Max Wilms first described Wilms tumor in 1899 after examining childhood kidney tumors. Wilms tumor is the most common malignant renal tumor in children, affecting around 7 per million children under 15 years old. The tumor is named after Max Wilms. Treatment has improved survival rates to around 90% with surgery, chemotherapy, and radiation therapy depending on tumor stage and histology. Genetic factors like WAGR, Beckwith-Wiedemann, and Denys-Drash syndromes increase risk by predisposing to mutations in genes like WT1 and CTNNB1.
This is a concise presentation on the pathology of endometrial cancer based on the latest WHO female genital tumors latest edition, 5th edition
prepared on April 2022
This is a concise presentation on the pathology of endometrial cancer based on the latest WHO female genital tumors latest edition, 5th edition
prepared on April 2022
Nephroblastoma also known as Wilms tumor, is the most common renal malignancy affecting one in 10,000 children <15 years old
Children with bilateral disease are diagnosed at an earlier age (median age, girls at 31 months and boys at 24 months): Patients with associated congenital anomalies are also diagnosed at an earlier age
Accounts for 6-7% of cases of childhood cancer in the developed world and 12% in South Africa
In Tanzania the prevalence is 6.7% ( Mgaya E et al., 2000), “third from leukemia and lymphoma” (Shakilu J, 2017)
The overall survival rate of nephroblastoma approaches 90% in the developed world but in developing countries the survival rates are much less and in some sub-Saharan countries it is only 40% at 8 months after diagnosis
These may occur in 1% of infantile kidneys but typically regress during childhood
Nephrogenic rests normally occur in 1% of newborn kidneys and regress early in childhood: in contrast, they are present in 35% of kidneys with unilateral Wilms tumor and almost 100% of kidneys with bilateral disease
Nephrogenic rests normally occur in 1% of newborn kidneys and regress early in childhood: in contrast, they are present in 35% of kidneys with unilateral Wilms tumor and almost 100% of kidneys with bilateral disease
Nephrogenic rests normally occur in 1% of newborn kidneys and regress early in childhood: in contrast, they are present in 35% of kidneys with unilateral Wilms tumor and almost 100% of kidneys with bilateral disease
Nephrogenic rests normally occur in 1% of newborn kidneys and regress early in childhood: in contrast, they are present in 35% of kidneys with unilateral Wilms tumor and almost 100% of kidneys with bilateral disease
Has been associated with loss of function mutations of a number of tumor suppressor and transcription genes
These include mutations of the WT1, p53, FWT1, and FWT2 genes and at the 11p15.5 locus
Histologically, the classic favorable histology Wilms tumor is comprised of three cell types:
Blastemal cells – Undifferentiated cells
Stromal cells – Immature spindle cells and heterologous skeletal muscle, cartilage, osteoid or fat
Epithelial cells – Glomeruli and tubules
Grossly, Wilms tumors are usually well-circumscribed and have a pseudo-capsule
Histologically, Wilms is divided into "Favorable" and "Unfavorable" histologies
"Favorable" Histology: 90% of Wilms tumors will demonstrate "favorable" histology which generally has a better prognosis
Most children with Wilms tumor present with an abdominal mass or swelling without other signs or symptoms
The definitive diagnosis of Wilms tumor is made by histologic confirmation at the time of either surgical excision or biopsy
Stage I indicates the tumor was completely contained within the kidney without any breaks or spillage outside the renal capsule and no vascular invasion
Stage II would be a tumor that has grown outside the kidney
Stage IIIunresectable tumor
Stage IV-Metastasis
Stage V-bilateral kidney
Surgery is the main treatment
Chromosomal Disorders. The types of chromosomal disorders: structural, deletion or addition. Down's syndrome, Turner's syndrome, Klinefelter's syndrome, Patau syndrome. Hope this presentation will help you.
WILMS’ TUMOUR-Pediatric Surgery
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on the commonest childhood solid tumour- Wilms’ tumour
• This is a malignant tumour arising from embryonal kidney cells
• It has excellent prognosis because of multi-disciplinary management
• In this video I have discussed the epidemiology, etiology, pathology, clinical features, investigations, staging, differential diagnosis and treatment of Wilms’ tumour.
