Renal cell carcinoma in children: A clinicopathologic study of 15 cases and review of the literature

358

March, I970 T h e J o u r n a l of P E D I A T R I C S

Renal cell carcinoma in children: A cli n icopa t hologic study of 15 cases and revie of the literature Renal cell carcinoma is an uncommon tumor in children. For this reason, the clinical and pathologic features have not been fully appreciated. Fifteen cases from the files of the Armed Forces Institute of Pathology represent the largest series of this entity studied to date. When the tumor occurs in children it usually makes its appearance in mid-childhood and presents with hematuria and flank or abdominal pain. The presence of renal vascular invasion by tumor and absence of a fibrous pseudocapsule are the most ominous anatomic features o] renal cell carcinoma in children.

Louis P. Dehner, Lieutenant (MC) USN, Jan E. Leestma, Major, USAF ( M C ) , and E. B. Price, Jr., M.D. "vVASHINGTON~

D.

C.

R E N A L C E L L C A R C I N O M A is generally considered to be rare in children; in the past some authorities have doubted its occurrence during childhood?, 2 During the past 25 years, however, a number of case reports have appeared in the literature, but the pathologic features and the behavior of these tumors in children have not been well documented. From the Director's Laboratory, the Genitourinary Pathology Branch, and the Registry of Pediatric Pathology, Armed Forces Institute of Pathology, and the Veterans Administration Special Reference Laboratory for Pathology at the AFIP. The opinions or assertions contained herein are the private uiews of the authors and are not to be construed as official or as reflecting the views of the Departments o~ the Army, Navy, Air Force, or Defense. Vol. 76, No. 3, pp. 358-368

This paper will review the clinical and anatomic aspects of renal cell carcinoma in children. Published cases of renal cell carcinoma will be critically reviewed and compared with the cases in this study. M A T E R I A L S AND M E T H O D S The 15 cases of renal cell carcinoma in children under the age of 15 years are ~rom the Kidney T u m o r Registry and the Registry of Pediatric Pathology of the American Registry of Pathology. Clinical records, surgical pathology reports, roentgenograms when available, and histologic sections were reviewed. Follow-up information was obtained in 14 cases. To our knowledge, 2 of the cases in this study have been reported previously: Case 8 by Robertson and asso-

Volume 76 Number 3

ciates 8 and sociates#

R e n a l cell carcinoma

Case

15 by H a r a

and

as-

RESULTS Clinical findings. T h e ages of the 15 patients in this study ranged from 3 to 14 years, with a mean age of 9 years. Nine patients were male. Except for one Mongolian and one Negro, all of the patients were Caucasian. Nine patients (60 per cent) reported episodes of painless gross hematuria (Table I), which had been present for 5 weeks or less in 7 patients. The cause of intermittent gross hematuria in one patient remained obscure, despite numerous diagnostic studies, until diagnosis was established by surgical exploration. Fever, flank pain, and vague gastrointestinal symptoms were other, less frequent complaints. Three patients gave a history of t r a u m a shortly before the appearance of the symptoms of the tumor. Symptoms were present for 1 month or less in 9 patients (60 per cent), for 1 to 6 months in 2, and for more than 6 months in 2 others. Information about the duration of symptoms was not available in the remaining two patients. Physical examination disclosed the presence of a palpable, tender, smooth abdominal or flank mass in 7 patients. One child had pretibial edema. Laboratory findings. Information about a hemogram and urinalysis was available in 11 patients. Two patients had a moderate degree of leukocytosis (11,000 and 14,000

Table I. Clinical features of renal cell carcinoma in 15 children Symptom or sign

No. o/ patients (total 15)

l:Iematuria Abdominal or flank pain Abdominal or flank mass Nausea and vomiting Fever Weight loss Anemia Night sweats Lumbar pain

