CASE PRESENTATION

ON
WILM’S TUMOR

PRESENTER:
MODERATOR:
DEEPIKA TOMAR
MRS. RIMPLE SHARMA
MSc (N) 1ST YEAR,
ASSOCIATE PROFESSOR
CON, AIIMS, NEWDELHI
CON, AIIMS, NEWDELHI
Sociodemographic Data:
Name of the child: Nityansh Jain
Age: 4 years 1 month and 21 days
Gender: Male
Religion: Hindu
UHID NO.: 105528457
Address: RZ-B/9A Madanpuri, west Sagarpur, Delhi
Ward: AB5 Ward
Unit: Pediatric surgery
Bed no.: 19
Date of admission: 9/10/21 at 3:22 pm
Diagnosis: Lt. Wilm’s tumor
Classification: Pre-schooler
Surgery: Lt. NFU+LN Sampling under GA on 11/10/21
Date of discharge:

INTRODUCTION; 1ST CONTACT DETAILS

Child was conscious, but lethargic, child was lying in bed, He has IV lines, he was afebrile. His
general condition was fair. Alopecia is seen.

FAMILY HISTORY

Sl no. Name of the Age Sex Relationship to Education Occupation Health

family child status
members

1. Anand jain 36y M Father MBA Businessma healthy

n
2. Neetu jain 35y F Mother B.Ed. Housewife healthy
3. Ansh jain 6y M Brother 1st Student healthy
 4. Nityansh jain 4y M Patient - - unhealthy
FAMILY TREE:
Anand jain,36y Neetu jain,35y

Ansh jain,6y Nityansh jain,4y

Indicates patient

Indicates healthy male

Indicates healthy female

FAMILY HISTORY ILLNESS:

There is no family history of diabetes, cancers, HIV, Hypertension, Tuberculosis, Asthma,
Thalassemia and congenital abnormalities.
Type of family: Nuclear family
Type of marriage- Non consanguineous marriage
SOCIOECONOMIC HISTORY
Middle class family. Stays at own house with adequate water and electricity, sanitation facility.
Father –business man, Mother – Housewife
PERSONAL HISTORY
Diet history:
Exclusively breast fed till 7 months and then weaning started.
Dietary pattern: Vegetarian
Sleeping pattern –sleeps for 6-7 hours a day
Elimination pattern-Normal bowel and bladder habits
Hygiene – Maintained
Allergic history – There is no drugs, dust, foods allergies
BIRTH HISTORY

A) ANTENATAL HISTORY
This is not a consanguineous marriage, antenatal period was supervised, mother received
all immunization, There is no history of exposure to drugs,radiation,viral infection and
other infections like HIV,Syphillis,PIH,STD,Diabetes mellitus.

B) INTRANATAL HISTORY
LSCS at term, birth weight was 3kg, Baby cried immediately after birth, there is no
history asphyxia, cyanosis.

C) POST NATAL HISTORY

Term baby, urine and stool passed within 24 hours of delivery, breast feeding started on
day 2 after delivery, there is no history of respiratory difficulty and NICU stay.

MOTHER- There is no history of post-partum hemorrhage, postpartum psychosis,

puerperal sepsis, breast abscess etc.

IMMUNIZATION HISTORY Immunized up to date.

DEVELOPMENT HISTORY Normal gross motor and fine motor milestones with history of
delayed speech.

PAST HEALTH HISTORY

No history of any communicable disease.
TREATMENT HISTORY - Chemotherapy started on 27/8/21.Last received on 7/10/21.
Underwent 6 times CT (vincristine, actinomycin, doxorubicin), No History of admissions related
to chemotherapy, No history of other comorbidities, previous surgery, allergies.
CHIEF COMPLAINTS ON ADMISSION
History given by: Mother, Reliability: good. Fullness in abdomen since 2 months.