• I hope you will like and enjoy watching the video
• You can watch all my surgery teaching videos in the following links:
• youtube.com/c/surgicaleducator surgicaleducator.blogspot.com
• Thank you for watching the video.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. Max Wilms, MD
• German surgeon Max Wilms, born
in Hünshoven, Germany
• At the start of his medical career,
Wilms examined children’s kidney
tumors, added seven cases to a
thorough review of the literature,
and produced what was the
definitive work on the subject in
1899
• He may be best remembered for
his thorough work with childhood
cancer
• This tumor derived the name from
MAX WILMS
• In May 1918, during World War l
Wilms died of diphtheria.
3. EPIDEMIOLOGY
• WT most common malignant renal tumor of
childhood
• Wilms’ tumor affects approximately 7 children per 1
million before the age of 15 years.
• Accounts for 6-7% of all childhood cancers in North
America.
• About 450-500 new cases are diagnosed each year
4. FACTS
• Most WTs are solitary lesions , multifocal within
a single kidney in 12 % and bilateral in 7 %
• In only 1% of the children who have a kidney
removed due to Wilms’ tumor, does the cancer
re-appear later in the other kidney.
• There is a family history of the disease in only 1%
of cases.
5. Mortality/Morbidity
Before the multimodality
approach was available, the
survival rate of patients was less
than 50%. With the current
NWTSG and SIOP strategies,
survival rates are approaching
90%. Most survivors of Wilms
tumor have good functional
outcomes and quality of life
6. Race
Wilms tumor is relatively more common in blacks than
in whites and is rare in East Asians. Estimates
suggest 6-9 cases per million person years in whites,
3-4 cases per million person years in East Asians
and more than 10 cases per million person years
among black populations.
10 cases
per million
6-9 cases
per million 3-4 cases
per million
7. Sex
Among patients with unilateral Wilms tumor
enrolled in all NWTSG protocols, the male-
to-female ratio was 0.92:1. For patients with
bilateral disease, the male-to-female ratio
was 0.60:1.
:
9. Pathogenesis and Genetics
The risk of Wilms tumor is
increased in association with at least
four recognizable groups of
congenital malformations
associated with distinct chromosomal
loci.
11. • Individuals with WAGR syndrome carry constitutional
(germline) deletions of 11p13. Studies on these
patients led to the identification of the first
Wilms tumor–associated gene, WT1,
and
a contiguously deleted autosomal dominant gene for
ANIRIDIA,
PAX6, both located on chromosome
11p13.
12. Patients with deletions restricted to
PAX6, with normal WT1 function,
develop sporadic ANIRIDIA,
but they are not at increased
risk for Wilms tumors.
13. Denys- Drash syndrome
A much higher risk for Wilms tumor (∼90%)
characterized by
GONADAL DYSGENESIS
(male pseudohermaphroditism) and
EARLY-ONSET NEPHROPATHY leading to
renal failure
14. Denys- Drash syndrome
The characteristic glomerular
lesion in these patients is a
diffuse mesangial sclerosis. As in
patients with WAGR, these
patients also demonstrate
germline abnormalities in WT1.
15. • In patients with the Denys- Drash
syndrome, however, the genetic
abnormality is
• A DOMINANT NEGATIVE
MISSENSEMUTATION in the zinc-
finger region of the WT1 gene
that affects its DNA BINDING
PROPERTIES
16. Despite the importance of WT1 in
NEPHROGENESIS and its unequivocal role as a
TUMOR SUPPRESSOR GENE, only about 10%
of patients with sporadic (nonsyndromic) Wilms
tumors demonstrate WT1 mutations, suggesting
that the majority of these tumors arise by
GENETICALLY DISTINCT
PATHWAYS.
17. Beckwith- Wiedemann
syndrome
characterized by
1. ENLARGEMENT OF BODY ORGANS (organomegaly)
2. MACROGLOSSIA
3. HEMIHYPERTROPHY
4. OMPHALOCELE
5. ABNORMAL LARGE CELLS IN THE ADRENAL
CORTEX (adrenal cytomegaly)
6. Genitourinary abnormalities
7. Ear creases ; Hypoglycemia
8. A predisposition to WT
18. • BWS has served as a model for a
nonclassical mechanism of
tumorigenesis in HUMANS—
GENOMIC IMPRINTING
• The chromosomal region implicated
in BWS has been localized to band
11p15.5 (“WT2”), distal to the WT1
locus.