9 8 7 4 4 3 2 1 1

359

white blood cells per cubic millimeter); both of these patients had a history of intermittent febrile episodes. Four patients were anemic, with hemoglobin values of 8 to 10 Gm. per 100 ml. No patient had polycythemia. At the time of admission, 5 patients had gross hematuria, and 4 others had microscopic hematuria. None of the urinary sediments examined contained casts or leukocytes. Six patients had blood urea nitrogen determinations that were within normal limits. Radiologic findings. Twelve patients had one or more radiographic examinations, including intravenous pyelography and skeletal surveys. T h e original films were available for study in 2 cases. In the other cases, radiographic data were obtained from the clinical records. The most frequent radiographic change was distortion and blunting of the calyceal system on the affected side. A fine, speckled calcification in the area of the tumor was identified in three cases. The kidney on the involved side was enlarged in two cases. One patient on initial examination had an osteolytic metastatic growth in the second lumbar vertebra. Peritracheal and peribronchial lymphadenopathy was identified on the initial radiograph of the chest of a 10-year-old boy who was found at postmortem examination to have metastatic tumor to these lymph nodes. Gross pathologic findings. Nine tumors were in the left kidney; 5 were in the right (Table I I ) . The side of involvement was not specified in 1 patient's clinical record. Information about the weight of the involved kidney was available in 7 cases, in 4 of which the kidney weighed more than 200 grams. T h e largest kidney weighed 720 grams and contained a 12 cm. tumor. The tumors arose in all portions of the kidney, with no particular predilection for site. The smallest tumor measured 1.3 c m . in diameter. T h e tumor-containing portion of the kidney was irregularly contoured in 10 cases. The renal capsule was densely adherent to the renal cortex overlying the tumor in these same 10 tumors. None of the tumors extended through the renal capsule. In two

3 60

Dehner, Leestma, and Price

The Journal of Pediatrics March 1970

T a b l e I I . M o r p h o l o g i c f e a t u r e s a n d f o l l o w - u p of 15 cases of r e n a l cell c a r c i n o m a in c h i l d h o o d

I

Case

Age

Side

1

14

L

2

14

--

3

6

4

Size

Cell type and pattern

Location

Presence Renal psf~dovascular invasion capsule

Middle third

Clear cell; papillary

No

5 cm.

Lower pole

Clear cell; papillary

No

Yes

15 yr.; living and well

L

5.5 cm.

Upper pole

Granular cell; papillary

Yes

Slight

20 too.; dead of metastasis

4

R

10 cm., Upper and Clear ceil; papillary, 435 Gm. middle third trabeeular, and tubular

No

Yes

15 yr.; living and well

5

7

L

1.3 cm., Lower pole 99 Gm.

Granular and clear cell; trahecular and papillary

Yes

Yes

2 yr.; dead of metastasis

6

5

R

7.5 cm., Upper pole 203 Gin.

Clear ceil; trabecular and tubular

No

Yes

9 yr. ; living and well

7

13

L

5 cm.

Middle third

Clear cell; papillary

Yes

Yes

13 mo.; dead of metastasis

8

3

L

3.5 cm., Middle third 80 Gin.

Clear cell; papillary

No

Yes

9 yr.; dead of ruptured appendix. No metastatic growths seen

9

5

L

12 cm., Middle and 720 gm. lower third

Clear ceil; trabecular and tubular

No

Yes

9 yr. ; living and well

10

12

L

3 cm.

Clear cell; papillary

No

Yes

7 yr. ; }iving and well

ll

10

R

5 cm., Lower pole 680 Gm.

Granular cell; papillary

Yes

Slight

19 mo.; dead of metastasis

12

8

L

2.5 cm, Lower pole 125 Gm.

Clear cell; trabecular

No

Yes

5 yr. ; living and well

13

13

R

7.5 cm.