HISTORY OF PRESENT ILLNESS

Child was apparently asymptomatic 2 months back when he developed one episode of fever for
which USG abdomen was done as a part of evaluation and a renal mass was noticed. Mother also
given a history of fullness in left side of abdomen since 2 months.
There is no history of loss of appetite, hematuria or decreased urine output, no history of pain
abdomen, vomiting, constipation. No history of UTI, loss of weight, swelling around eyes, limbs.
No history of increased water intake.

PHYSICAL EXAMINATION
WEIGHT- 15 kg
1. GENERAL APPEARANCE - Thin
2. BEHAVIOR - Conscious, alert, oriented
3. VITAL SIGNS - Temperature -37 c
Pulse rate -112/min
Respiratory rate - 36/mint
Blood pressure - 118/74 mmhg
4. HEAD SIZE AND SHAPE - Round in shape.
Alopecia seen
5. FACE - Normal
6. EAR - Normal and responds to sound.
7. EYES - Sclera is normal
8. MOUTH - Normal
9. NECK - There is no signs of thyroid swelling
10. TEETH - Clean and one incisor is dead in upper jaw.
11. SKIN - Normal color, turgor also good
12. LYMHNODES - Normal
13. RESPIRATORY SYSTEM - Bilateral air entry present, no abnormality detected.
14. CARDIOVASCULAR SYSTEM – S1S2 heard,
no murmur
Peripheral pulses palpable
HR – Regular
15. ABDOMEN - Firm, non-tender, no guarding/ rigidity. Hard lump
felt in left flank, full mass cannot be
assessed.
Spleen not palpable, Bowel sounds heard.
16. CENTRAL NERVOUS SYSTEM- Alert, conscious
17. GENITALIA - Normal
18. LOWER LIMBS - No abnormality detected.

INVESTIGATIONS

Date Test done Patient’s Normal value Inference

value
8/10/2021 Na 136 130-147mEq/L Normal
K 4.6 4-6.2mEq/L Normal

9/10/21 Covid test Negative negative Covid negative

11/10/202 Hb 10.2 10.5-14mg/dl Low

1 Tlc 1990 6000-17000/mm3 Low
Platelets 3.5L 1.5-4.5 L/ mm3 Normal
PT/INR 11.3/1.0 11-13.5secs. / 0.8-1.1 Normal
UREA 26 5-18 mg/dl Elevated
CREATININE 0.3 0.3-0.7 mg/dl Normal
Na 137 130-147mEq/L Normal
K 4.4 4-6.2mEq/L Normal
  On 14/08/2021, USG Done in private hospital.
Inference: Very large retroperitoneal mass lesion diffusely in abdomen.

 On 17/08/2021, CT Scan of abdomen and pelvis done in private hospital.

Inference: large lobulated heterogenous retroperitoneal mass arising from Lt. kidney, tiny
calcified foci mass is completely replacing Lt. kidney, crossing midline, multiple
torturous vessels seen adjacent to mass- Wilm’s tumor.

 On 26/8/21, chest NCCT Done in aiims.

Inference: No lung metastasis.

 On 4/10/21 Abdomen, pelvis, chest CT done in aiims.

Inference: Heterogenous 13.5 x 10.9 x 16.4, T11 to L5 level replacing Lt. kidney crossing
midline, displace pancreatic tail and spleen, encasement of Lt. renal artery and vein.

 On 1/9/21 FNAC done.

Inference: Lt. side abdomen mass- few atypical cells, inconclusive.

