NEPHROBLASTOMA (WILMS TUMOR)
routinely in children of this age, so the tumor
Nephroblastoma (Wilms tumor) is a
malignant tumor that rises from the
metanephric mesoderm cells of the upper
pole of the kidney (Malkan, Loh, Bahrami, et
al., 2015). It accounts for 20% of solid
tumors in childhood, and overall survival
rates are greater than 90%. It may occur in
association with congenital anomalies such
as aniridia (lack of color in the iris),
cryptorchidism, hypospadias,
pseudohermaphroditism, cystic kidneys,
hemangioma, and talipes disorders. A
number of gene mutation has been
identified as associated with the disease.
Without therapy, metastatic spread by the
bloodstream is most often to the lungs,
regional lymph nodes, liver, bone, and,
eventually, brain.
Assessment
A nephroblastoma is usually discovered
early in life (6 months to 5 years; peak at 3
to 4 years), although it apparently arises
from an embryonic structure present in the
child before birth. Nephroblastomas distort
the kidney anteriorly so that the tumor is felt
as a firm, nontender abdominal mass.
Parents are aware their infant has a mass in
the abdomen but bring the infant to their
healthcare provider thinking that it is hard
stool from chronic constipation. Parents
often report that the mass seemed to
appear overnight. This actually can happen,
because tumors can hemorrhage into
themselves, doubling their size in a matter
of hours. If this happens, accompanying
signs may be hematuria and a low-grade
fever. The child may be anemic from blood
loss and lack of erythropoietin formation by
the diseased kidney. Although hypertension
may also occur because of excessive renin
production, blood pressure is not taken
is rarely discovered by this method. A CT
scan or ultrasound reveals the primary
tumor and any points of metastasis. Kidney
function studies, such as glomerular
filtration rate or blood urea nitrogen, will be
done to assess function of the kidneys
before surgery. Little time, however, can be
allotted for preoperative testing, because
these tumors metastasize rapidly as a result
of the large blood supply to the kidneys and
adrenal glands.
Therapeutic Management
Nephroblastomas are staged to predict
therapy and prognosis. The tumor will be
removed by nephrectomy (excision of the
affected kidney). This is usually followed
immediately by chemotherapy with
dactinomycin, doxorubicin, or vincristine,
cyclophosphamide, and etoposide.
Chemotherapy may be given at varying
intervals for as long as 15 months.
Radiation is usually limited to high-risk
disease (anaplastic histology) or advanced
disease (Dome, Graf, Geller, et al., 2015). If
tumor involvement is bilateral, the operative
decisions obviously become more complex.
If the tumors are small, both tumors may be
removed, leaving functioning kidney on both
sides intact. In other children, the kidney
with the larger tumor is removed and the
tumor site in the remaining kidney is then
treated with both radiation and
chemotherapy. Complications such as
nephritis, small bowel obstruction, and
hepatic damage caused by fibrotic scarring
from radiation or scar tissue from surgery
can occur. In girls, radiation-related damage
to the ovaries may result in sterility.
Radiation to the lungs may result in
interstitial pneumonia.
Nephroblastoma (Wilms tumor) is a
malignancy that arises from the
metanephric mesoderm cells of the kidney.
It is usually discovered early in life. Therapy
is surgery followed by chemotherapy and
radiation for high-risk or advanced stage
disease.
Staging Nephroblastoma (Wilms’ Tumor)
Stage Description
I Tumor confined to the kidney and
completely removed surgically
II Tumor extending beyond the
kidney but completely removed
surgically
III Regional spread of disease
beyond the kidney with residual
abdominal disease
postoperatively
IV Metastases to lung, liver, bone,
distant lymph nodes, or other
distant sites
V Bilateral disease
What is an important intervention to take for
a child with nephroblastoma (Wilms’
tumor)?
a. Post a sign over the crib: “No
Abdominal Palpation.”
b. Alert the mother that her child will be
infertile after surgery.
c. Be certain the child eats no red
vegetables before surgery.
d. Record a head circumference in the
nursing care plan.