Middle and lower third

Clear cell; trabecular and tubular

No

Yes

5 yr. ; living and well

14

14

L

Total replacement

Granular cell; papillary

Slight

Lost to follow-up

15

3

R

Upper pole

Clear cell; papillary

Yes

4 yr. ; living and weI1

Upper pole

No

No

Length of ]ollow-up and status 5 too.; dead of metastasis

eMaterlal inadequate to evaluate renal vascular invasion.

t h i r d s of t h e cases, t h e c u t s u r f a c e of t h e t u m o r a p p e a r e d soft, n e c r o t i c , yellowish, a n d p a r t i a l l y h e m o r r h a g i c . F o u r of t h e t u m o r s w e r e well c i r c u m s c r i b e d , w h e r e a s 5 h a d ext e n d e d i n t o t h e ,renal pelvis. R e n a l v e i n inv a s i o n was identified in 4 cases (27 p e r cent).

Microscopic a p p e a r a n c e . T h e t u m o r s h a d a p a p i l l a r y (Fig. 1), t u b u l a r , o r t r a b e c u l a r p a t t e r n , o r a m i x t u r e of t u b u l a r a n d t r a b e c u l a r p a t t e r n s (Fig. 2). T h e c y t o p l a s m was e i t h e r c l e a r o r h a d a n a m p h o p h i l i c g r a n u l a r a p p e a r a n c e . E l e v e n t u m o r s (73 p e r cent) w e r e c o m p o s e d e n t i r e l y o f c l e a r cells

Volume 76 Number 3

R e n a l ceil carcinoma

36 1

Fig. 1. Papillary renal cell carcinoma composed predominantly of granular cells. There is a minimal amount of fibrovascular stroma. (AFIP Neg. 69-437. x35.)

(Fig. 2), 3 tumors were composed entirely of granular cells (Fig. 1), and one tumor had a mixture of the 2 cell types. T h e nuclei of the clear cells were regular and small without mitotic figures; nuclear pleomorphism and mitotic activity were limited to the tumors composed of granular cells. The tumor cells were characteristically cuboidal or columnar except in focal areas where the cells were closely packed and had a spindle appearance (Fig. 3). The clear cells were rich in glycogen and lipid as shown by Best's carmine and oil red O stains. T h e papillary portions of the tumors were characterized by a delicate fibrovascular stroma, whereas the supporting stroma of the tubular and trabecular portions was inconspicuous. P s a m m o m a bodies were conspicuous only in papillary areas. Eleven tumors (73 per cent) had fibrous pseudocapsules and accompanying fibrous bands extending through and around the masses of "tumor cells. Atrophic glomeruli

and tubules were noted in the pseudocapsule (Fig. 4). Amorphous masses of calcium or ealcospherites could also be seen in the fibrous network. The compressed renal parenchyma adjacent to the capsule often contained a moderate to very dense chronic lymphocytic inflammatory infiltration. The tumors without the pseudocapsule invaded and infiltrated the adjacent renal parenchyma with only a moderate i n f l a m m a t o r y reaction. Sites of metastasis. A postmortem examination was carried out on 3 of the 5 patients who died of metastatic renal cell carcinoma. Metastatic growths were generally multiple in the organs involved. The tumor deposits were grayish tan to yelloW, with var: iable amounts of hemorrhage and necrosis. The skeletal metastatic growths were very hemorrhagic. The liver, the lungs, and the periaortic lymph nodes were the most common sites of metastasis and were found in all 3 patients. Anterior mediastinal and peri-

362

Dehner, Leestma, and Price

The Journal of Pediatrics March 1970

Fig. 2. Clear cell renal carcinoma with a mixed tubular and trabecular pattern. Focal areas of hemorrhage may be prominent. (AFIP Neg. 69-663. •

Fig. 3. Renal cell carcinoma with compressed clear cells imparting a spindle cell appearance to the tumor. This pattern may be confused with that of spindle cell sarcoma. (AFIP Neg. 69-664. x130.)

