The patient is an 1 I-year-old girl with a 6-month history of lethargy, decreased appetite with 20 pound weight loss (17% of body weight), weakness, and anemia. One week earlier, she developed symptoms of a urinary tract infection with a high fever. An excretory urogram and abdominal CT were consistent with a left-sided intrarenal mass. The right kidney was functional. Chest films were negative. The left kidney and about 20 perirenal nodes were removed using a transthoracic approach. The pathology was consistent with a well-differentiated Stage I Wilms' tumor. She was started on vincristine and dactinomycin.
Postoperatively, she complained of lower back pain. This persisted for several weeks and tenderness was elicited over the lower vertebral column, but she complained of tenderness to examination almost everywhere. Rectal examination at that time revealed good sphincter tone, but spinal films showed wedging of T1 1 . The pain increased during the next week. Rectal examination 1 week later revealed poor sphincter tone, and a bone scan revealed increased uptake in LI and in the left 12th rib adjacent to the surgical site. An emergency MRI dernonstrated destructive lesions at TI I , L1, and L2, with an epidural mass compressing the spinal canal.
An open biopsy of the pedicle of L1 was performed. Pathology demonstrated that the lesion was consistent with a treated Wilms' tumor. High-dose steroids and radiation therapy were initiated. A large portion of the right kidney and a small portion of the apex of the heart were within the radiation field. She had a good response and within several days had markedly decreased back pain and no progression of her neurologic symptoms. However, the biopsy site became infected with Stuphylo- coccus aureus, was drained, and IV antibiotics were given. Hyperalimentation (HAL) was started because of poor wound healing. Appreciable weight gain and good wound healing repair resulted.