David, age 15 months, is recovering from
surgery to remove Wilms' tumor. Which
findings best indicates that the child is free
from pain?
"a. Decreased appetite
b. Increased heart rate
c. Decreased urine output
d. Increased interest in play"
"Correct: D
Answer D. One of the most valuable clues
to pain is a behavior change: A child who's
pain-free likes to play. A child in pain is less
likely to consume food or fluids. An
increased heart rate may indicate increased
pain; decreased urine output may signify
dehydration."
A child is diagnosed with Wilms' tumor. In
planning teaching interventions, what key
point should the nurse emphasize to the
parents?
1. Do not put pressure on the abdomen.
2. Frequent visits from friends and family
will improve morale.
3. Appropriate protective equipment should
be worn for contact sports.
4. Encourage the child to remain active."
Correct answer: 1. Do not put pressure on
the abdomen. Palpation of Wilms' tumor can
cause rupture and spread of cancerous
cells. Frequent visitation might allow the
child to be exposed to more infections, and
activity and sports are discouraged because
of the risk of rupture of the encapsulated
tumor.
"A child is diagnosed with Wilms' tumor.
During assessment, the nurse in charge
expects to detect:
a. Gross hematuria
b. Dysuria
c. Nausea and vomiting
d. An abdominal mass
"CORRECT: D
The most common sign of Wilms' tumor is a
painless, palpable abdominal mass,
sometimes accompanied by an increase in
abdominal girth. Gross hematuria is
uncommon, although microscopic hematuria
may be present. Dysuria is not associated
with Wilms' tumor. Nausea and vomiting are
rare in children with Wilms' tumor."
"When assessing a child with Wilm's tumor,
the nurse should keep in mind that it is most
important to avoid which of the following?
A. Measuring the child's chest
circumference
B. Palpating the child's abdomen
C. Placing the child in an upright position
D. Measuring the child's occipitofrontal
circumference
Answer: B. The abdomen of the child with
Wilm's tumor should not be palpated
because of the danger of disseminating
tumor cells. Children with Wilm's tumor
should always be handled gently and
carefully.
Other answers. The child's head and chest
measuring will not affect Wilm's tumor.
Repositioning a child in the upright position
may cause more pain to the child, but
priority this is not worse than disseminating
tumor cells."
"The mother of a 4 year old child brings the
child to the clinic and tells the pediatric
nurse specialist that the child's abdomen
seems to be swollen. During further
assessment of the subjective data, the
mother tells the nurse that the child has
been eating well and that the activity level of
the child is unchanged. The nurse,
suspecting the possibility of a Wilm's tumor,
would avoid which of the following during
the physical assessment?
1. Palpating the abdomen for a mass.
2. Assessing the urine for hematuria
3. Monitoring the temperature for presence
of fever
4. Monitoring the blood pressure for
presence of hypertension
"Answer: 1
Rationale: Wilm's tumor is the most
common intra-abdominal and kidney tumor
of childhood. If Wilm's tumor is suspected,
the tumor mass should not be palpated by
the nurse. Excessive manipulation can
cause the seeding of the tumor and spread
of cancerous cells. Fever, hematuria, and
hypertension are all clinical manifestations
of Wilm's tumor."
"A 10 year old child with hemophilia A has
slipped on the ice and bumped his knee.
The nurse should prepare to administer an:
"A. injection of factor X
B. intravenous infusion of iron
C. intravenous infusion of factor VIII
D. intramuscular injection of iron using the Z
track method"
"CORRECT: C
Hemophila refers to a group of bleeding
disorders resulting from a deficiency of
specific coagulation proteins. the primary
meds used are to replace missing clotting
factor. Factor VIII will be prescribed
intravenously to replace the missing clotting
factor and minimize the bleeding,"
A nurse is discussing childhood cancer with
the parents of a child in an oncology unit.
Which statement by the nurse would be the
most accurate?
"A. ""The most common site for
children's cancer is the bone marrow.""
B. ""All childhood cancers have a high
mortality rate.""