Volume 76 Number 3

Renal cell carcinoma

36 3

Fig. 4. Renal cell carcinoma adjacent to the relatively acellular pseudocapsule with residual obsolescent glomeruli. (AFIP Neg. 69-661. x40.)

bronchial lymph nodes and the vertebral column were the next most frequent sites. T h e r e was one example each of invasion of the inferior vena cava with metastatic loci in the adrenal and pancreas. T h o u g h the p r i m a r y t u m o r in 2 of the 3 cases was composed of granular cells, the metastatic tumors histologically were }olid sheets of clear cells, with little tendency to form papillary, trabecular, or tubular patterns. P s a m m o m a bodies and amorphous calcium deposits were not seen outside the p r i m a r y t u m o r in the kidney. TREATMENT

All of the patients were treated by nephrectomy; 4 of them received radiation therapy for palliation at some point in the clinical course; 2 of the 3 patients had demonstrable, metastatic growths preoperative-

Table I I I . Patient survival at last known status

Status Living and well Dead with tumor Dead, no evidence of tumor Lost Total

No. of 1 patients 8 5 1 1 15

% 53 33 7 7 100

ly. Each patient received 5,000 to 6,0,00 r to the flank and abdominal area. C O R R E L A T I O N OF C L I N I C A L AND P A T H O L O G I C F E A T U R E S WITH SURVIVAL DATA Eight patients are living without signs of recurrence or metastasis for a period of 4 to 15 years following treatment (Tables I I

3 64

Dehner, Leestma, and Price

The Journal o[ Pediatrics March 1970

and I I I ) . T h e crude 5 year survival is 57 per cent, and the actuarial survival, excluding one patient lost to follow-up, is 64 per cent at 3 years (Fig. 5). Those developing metastasis did so within 2 years of p r i m a r y treatment. O n e patient died of unrelated

causes 9 years following surgery; autopsy revealed no evidence of carcinoma. Factors that appeared to correlate with survival were duration of symptoms, histologic pattern, pseudocapsule formation, and absence of renal vascular invasion. T h e pa-

I00~ ~ e , \

k.

80 70

e.~

60 e---eAuthors' Coses (14)

:

5q

0

:L/terature Coses (18)

I I

I 2 YEARS

AFTER

I 3 D/AGNOS/S

I 4

I 5

Fig. 5. Actuarial survival of 14 cases in the present study, excluding 1 case lost to follow-up, and 18 cases from the literature, of renal cell carcinoma in childhood.

Fig. 6. Papillary carcinoma occluding small intrarenal vessel. (AFIP Neg. 69-657. •

Volume 76 Number 3

R e n a l ceil carcinoma

365

c l e a r cells w i t h a m i x e d t r a b e c u l a r a n d t u bular pattern had a better prognosis than t h o s e h a v i n g a p a p i l l a r y t u m o r c o m p o s e d of g r a n u l a r cells. E i g h t y p e r c e n t of t h e p a tients were alive at the end of the follow-up i n t e r v a l in t h e f o r m e r g r o u p , a n d o n l y o n e

t i e n t s w h o h a d s y m p t o m s f o r 1 w e e k o r less or longer than 6 months had a far better p r o g n o s i s (85 p e r c e n t s u r v i v a l ) t h a n p a tients with symptoms that had persisted for f r o m 1 to 6 m o n t h s (45 p e r c e n t s u r v i v a l ) . P a t i e n t s w h o s e t u m o r s w e r e c o m p o s e d o,f

T a b l e I V . R e n a l cell c a r c i n o m a i n c h i l d h o o d : A r e v i e w of 32 cases f r o m t h e literature

Author(s)

Year

Age (yr.)

