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Wilms Tumor

 

 

Follow up after Therapy

 

After treatment for Wilms tumor there are many chronic health problems to be aware of and to screen for in long-term survivors of this disease.  Some of these are secondary to previous nephrectomy, some to radiation therapy (RT) and some to chemotherapy.

Here is a PDF (which can be printed) giving an example of the type of follow up necessary for a long-term survivor of childhood Wilms tumor: 

 

Example of annual follow up:

Investigation Important aspects to screen for:
History

General:

  • Level of energy, general health
  • Social/relationship/employment situation
  • Depression
  • Exercise
  • Smoking, recreational drugs and alcohol ingestion
  • Current medications
  • Family history: Wilms is associated with inherited syndromes
  • List of physicians/HCPs currently following patient

 

Chemotherapy related:

 

Previous chest RT:

  • Does the patient smoke? (tobacco or marijuana)
  • Respiratory symptoms: cough, shortness of breath, chest pain
  • Energy level (at risk for hypothyroidism)

 

Previous abdominal and pelvic RT:

  • Abdominal pain and cramping
  • Diarrhoea/constipation
  • Change in bowel habit
  • Rectal bleeding
  • Bladder symptoms (dysuria, hematuria, frequency and any bladder infections)
  • Women: menstrual cycle, menopausal symptoms, sexual function
  • Men: sexual function
  • Problems with fertility - unable to conceive
  • Back pain, history of fractures - after RT to spine and intensive chemotherapy patients are more at risk for osteoporosis

 
Examination

General:

  • BLOOD PRESSURE  It is very important to check Wilms tumor survivors' blood pressure on a regular basis
  • Weight and height (Body Mass Index: BMI)
  • General examination

 

Chemotherapy related: Signs of:

  • Cardiac dysfunction/failure
  • Peripheral neuropathy

 

Previous chest RT:

  • Examine neck to exclude thyroid nodules
  • Check for scoliosis of thoracic spine
  • Respiratory examination
  • Cardiac examination
  • In females check for palpable breast abnormalities

 

Previous abdominal and pelvic RT:

  • Check for scoliosis as spinal growth may have been affected by RT
  • Abdominal and pelvic examination
  • In previous right sided tumors check for signs of liver/veno-occlusive disease

 
Blood work

General:

  • Routine blood work including blood count, electrolytes, BUN, serum creatinine and liver function tests.
  • Fasting blood lipids and glucose to exclude metabolic syndrome.

 

Previous chest RT:

  • Thyroid function tests (at least free T4 and TSH)

 
Radiology screening

Previous chest RT:

  • Ultrasound scan of the thyroid every 3 years to exclude papillary carcinoma of the thyroid
  • If survivor smokes, then increased risk of lung cancer in long term and intermittent chest X-ray and CT scanning would be appropriate.  There are no firm guidelines about timing of these investigations
  • Women who had lung RT should have early screening for breast cancer even though the dose given is likely to be less than 20 Gy. On occasion the flank RT field may have extended superiorly to include the ipsilateral breast.  This may result in hypoplasia and these patients also require screening for breast cancer on the affected side.

 

Previous abdominal and pelvic RT:

  • Ultrasound of the abdomen and pelvis every year or so may be helpful to exclude new masses and to ensure that there is no hydronephrosis affecting the remaining kidney

 
Special investigations

General:

  • Any adriamycin exposure - echocardiogram every 3 years or so
  • Routine urinalysis ( e.g. to rule out proteinuria)

 

Previous chest RT:

  • Pulmonary function tests to look for restrictive defect
  • If Adriamycin was also given, increased risk of cardiac dysfunction - echocardiogram every 2 - 3 years 

 

Previous abdominal and pelvic RT:

  • Screening for infertility, hypogonadism and early menopause in women
  • Screening for malabsorption may be important if there is a history of chronic diarrhoea (this would be an unusual complication in WT as the RT doses are generally low)

 

Specialist

follow-up

General:

  • Many patients need to have other specialist physicians involved in their follow up with assessment every 1 - 2 years (e.g. nephrologist)
  • Any long term survivor of WT who has had intensive chemotherapy is at risk for early onset osteoporosis and should be seen in consultation by a specialist with expertise in this area when more than 10 years off therapy

 

Previous abdominal and pelvic RT:

  • Gastroenterologist for chronic diarrhoea and malabsorption
  • Orthopedic/spinal service for management of scoliosis
  • Fertility specialist
  • Endocrinologist for hypogonadism
  • Immunologist may be important if there is splenic dysfunction
  • PREGNANCY: Pregnant survivors of WT should be referred to an obstetrician who specializes in high risk pregnancy management (significantly increased risk of premature birth)

 
Supportive care

Most Wilms tumor survivors manage very well, but might require support from:

  • Family counselling
  • Psychology

 
Advice

General:

  • Wilms tumor patients will have almost certainly had a nephrectomy and should avoid activities that might damage the remaining kidney.  It would be recommended to avoid contact sports.
  • Urinary tract infections should be treated very promptly (single kidney more vulnerable to damage).
  • The patient should seek immediate medical help if a new swelling (painless or painful) appears within the previous RT field as this may be due to a second malignant neoplasm.

 

Lifestyle:

  • Advise about diet, exercise and lifestyle choices (such as smoking) which may further increase the risk of vascular disease.
  • Diet rich in Vitamin D, calcium and dairy servings to reduce risk of osteoporosis.
  • Skin previously in the RT field should be protected from the sun (more vulnerable to damage).        

 

Previous chest RT:

 

Previous abdominal and pelvic RT:

  • Patients should avoid lifting heavy weights (spine more vulnerable to damage)
  • Bone density should be checked roughly 10 years before one would normally worry about osteoporosis
  • Important to maintain bone density (Vit D, calcium, dairy servings in diet and exercise)
  • PREGNANCY: Obstetrician who specializes in high risk pregnancy management (significantly increased risk of premature birth) should be involved in prenatal care.
  • Early screening for colon cancer if any abdominal RT of 30 Gy or higher to the abdomen, pelvis, or spine.  Colonoscopy should be performed beginning at age 35 years or 10 years following RT (whichever occurs last).

 

Patient information

(COG) Survivorship Guidelines

General:

 

After chest RT:

 

After abdominal and pelvic RT:

 

 

 

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