MEDICATION AND TREATMENT

MEDICATI FUNCTIO ACTION USES DOSA SIDE NURSING

ON NA L GE EFFECTS ROLE
CLASS
Inj. Antibiotic Broad Treatmen 375 mg Nausea, Assess drug
Augmentin spectrum t of Q8H vomiting, allergy.
bactericidal Bacterial Diarrhea, Assess liver,
activity. infections Allergy renal function.
. Monitor patient
for side effects.
And notify
physician.
 Culture
sensitivity to be
taken.
Inj. Antibiotic Bactericidal Treat 30 mg Ototoxic, Monitor blood
Gentamicin in action. bacterial Q8H Neurotoxic, levels of drug.
Inhibit protein infections Nephrotoxic, Monitor
synthesis. mainly Allergic rxn. symptoms of
caused adverse effects
by gram and notify
–ve physician.
bacteria.
Inj. PCM Analgesic Exact is Relieve 225 mg Nausea, Monitor liver
and mechanism fever and Q6H vomiting, function and
Antipyretic not known. pain. Loss of kidney function.
Works by appetite, Monitor patient
inhibiting Cox stomach pain for allergy to
which are , confusion., drug and notify
involved in allergy. physician.
prostaglandin
synthesis.
Inj. Antiemetic. Selective Treat 2mg Headache, Monitor for
Ondansetron serotonin nausea, BD constipation, hypersensitivity
receptor vomiting. arrhythmias, to drug.
antagonist. (post- tachycardia, Monitor patient
surgery, tremors, BP for side effects
gastroent fluctuating, and notify
eritis, confusion, physician.
side GI upset, Monitor cardiac
effects allergy. function.
from
chemo
drugs)
DIAGNOSIS;
LT. WILM’S TUMOR.
ANATOMY AND PHYSIOLOGY OF KIDNEY:
Anatomy:
The kidneys are 11 centimeters long, paired, reddish brown organs situated on the posterior wall
of the abdominal cavity, one on each side of the vertebral column and capped by the adrenal
gland. Due to the presence of the liver, the right kidney is slightly lower than the left kidney. The
kidneys are located between muscles of the back and the peritoneal cavity.

Each kidney is surrounded by three layers of tissue. A fibrous renal capsule covers the surface
of the kidneys. The adipose capsule is a mass of perirenal fat that surrounds the renal capsule. A
double layer of fascia called the renal fascia completely encloses the kidney and the adipose
capsule, firmly anchoring them to the abdominal wall.

Three general regions can be distinguished in each kidney. The cortex is the outer layer of the
kidney just deep into the renal capsule. The medulla is consist is consist of several triangular
renal pyramids and located deep into the cortex. The tips or papilla of the renal pyramids projects
into a funnel shaped chamber called a minor calyx. The minor calyces join up to form the renal
pelvis. Urine passes from the papillae into the minor calyces and then travels to the renal pelvis
through the ureter and to the urinary bladder.

The functional unit of the kidney is called the nephron. There are approximately 1 million
nephrons in each kidney. Each nephron is consisting of two parts: a glomerulus (a network of
capillaries) and a tubule. The tubule is an elongated hollow duct with the proximal end forming
a double walled cap known as the Bowman’s capsule. Another part of the tubule twists and
folds and another straightens after folding back in itself and yet another one forms characteristic
loops. These are the proximal and distal convoluted tubules and the loop of Henle.

Blood flows to the kidney via the renal artery, ultimately delivering to the glomerulus by means
of the afferent arteriole. Blood then drains from the glomerulus through the efferent arteriole.
This vessel carries blood from the glomerulus to the peritubular capillaries. It is a second larger
vessel network that surrounds the nephron tubule. From these vessels, blood moves into the veins
that drains the nephron and into the renal vein.

Physiology

The ability of the kidney to alter blood composition and maintain homeostasis is base on three
processes:

 Glomerular Filtration– the physical separation of the blood’s formed elements and
its plasma proteins from the fluid component. It allows water and small molecules to
 move from the glomerular capillary into the lumen of Bowman’s capsule. The fluid
product is called glomerular filtrate. Normal GFR is 180 liters per day.
 Selective Reabsorption– substances in the filtrate pass from the nephrons back into
the blood of the peritubular capillaries avert their loss. Not all the filtrate is
reabsorbed, some are excreted. Selection depends on the relative permeability of the
tubule to various components.
 Tubular Secretion– Upon completion of the reabsorption and secretion processes, the
remaining fluid is transported to components of the urinary system to be secreted as
urine.
Urine is composed of water and materials that has been filtered but not reabsorbed. Substances
present in urine represents amount in excess of those required for homeostasis.
DISEASE CONDITION
LT. WILM’S TUMOR
INTRODUCTION:
Wilms' tumor or nephroblastoma is malignant tumor of the kidneys that typically occurs in
children.
Dr. Max Wilms , the German surgeon (1867–1918) first described this kind of tumor.
Wilms tumor is the fifth most common pediatric malignancy (7% of all childhood tumors).
DEFINITION:
Wilm’s Tumor is also known as Nephroblastoma. It is a highly malignant embryonal neoplasm.
It may involve one or both kidney.
INCIDENCE:
Usually the tumor is unilateral, but in 5% cases it may be bilateral. The tumor involves left
kidney more than right kidney. It affects children between 3-5 year of age. The disease occurs in
about 1 out of 2-2.5 lakh children.
ETIOLOGY:
 Unknown
 Genetic abnormalities WT1 gene; dominant oncogene (at chromosome 11p13), WT2
gene (at chromosome 11p15)
 It is believed that tumor begins to grow as a fetus develops in the womb, with some cells
that are destined to form into the kidneys malfunctioning and forming a tumor. The exact
etiology of the tumors are still being investigated.
 Tumor is exceedingly vascular, soft, mushy, or gelatinous in character. • Wilms tumor
has capacity for rapid growth, usually grows to a large size.
 Tumor is usually uniform, well demarcated by a pseudocapsule of compressed renal
tissue. • Tumor develops from primitive renal tissue and can have epithelial ( tubules and
glomeruli), stromal (fat, skeletal muscles, cartilage) and blastemal elements (An
immature material from which cells and tissues develop).
 Wilms tumor may be associated with
 o Hemihypertrophy-one side of body is larger than other
o Aniridia (complete loss of iris) and
o Genitourinary anomalies.
In this child: Unknown
PATHOPHYSIOLOGY:
Mostly wilm’s tumor is unilateral but it may be bilateral in less than 5% cases. Nephroblastomas
are generally large and rapidly growing lesions. They reach a considerable size before being
detected. They develop in Renal parenchyma, in either Central or polar location (tip of kidney).
The entire renal parenchyma may appear replaced by tumor with only a rim of compressed
normal tissues remaining. Majority of tumors present as a single expanding mass, surrounded by
a pseudocapsule of connective tissue, that separates the kidney and tumor. Although the tumor is
encapsulated, the membrane may be very thin and gets easily torn. A rupture of wilm's tumor
puts the patient at risk of hemorrhage and peritoneal dissemination of tumor. In cases of
metastasis, it is usually to lungs.
The first identified Wilms tumor gene, WT1 , located at 11p13, is homozygously mutated in 10–
15% of tumors, resulting in loss of function of the encoded zinc finger transcription factor. The
majority of WT1 mutations are somatic; however, WT1 mutations can also be germline.
Germline truncating mutations are usually associated with Wilms tumor in the context of
genitourinary anomalies or the WAGR syndrome (Wilms tumor, aniridia, genitourinary
anomalies, mental retardation).
CLINICAL FEATURES:

BOOK PICTURE PATIENT PICTURE

Wilm's tumor is asymptomatic in early stages:  Enlarging abdomen
The most common presenting feature of  Accidently detected by mother during
wilm's tumor is presence of an abdominal clothes changing.
mass or an enlarging abdomen. The mass is  Increased growth on only one side of
discovered accidently by parents during body.
diaper changing or bathing the baby or may
be detected when the child complains of
abdominal discomfort.
Other features include:
 Pain, if tumor is rapidly enlarging or
due to haemorrhage, necrosis or
invasion of neighbouring structures.
 Urethral obstruction, if the tumor is
large, which may lead to urinary
infection.
 Anorexia
 Hematuria
 High blood pressure
 Increased growth on only one side of
body
 Nausea and vomiting.
DIAGNOSTIC EVALUATION:

BOOK PICTURE PATIENT PICTURE

Diagnosis of wilm's tumor can be made by:  No family history of cancer.
 History: The child may have a positive
 Abdominal mass present, enlarging
family history of cancer.
abdomen.
 Physical examination: It reveals
presence of an abdominal mass and
 Abdominal ultrasound
hypertension.
 Blood investigations including BUN,
 Urinalysis : It may show presence of
creatinine and complete blood count.
 blood in urine (present in less than  Chest CT done.
25% cases)  Abdominal and pelvis CT done.
Other tests include:  Fine needle aspiration cytology done.
 Abdominal ultrasound
 Abdominal x ray, CT
 Chest X-ray, CT, MRI (to detect
metastatic to lungs).
 Blood investigations including BUN,
creatinine and complete blood count.
 Intravenous pyelography
 Fine needle aspiration cytology.
All these tests help to determine the tumor's
position, size and dissemination to other
organs.

STAGING AND PROGNOSIS:

BOOK PICTURE PATIENT PICTURE

 Wilms tumor arises from a malignant,  Left kidney is involved.
undifferentiated metanephrogenic blastoma (a
 Favorable histology.
cluster of primordial cells capable of initiating
 Staging is not clearly
the regeneration of an abnormal structure).
 Its occurrence slightly favors the left kidney,
specified.
which is advantageous because surgically this
kidney is easier to manipulate and remove.
Although the tumor may become large, it
remains encapsulated for an extended period.
 The histology of the tumor cells is identified and
classified according to two groups: favorable
histology (FH) and unfavorable histology (UH).
 Only about 10% of Wilms tumors demonstrate
 UH, which is associated with a poorer prognosis
and demands a more aggressive treatment
protocol, regardless of the clinical stage.
 STAGING:
Stages of wilm's tumor
 Stage 1 (43% patients): Tumor limited to kidney
and is completely resectable.
 Stage 2 (23% patients): Tumor extends beyond
kidney but is resectable.
 Stage 3 (23% patients): Non hematogenous
spread in abdomen.
 Stage 4 (10% patients): Hematogenous
metastasis to lungs and liver.
 Stage 5 (5% patients): Bilateral renal
involvement.

MANAGEMENT:
Management of wilm’s tumor includes:
1. Radiation therapy
2. Chemotherapy
3. Surgery
Most children with Wilms tumors will get more than one type of treatment. 

Radiation Therapy
Wilm’s tumor may be bilateral or large in size , may be inoperable, for such cases radiation
therapy may be used to reduce the size of tumor, so that surgery can be performed.
Chemotherapy
The objective of chemotherapy is to treat any metastatic lesions that may exist and destroy any
cells in blood stream, before they get implanted. The drugs used for chemotherapy are
Actinomycin D, Doxorubicin and Vincristine.
Surgical management
Partial or complete nephrectomy is done for unilateral and for bilateral partial nephrectomy is
done. After surgical management, chemotherapy and radiation therapy is given if indicated.

Treatment for wilm’s tumor is based mainly on the stages of the cancer: -
STAGE I- These tumors are still only in the kidney. Standard treatment starts with surgery to
remove the part of kidney containing tumor. These children need to be watched closely because
the chances of recurrence are higher. If tumor comes back, chemotherapy (Actinomycin D and
Vincristine) is effective.
STAGE 11- These tumors have grown outside the kidney into nearby tissues, but surgery can
remove all visible signs of cancer. Standard treatment is surgery (radical nephrectomy), followed
by chemotherapy with Actinomycin D and Vincristine. The chemotherapy is given for 18 weeks.
STAGE III- Treatment is usually surgery followed by radiation therapy to the abdomen over
several days. This is followed by chemotherapy for about 6 months.
STAGE IV- These tumors are already spread to distant parts of the body at the time of
diagnosis, so standard treatment id surgery followed by radiation and chemotherapy.
STAGE V- In this stage usually tumor is bilaterally present, standard treatment involves surgery,
radiation and chemotherapy repeatedly until normal kidney tissue left behind. In case if not
enough kidney tissue is left after surgery that child may need to place on dialysis. If there is no
evidence of any cancer after year or two, a donor kidney transplant may be done.
IN THIS CHILD:
Underwent 6 chemotherapy prior to surgery and then followed by surgery (NFU + LN
Sampling).