Boyd and Lisa ~

1934

8

McCurdy6

1934

2

Nicholls s, 9

1936, 1960

1~

Size (cm.) 10

--

Cell type and pattern

Length of follow-up and status

Mixed granular and Dead on arrival clear cell; papillary Tumor embolus Mixed granular and clear cell ; papillary

1 wk.; dead of metastasis

Clear cell; papillary

24 yr. ; living and well

KalSlan et al. 1~

1952

8

6

Clear cell

He mps.tead et al. 11

1953

8 I4

15 8

Clear cell; papillary Clear cell; papillary

8 mo. ; living and well I yr.; dead of metastasis

Beattie v,'

1954

7

10

Clear cell

2 yr. ; living and well

Carlson13

1955

9

Johnson and Marshall 14

1955

18

Clear cell

8 too. ; living and well

2 2~ 15 11 89 11 ~2

------

Papillary Papillary Papillary Clear cell Clear cell

4 wk.; dead of metastasis 4 ~ yr. ; living and well I yr,; dead of metastasis

--

Clear cell; papillary

3 ~ yr.; dead of metastasis

CurriO~

1955

6

Del Pobil y Bensusan r6

1955

1

5

Clear cell

Clinton-Thomas and RobinsorY

1956

10

9

Granular and clear cell

Reiser and Creevy as

1956

6

Clear cell; papillary

Stout 19

1957

14

8~/2

Clear cell; papillary

Mogg~O

195 7

I0

--

Clear cell

Klinger and DeLeon 2x

1957

I1

--

Clear cell; papillary

Hogan and Simons 22

1957

5

2~

2 ~ yr. ; living and well

6 wk.; dead o,f metastasis

8 too.; dead of metastasis

3

Clear cell

2 yr. ; living and well

6

Clear cell

1 ~ yr. ; living and well

Marcial-Rojas et al. 23

1958

8

Nourse and Yurdin 24

1959

12 14

Cresson and Pilling 25

1959

8 11

10 5.5

Clear cell Clear cell

6 mo.; dead of metastasis 6 yr. ; living and well

Scruggs and Ainsworth~

1961

9 9

5 --

Clear cell Clear cell

1 yr. ; li,Ang and well 6 days; postoperative death

"850 gm." Clear cell; papillary 13 Clear cell

Woodward 26

1961

11

5

Clear cell

6 yr. ; living and well

Borovoy and Rome 27

1963

10

4~

Clear cell

8 mo. ; living and well

Holtz 28

1963

4

Clear cell; papillary

5 yr. ; living and well

Marcus and W a t t 29

1966

7 89

Clear cell

2 yr. ; living and well

3~2 10

366

Dehner, Leestma, and Price

of the latter group (Table I I ) . Nine of the 11 patients (82 per cent) whose tumors had a well-formed fibrous pseudocapsule did not have recurrent disease at last contact, whether the patient was dead or alive. Patients with tumors judged to have poorly formed or lacking pseudocapsules had a much poorer chance of survival (Table I I ) . All patients whose tumors demonstrated vascular invasion died of tumor (Fig. 6). Those patients whose tumor-bearing kidney was free of vascular invasion were living and well. The presence or absence of a palpable abdominal or flank mass on the initial physical examination did not influence the prognosis, The size and location of the tumor also did" not correlate with survival. Specific dimensions were given for 12 of the tumors. T h e smallest tumor in the series measured 1.3 cm., and the patient with this tumor died of metastasis 2 years after surgery. T h e patient who had the largest tumor (12 cm.) was alive without disease 9 years after operation. DISCUSSION

The earliest well-documented discussions of renal cell carcinoma in children in the English and American literature were by Boyd and Lisa 5 and McCurdy ~ in 1934. By 1961, 51 cases had been described, 7 but a number of these are poorly documented, and repeated citation in reviews only adds confusion. Thirty-two cases Table I V ) have been found suitable for eview in the available literature from 1934 through 1966. T h e criteria for acceptance were similar to those that were applied to the study group. These included adequate clinical documentation, specific localization o.f the tumor to the kidney, and clear-cut histologic documentation, preferably with photomicrographs. T h e youngest patient in our series was 3 years of age, whereas the youngest in the literature was 1 year of age. 21 Most children were 9 years or older at the hme of diagnosis. Perusal of all the cases, including those in our study group and those in the Iitera-