19. 11p15.5
This region contains multiple genes that are
normally expressed from only one of the two
parental alleles, with transcriptional silencing
(i.e., imprinting) of the other parental
homologue by METHYLATION of the promoter
region.
20. Unlike WAGR or Denys- Drash
syndromes, the genetic basis for
BWS is considerably more
HETEROGENEOUS in that NO
SINGLE 11P15.5 GENE IS INVOLVED
IN ALL CASES.
21. • Moreover, the phenotype of BWS, including
the predisposition to tumorigenesis, is
influenced by the specific “WT2”
imprinting
abnormalities present.
22. • One of the genes in this region—
•insulin-like growth
factor-2 (IGF2)—is
normally expressed solely from the
PATERNAL ALLELE, while the
maternal allele is silenced by
imprinting.
23. • In some Wilms tumors, loss of imprinting
(i.e., re-expression of the maternal IGF2
allele) can be demonstrated, leading to
overexpression of the IGF-2 protein.
• In other instances there is a selective
deletion of the imprinted maternal
allele, combined with duplication of the
transcriptionally active paternal allele in
the tumor (uniparental paternal disomy),
which has an identical functional effect
in terms of overexpression of IGF-2.
24. • Since the IGF-2 protein is an
embryonal growth factor, it could
conceivably explain the features of
OVERGROWTH associated with BWS,
as well as the increased risk for Wilms
tumors in these patients.
• Of all the “WT2” genes, imprinting
abnormalties of IGF2 have the
strongest relationship to tumor
predisposition in BWS.
25. • In addition to Wilms tumors, patients
with BWS are also at increased risk for
developing
HEPATOBLASTOMA,
•PANCREATOBLASTOMA,
•ADRENOCORTICAL
TUMORS, and
RHABDOMYOSARCOMAS.
26. β- catenin
• Recent genetic studies have also elucidated the
role of β- catenin in Wilms tumor. It will be
recalled that β- catenin belongs to the
developmentally important WNT (wingless)
signaling pathway.
• Gain-of-function mutations of the gene
encoding β -catenin have been demonstrated in
approximately 10% of sporadic Wilms tumors;
there is a significant overlap between the
presence of WT1 & β- catenin mutations,
suggesting a synergistic role for these events in
the genesis of Wilms tumors.
27. Nephrogenic Rests
• Nephrogenic rests are putative precursor
lesions of Wilms tumors and are seen in the
renal parenchyma adjacent to approximately
25% to 40% of unilateral tumors;
this frequency rises to nearly 100%
in cases of bilateral Wilms tumors.
28. • Nephrogenic rests consists of
embryonal nephroblastic tissue
and are found in 35 % of kidneys
with unilateral WT and in nearly
100 % of kidneys with bilateral WT
• Most nephrogenic rests undergo
spontaneous regression and only a
small proportion 1 % to 5 %
transform into WT
29. • In many instances the nephrogenic rests
share GENETIC ALTERATIONS with the
adjacent Wilms tumor, underscoring their
preneoplastic status.
• The appearance of nephrogenic rests varies
from EXPANSILE MASSES that resemble
Wilms tumors (hyperplastic rests) to
SCLEROTIC RESTS consisting predominantly
of fibrous tissue and occasional admixed
immature tubules or glomeruli.
30. It is important to document the
presence of nephrogenic rests in
the resected specimen, since these
patients are at an increased risk of
developing Wilms tumors in the
contralateral kidney and require
frequent and regular surveillance
for many years.
31. HISTOLOGY
ANAPLASIA
Focal or Diffuse : reflect the
distribution of anaplastic cells in
tumor and are of prognostic
significance
The 4 year survival rates for patients
with stages ll , lll , lV FA were 90%
,100% and 100% compared with 55%,
45%, and 4% for patient with similar
stage DA WT
32. Morphology
Grossly, Wilms tumor tends to
present as a large, solitary, well-
circumscribed mass, although
10% are either bilateral or
multicentric at the time of
diagnosis.
