similar toCerebellar astrocytoma but
5. without lateralising signs usually
TREATMENT: Surgery + chemo + irradiation
24. Salient clinical features contd
Ependymoma of 4th ventricule
1. Rapidly evolving signs of ICP are the major features
2. Cranial nerves palsies
3. +ve Babinskis sign may be seen due to brain stem infilteration
Surgical excision + Irradiation + chemo
Glioma of the brain stem
1. Peak age is 6-8years
2. Progressive bilateral cranial nerve palsies: 6th&7thnerves commonly
3. Any other cranial nerve can be affected
4. Upper motor neuron lesions types : Hypertonia, Hyperreflexia etc
6. Usually does not present with features of raised ICP
Not amenable to surgery only LOCAL IRRADIATION + chemo
25. SALIENT FEATURES CONTD
Inicidence: Any age during childhood The tumour arises from
the squamous epithelia cells of the embryonal Ratchke`s pouch
1. Growth failure
2. Arrest of linear growth
3. Raised intra-cranial pressure
4. Diabetes insipidous
5. Visual impairments may include
a. Bitemporal hemianopsia: Optic chiasma lesion/involvement
b. Assymetric field defect
c. Decreased visual acuity
Use of steroids to shrink tumour before surgery & maintanance after
Tumour cyst aspiration + follow up RADIOTHERAPY