ABDOMINAL PAIN SECUNDARY TO PRE-OPERATIVE RUPTURE OF A WILLM´S TUMOR: REPORT OF A CASE
Víctor Salirrosas Bermúdez, Edwing Azabache Vásquez, José Lecca Zavaleta
Department of Urology “Hospital Regional Docente de Trujillo”
Universidad Nacional de Trujillo. La libertad, Perú
The authors in this article describe a clinical case of a 4-year-old boy with no history of interest who was admitted to the emergency department for a 4-day history of abdominal pain that had increased in intensity in the last few hours.
On admission, the UroTAC showed a mass in the lower half of the left kidney measuring 7.7×6.7x 12.6 cm with necrotic cystic areas and fluid in the subhepatic, perisplenic and pelvic cavities.
Although the patient showed no signs of hemodynamic instability, she underwent an emergency laparotomy, which revealed blood in the peritoneal cavity due to anterior left kidney rupture. The kidney was removed and the histology confirmed Wilms’ tumor diagnosis.
Pre-operative rupture of a Wilms’ tumor is not common and in this case, the authors, despite the patient being hemodynamically stable, decided to perform an emergency nephrectomy. However, in most publications similar to this clinical case, they suggest giving preoperative chemotherapy (SIOP protocol) and deferring nephrectomy if the patient is hemodynamically stable with conservative measures. Emergency nephrectomy for tumor rupture is associated with 25% more postoperative complications than deferred nephrectomy.
From a radiological point of view it is important to differentiate between retroperitoneal rupture (localized bleeding within the kidney, subcapsular or in the perirenal space) and intraperitoneal rupture (intraperitoneal bleeding, tumor rupture with infiltration of the mesentery or peritoneal effusion). Intraperitoneal rupture is more frequent in Wilms’ tumors of the right kidney. The prognosis is better for retroperitoneal rupture with a lower incidence of abdominal recurrence than for intraperitoneal rupture.
The authors, unfortunately do not mention in the text, the tumor´s histology, if the patient received radiotherapy and how was his follow-up that I think they should be important to know.
1.- Brisse HJ. et al Cancer. Preoperative Wilms Tumor Rupture. 2008; 11(1): 202-13
Dr. Pedro López Pereira, MD, PhD, FEAPU