33. On cut section
The tumor is soft,
homogeneous,
and tan to gray with
occasional
foci of hemorrhage,
cyst formation,
and necrosis.
34. Microscopy
• Microscopically, Wilms tumors are characterized
by recognizable attempts to recapitulate
different stages of nephrogenesis.
• The classic triphasic combination of
• BLASTEMAL,
• STROMAL, &
• EPITHELIAL cell types is observed in the vast
majority of lesions, although the percentage of
each component is variable.
35. 1. Sheets of small blue cells with few
distinctive features characterize the
BLASTEMAL component.
2.EPITHELIAL
DIFFERENTIATION is usually in
the form of abortive tubules or
glomeruli.
3. STROMAL CELLS are usually
fibrocytic or myxoid in nature,
although skeletal muscle
differentiation is not uncommon.
36. HISTORY AND PHYSICAL EXAMINATION
• Detection of an
asymptomatic
abdominal mass bulging
in the flank.
• Non specific systoms like
abdominal pain, fatigue
• Haematuria (in <10%)
• Hypertension (V. rare )
• Associated Urogenital anomalies,
Aniridia, overgrowth Syndrome.
39. IMAGING STUDIES
1. Abdominal USG Organ of origin
Identify contralateral Kidney
Presence/absence of tumor
thrombus in IVC
2. CT Scan Further evaluation of extent
of tumor Extension into adjoining
structures such as
Liver spleen & colon.
Visualisation and function of
contralateral Kidney
3. X-ray chest PA Pulmonary Metasteses
40. • 4. Bone scan & X-ray Skelatal
survey Bone mets in clear cell Sarcoma of
Kidney (CCSK)
• 5. Brain imaging (MRI / CT-Scan)
Intracranial mets in Rhabdiod Tumor (RT) &
CCSK
• 6. Fine needle aspiration cytology
of mass Cytological confirmation of
diagnosis prior to prenephrectomy
Chemotherapy.
41. National Wilms Tumor Study (NWTS) staging
Stage I : Tumor confined to the kidney & completely
excised
Stage II : Tumor outside the kidney but completely
excised
Local tumor spillage during surgery
Lymph nodes negative
Stage III : Non hematogenous disease confined to the
abdomen
Perioperative rupture of renal capsule
Diffuse tumor spillage during surgery
Peritoneal implants
Positive lymph nodes
Stage IV : Hematogenous metastases to lungs or liver
Stage V : Bilateral Wilms’ tumor
43. • The diagnosis of WT is usually made
before surgery and confirmed at
surgery.
• A TRANSVERSE TRANSABDOMINAL ,
TRANSPERITONEAL INCISION is
recommonded
• Lymph node sampling from para –aortic
, celiac and iliac areas must be
performed
44. Absolute Indications for
Prenephrectomy Chemotherapy
1. Large tumor technically difficult to deliver at
surgery.
2. Presence of major tumor thrombus in the
inferior venacava.
3. Bilateral Wilm’s tumor
4. Wilm’s tumor in a solitary Kidney or horse
shoe Kidney.
45. Radiation Therapy
Wilms Tumors - high sensitivity – ionizing radiation
RT Management varies according to:
Age of patient (avoided in < 6 months
infants / <2yrs FH)
Preoperative extent on imaging
Operative stage
Post operative histology
46. RT - Indications : Post OP RT
• WT - Favourable Histology
– Stage III:
– residual T
Gross/Micro
+ve Margin
Local Infiltration Vital Structures
- Abd / Pelv -Ly N +
- peritoneal surface
Penetration
Tumour implants
T Spillage (pre / intro OP)
- Bx – trucut, Bx, FNAC
- T removed in Pieces : eg - extra
adrenal , T thrombus in renal vein
• Standard Risk FH WT
without LOH at 1p & 16q
• Higher Risk FH with LOH at
1p & 16q
• WT Unfavourable Histology
– Anaplasia
• Stage I – diffuse
• Stage II-IV – diffuse
• Stage I-IV - Focal
– Clear cell CCSK
• Stage I-III
• Stage IV
– Rhabdoid RTK
• Stage I -IV
47. –Stage IV
• Rapid responders of
lung metastasis at
week 6 on DD4A
• (Possibility of no-RT to
rapid complete
responders on CT scan)
• Slow responders
(lungs) & non-
pulmonary metastasis
48. RT Technique
• Timing of RT : not later than 9
days after surgery (max 14 days)
• Delay of >10dys – significantly
higher abdominal relapse rate ,
particularly UH.