NURSING MANAGEMENT:
PREOPERATIVE CARE
Prepare the parents and child for surgery.
Explain parents not to palpate the abdomen of the child.
Explain child about post-operative care, if he or she is old enough.
 Caution should be taken while turning and handling the child.

POST OPERATIVE CARE

Monitor vital signs.
Monitor renal functioning by monitoring weight, intake output and KFT values.
Observe for the signs of functioning.
Use aseptic techniques while doing dressing
Explain parents about follow up and continuing treatment at the time of discharge.

NURSING DIAGNOSIS
 Ineffective protection related to antineoplastic agents, radiation therapy, or leukopenia.
 Impaired oral mucous membrane related to chemotherapy.
 Anxiety related to change in health status and threat of death.
 Risk for injury related to side effects of medications and complications.

1. Ineffective protection related to antineoplastic agents, radiation

therapy, or leukopenia.
Possibly evidenced by

 Altered clotting
 Bone marrow suppression
 Deficient immunity against infection
 Hematuria
 Hemorrhagic cystitis
 Petechiae, bleeding from nose and gums
Desired Outcomes
  Child will be protected from illness or injury.

2. Impaired oral mucous membrane related to chemotherapy.

Possibly evidenced by

 Hyperemia
 Oral pain or discomfort
 Oral plaque
 Oral ulcers
  Stomatitis
Desired Outcomes

 Child will be free of oral mucous membrane irritation.

3. Anxiety related to change in health status and threat of death.

Possibly evidenced by

 Increased apprehension and fear of diagnosis

  Expressed concern and worry about preoperative procedures
and preparation postoperative care and effects of therapy, possible metastasis of the
disease
Desired Outcomes

 Clients will experience decreased anxiety.

 4. Risk for injury related to side effects of medications and complications.
Desired Outcomes

 Child will not experience injury.

SUMMARY:
Definition of Wilm’s tumor
Incidence
Etiology
Pathophysiology
Clinical manifestations
Diagnosis
Staging and prognosis
Management
Nursing management of Wilm’s tumor

CONCLUSION:
Wilms tumor (nephroblastoma) is recognized as the most common pediatric malignant renal
tumor in children. The incidence of Wilms tumor is slightly less frequent in boys than in girls.
The average age at diagnosis with unilateral tumors is 41.5 months and with bilateral tumors is
29.5 months. It occurs in association with congenital anomalies and chromosomal abnormalities.
Over the years, advancements in the diagnosis and treatment of Wilms' tumor have greatly
improved the outlook (prognosis) for children with this disease. With appropriate treatment, the
outlook for most children with Wilms' tumor is very good.
REFERENCES:

 Hockenberry MJ., Wilson D., Rodgers Cheryl C. Wong’s Essentials of Pediatric Nursing.
10th ed. St. Louis, Missouri: Elsevier;2017. Page no. 1637-1639.
 Kliegman RM.,et.al. Nelson Textbook of Pediatrics. 21st ed. Canada: Elsevier;2020. Page
no. 2681-2685,2781.
 Sharma R., Essentials of Pediatric Nursing. 2nd ed. New Delhi: Jaypee publishers;2017.
Page no.399-402.
 Paul V. K., Bagga A. Ghai Essential Pediatrics. 9 th ed. New Delhi: CBS
publishers,2019.Page no. 609-610.

 https://www.slideshare.net/sheenabhatia3/wilms-tumor-152388934
 https://www.cancer.org/cancer/wilms-tumor/treating.html
 https://www.mayoclinic.org/diseases-conditions/wilms-tumor/symptoms-
causes/syc-20352655