Bilateral Wilms' Tumor Metastasis to Right Spermatic Cord
The patient is a 33-month-old male whom his mother had discovered right flank mass at the time of dressing one week before admission. Abdominal examination revealed right and left flank mass and mild distention. His physical examination was otherwise unremarkable except blood pressure 130/90 mmHg. The patient was one of two identical twins. He had not congenital anomalies and the other twin was normal. Two months earlier, he had undergone herniorrhaphy for right inguinal hernia. Ultrasound of the abdomen revealed a 73×79 mm and 75×78mm heterogeneous mass without calcification in the right and left kidney, respectively and lymph node in Para-aortic area with 25mm in diameter. Contrast-enhanced computed tomography (CT) scan of the abdomen findings were similar to that of ultrasound without evidence for inferior vena cava and renal vein involvement. Chest CT scan did not show evidence of metastases. Then open biopsies from both kidneys were performed. The histopathology showed infiltration of both kidneys with blastemal cell predominant component, vascular invasion in the tumoral tissue and favorable histology without anaplasia ().\nPara-aortic lymph node biopsy was positive for tumoral involvement. Complete blood count with differential, liver and renal function tests were all within normal range. Erythrocyte sedimentation rate was 89mm/hr. Diagnosis was consistent with stage V favorable-histology Wilms' tumor and treatment was initiated with chemotherapeutic agents including vincristine, actinomycin D, and doxorubicin. Eight weeks following treatment the tumor size of both sides decreased more than 50% and ultrasound demonstrated a 28×40mm and 34×36mm tumor mass in the right and left kidney, respectively. Blood pressure returned to normal range. He underwent right radical nephrectomy and immediately received abdominal irradiation (1080 cGy in 10 fraction dose). Chemotherapy continued with previous drugs. Two months later, ultrasonography revealed a mass measuring 69×69mm in right renal fossa, but tumor size in the left side was without any significant change. Subsequently, the chemotherapy regimen changed to ifosfamide, crboplatin and etoposide (ICE). Following the fourth cycle of ICE, at routine physical examination a right scorotal mass on spermatic cord was noted. Ultrasound revealed a spermatic cord mass measuring 1×1.5×2cm without testicular involvement. The patient then underwent exicisional biopsy and histologic examination suggested WT metastases to spermatic cord (). Two weeks later, lungs CT scan showed multiple nodules and on the ultrasound examination, liver metastases and widely disseminated tumor spread in abdomen were identified. Chemotherapy with ICE regimen continued but unfortunately, he died 2 months later owing to progressive disease and distant metastases.