50. RT Techniques
• Flank RT
• Whole Abdomen RT (WAI):
– Indicated –
• diffuse tumor spillage - Pre-OP / Intra OP Tumor Rupture
• Peritoneal T seeding
• Ascites +ve Cytology
• Whole Lung RT
– Localized foci of lung disease persisting 2 weeks after 12 Gy can be
excised or given additional 7.5 Gy
– Treat both lungs regardless of the number or location of visible
metastases
– Patients with CT only pulmonary mets – at the discretion of the
treating institution
51. General Principles : RT planning
• Pt position : Supine
• Immobilization: Vacuum Cushion
• Sedation / Anesthesia during RT / Simulation
• Simulation:
– Simulator – X –Ray + IVP (to Exclude Opposite kidney)
– CT Simulation
• Ensure – Anesthesia & Patient monitoring equipments in the RT
Bunker
• Opposed AP:PA fields
– Field Shaping : 3DCRT / Contouring
– Shielding opposite kidney & selected normal structures
– Complete Vertebrae to be included in the RT field
53. • Stage III
Diffuse anaplasia
• Stage I-III
RTK
FLANK RT : 19.8Gy
(Infants -10.8Gy), 180cGy/ fx
54. • Whole Abdomen RT
FH : 10Gy, 150cGy/ Fx
Gross Residual disease : Boost of + 10Gy
(Renal Shielding / Limit the dose to
remaining kidney <14.4Gy)
55. • Lung (mets.)
FH / UH : 12Gy WLI in 8#
• Liver (mets.) : 19.8Gy whole liver in 11#
• Brain (mets.) : 36.6Gy WB in 17#
Or 21.6Gy WB + 10.8Gy IMRT
/Stereotactic Boost
56. • Unresected Lymph nodes : 19.8Gy in 11#
• Bone ( mets.) : 25.2 Gy in 14#
57. Flank Radiation
• Treatment Portal design :
– Should encompass the tumor bed and the site of
the excised kidney
– 2-3 cm margins should be given circumferentially
• 3D Plans: Pre OP CT/MRI – CTV : kidney +
Tumor with 1cms Margin
• Field sizes ~ 10 x 10 / 12 x 12 cms
• Beam energy : 4-6 MV
59. Whole Abdomen Radiation
• Indicated in few patients now a days
• energy - 4-6 MV photons
• Shielding :
– Opposite kidney
– Acetabulum and femoral heads – both AP-PA shields
• Superior border : dome of diaphragm (nipples)
• Inferior border : inferior border of the obturator foramen(
pubis symphysis )
• Lateral border : to the lateral peritoneal reflection
60.
61.
62. Lung Irradiation
• Superior border : 3cm above the middle 1/3 rd
of clavicle
• Inferior border : ( below the costophrenic
angles) Below the xiphisternum / level of L1
(transpyloric plane)
• Lateral borders : Lateral border of areola of
nipple
• Shielding
– humeral head
– larynx
63.
64. bilateral Wilms’
• Dose to more than 1/3 of the
contralateral kidney or residual kidney
should not exceed 14.4 Gy
• Inoperable Bilateral WT- role of Cyber
Knife, Tomotherapy, Rapid Arc, True
Beam, IMRT to be considered . PET based
planning.
65. Evaluation in Late effect Clinic
. Evaluation of Renal Functions on annual basis
. Evaluation of Anthracycline related
cardiotoxicity with 2 DEcho on annual/biennial
basis
. Assessment of growth and Sexual development.
. Assesment of musculoskeletal development in
irradiated patients.
. Assesment of fertility
. Watch out for second Malignant Neoplasia.