C. ""Children with leukemia have a higher
survival rate if they are older than 11 when
diagnosed.""
D. ""The prognosis for children with cancer
isn't affected by treatment strategies."""
"Correct: A.
Childhood cancers occur most commonly in
rapidly growing tissue, especially in the
bone marrow. Mortality depends on the time
of diagnosis, the type of cancer, and the age
at which the child was diagnosed. Children
who are diagnosed between the ages of 2
and 9 consistently demonstrate a better
prognosis. Treatment strategies are tailored
to produce the most favarable prognosis.
(NCLEX-RN Questions & Answers, made
Incredibly Easy)"
"A 4-year-old has a right nephrectomy to
remove a Wilms tumor. The nurse knows
that it is essential to:
"A. Request a low-salt diet
B. Restrict fluids
C. Educate the family regarding renal
transplants
D. Prevent urinary tract infections"
Answer D is correct. Because the child has
only one remaining kidney, it is important to
prevent urinary tract infections. Answers A,
B, and C are not necessary, so they are
incorrect.
Which condition assessed by the nurse
would be an early warning sign of childhood
cancer?
1. difficulty swallowing \
2. nagging cough or hoarseness
3. slight changes in bowel and bladder
function
4. swelling, lumps, masses on body
"Correct: 4.
Swelling or lumps or masses anywhere on
the body are early warning signs whereas
difficulty swallowing or cough or hoarseness
are signs of cancer in adults. there may be
a marked sign in changes to bowel or
bladder function, not a slight change"
"A child is admitted to the hospital with a
diagnosis of Wilm's tumor, Stage II. Which
of the following statements most accurately
describes this stage?
"A) The tumor is less than 3 cm. in size and
requires no chemotherapy.
B) The tumor did not extend beyond the
kidney and was completely resected.
C) The tumor extended beyond the
kidney but was completely resected.
D) The tumor has spread into the abdominal
cavity and cannot be resected."
"1. Answer: C
The staging of Wilm's tumor is confirmed at
surgery as follows: Stage I, the tumor is
limited to the kidney and completely
resected; stage II, the tumor extends
beyond the kidney but is completely
resected; stage III, residual
nonhematogenous tumor is confined to the
abdomen; stage IV, hematogenous
metastasis has occurred with spread
beyond the abdomen; and stage V, bilateral
renal involvement is present at diagnosis."
ABE - Acute Bilirubin Encephalopathy
ALTE - Apparent Life-Threatening Event
AGA - Appropriate for Gestational Age
ELBW - Extremely-Low-Birth-Weight
ECMO - Extracorporeal Membrane
Oxygenation
FASD - Fetal Alcohol Spectrum Disorder
HF - Hydrops Fetalis
IUGR - Intrauterine Growth Restriction
LGA - Large for Gestational Age
LBW - Low-Birth-Weight
PVL - Periventricular Leukomalacia
ROP - Retinopathy of Prematurity
SGA - Small for Gestational Age
VLBW - Very-Low-Birth-Weight
RDS - Respiratory Distress Syndrome
TTN - Transient Tachypnea of the Newborn
MAS - Meconium Aspiration Syndrome
RHIG - Rh Immune Globulin
HDN - Hemolytic Disease of the Newborn
QSEN - Quality and Safety Education for
Nurses
CROUP - Laryngotracheobronchitis
RSV - Respiratory Syncytial Virus
CHF - Congestive Heart Failure
SVT - Supraventricular Tachycardia
WPW - Wolff Parkinson-White Syndrome
ITP - Immune Thrombocytopenic Purpura
DIC - Disseminated Intravascular
Coagulation
DES - Dysfunctional Elimination Syndrome
PBS - Prune Belly Syndrome
PID - Pelvic Inflammatory Disease
PDD - Premenstrual Dysphoric Disorder
STI - Sexually Transmitted Infection
TSS - Toxic Shock Syndrome
GH - Growth Hormone
ADH - Antidiuretic Hormone
ICP - Intracranial Pressure
CP - Cerebral Palsy
CSF - Cerebrospinal Fluid