WILMS TUMOR

Wilms tumor is the most common renal tumor and the fourth most common solid tumor in children (Hendershot, 2010). Peak
incidence occurs between the ages of 2 and 3 years (Hendershot, 2010). It usually affects only one kidney (Fig. 28.7). The etiology is
unknown, but some cases occur via genetic inheritance. Associated anomalies may occur with Wilms tumor. Wilms tumor
demonstrates rapid growth and is usually large at diagnosis. Metastasis occurs via direct extension or through the bloodstream. Wilms
tumor most commonly metastasizes to the perirenal tissues, liver, diaphragm, lungs, abdominal muscles, and lymph nodes. The
prognosis depends on staging at diagnosis and the extent of metastasis (Box 28.4). The overall survival rate is about 90%
(Hendershot, 2010). Complications include metastasis or complications from radiation therapy such as liver or renal damage, female
sterility, bowel obstruction, pneumonia, or scoliosis.
FIGURE 28.7 Wilms tumor is usually unilateral.

Therapeutic Management
Surgical removal of the tumor and affected kidney (nephrectomy) is the treatment of choice and also allows for accurate staging and
assessment of tumor spread. Radiation or chemotherapy may be administered either before or after surgery.

Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1029. Assessment findings pertinent to Wilms
tumor are discussed below.

Health History
Parents typically initially observe the abdominal mass associated with Wilms tumor and then seek medical attention. Elicit the health
history, noting when the mass was discovered. Note abdominal pain, which may be related to rapid tumor growth. Document history
of constipation, vomiting, anorexia, weight loss, or difficulty breathing. Determine risk factors such as hemihypertrophy of the spine,
Beckwith-Wiedemann syndrome, genitourinary anomalies, absence of the iris, or family history of cancer.

BOX 28.4

STAGING OF WILMS TUMOR

• Stage I: unilateral, limited to kidney, completely resectable
• Stage II: unilateral, tumor extends beyond kidney but is completely resectable
• Stage III: unilateral, tumor has spread outside of kidney, located in abdominal cavity only, not fully removed
• Stage IV: unilateral with metastasis in liver, lung, bone, or brain
• Stage V: bilateral kidney involvement
Adapted from Hendershot, E. (2010). Solid tumors. In D. Tomlinson & N. E. Kline (Eds.), Pediatric oncology nursing. New York, NY: Springer.
Physical Examination
Measure blood pressure; hypertension occurs in 25% of children with Wilms tumor (Maloney et al., 2011). Inspect the abdomen for
asymmetry or a visible mass. Observe for associated anomalies as noted above. Auscultate the lungs for adventitious breath sounds
associated with tumor metastasis. Palpate for lymphadenopathy.

Take Note!
Avoid palpating the abdomen after the initial assessment preoperatively. Wilms tumor is highly vascular and soft, so excessive handling of the tumor may result in
tumor seeding and metastasis.

Laboratory and Diagnostic Testing

Laboratory and diagnostic testing may include:
• Renal or abdominal ultrasound to assess the tumor and the contralateral kidney
• CT scan or MRI of the abdomen and chest to determine local spread to lymph nodes or adjacent organs, as well as any distant
metastasis
• Complete blood count, BUN, and creatinine: usually within normal limits
• Urinalysis: may reveal hematuria or leukocytes
• 24-hour urine collection for HVA and VMA to distinguish the tumor from neuroblastoma (levels will not be elevated with Wilms
tumor)

Nursing Management
Postoperative care of the child with Wilms tumor resection is similar to that of children undergoing other abdominal surgery.
Assessment of remaining kidney function is critical. The child may have adverse effects related to chemotherapy or radiation. Refer to
the nursing process overview section and Nursing Care Plan 28.1 to individualize care for the child based on the child's response to
therapy.

Take Note!
To avoid injuring the remaining kidney, children with a single kidney should not play contact sports.