The Journal of Pediatrics March 1970

ture, revealed no sex predilection, but the overwhelming number of patients were Caucasian. Hematuria, fever, weight loss, colicky abdominal pain, and gradual abdominal enlargement were the most common clinical manifestations. Episodic hematuria led to a clinical diagnosis of glomerulonephritis in two cases. Asymptomatic tumors were sometilnes found fortuitously on physical examination. Three patients from the study group and two from the literature came to medical attention as a result of trauma. The tumors in all these patients were large and thus more prone to injury. Painful bony metastatic lesions and exophthalmos have been other less common presenting symptoms. A tender abdominal or flank mass was the most frequent physical finding, both in our series and in the cases from the literature. Hypochromic anemia and the presence of hematuria m a y be the only clues provided by the laboratory examination. The radiographic examination is much more revealing, in that an abnormality is detectable in nearly 100 per cent of cases. A mass with distortion of the calyceal system is the usual finding on intravenous pyelography; retrograde pyelography was necessary in 10 per cent of patients because of a nonfunctioning kidney. Plane films of the abdomen disclosed speckled calcifications in the kidney region in t5 to 25 per cent of recorded examples. The differential diagnosis of a renal mass in children is often restricted to a consideration of Wilms' tumor and neuroblastoma. While this is undoubtedly true for very young children, the possibility of renal cell carcinoma merits serious consideration in older children. This study has shown that the single most important anatomic feature indicative of prognosis was the presence or absence of vascular invasion. In addition, tumors having a papillary pattern composed of granular cells tended to have a poorer prognosis than the tubular-trabecular clear cell pattern. Apparent pseudoencapsulation of the tumor by compressed atrophic renal parenchyma correlated well with good progno-

Volume 76 Number 3

sis. Features of no prognostic significance included calcification, site a n d size of the t u m o r i n the kidney, a n d side of involvement. T h e actuarial survival of the study group a n d the literature coincided r a t h e r closely (Fig. 5 ) . T h e over-all survival for both groups was 64 per cent, which is slightly more favorable t h a n the figures ;for renal cell c a r c i n o m a in the adult given by K a y 3~ a n d by Fetter a n d Snyder, 31 49 per cent a n d 52 per cent, respectively. It remains a moot point whether one calls these tumors renal cell carcinomas or adenomas, since it is impossible to predict their biologic behavior on morphologic grounds. Vascular invasion is certainly a very suggestive p o i n t in favor of m a l i g n a n t potential. O n l y c o n t i n u e d observation of the p a t i e n t will resolve the individual problem. SUMMARY

T h e clinical a n d pathologic features of 15 renal cell carcinomas, a t u m o r of the kidney t h a t is u n c o m m o n in the pediatric age group, are described. T h e age distribution, with some overlap, is different from t h a t of the more c o m m o n l y occurring flank tumors of childhood, Wilms' tumor, a n d neuroblastoma. T h e symptoms are usually of short duration, with i n t e r m i t t e n t painless gross h e m a t u r i a being the most c o m m o n symptom. A radiographic defect is n e a r l y always present in the affected kidney. T h e size of the tumors varies considerably, a n d size alone is a poor indicator of subsequent behavior. Histologically, these are either clear cell or g r a n u l a r cell tumors with a papillary or a mixed t r a b e c u l a r a n d t u b u l a r p a t t e r n . T h e development of a pseudocapsule a b o u t the t u m o r a n d the absence of renal vascular invasion were the morphologic features t h a t correlated best with survival. T h e actuarial survival at 3 years is 64 per cent, a n d there were no deaths from t u m o r 2 or m o r e years after surgery. REFERENCES

Gross, R. E.: The surgery of infancy and childhood, Philadelphia, 1953, W . B. Saunders Company, p. 592.

R e n a l cell carcinoma

367

2. Bell, E. T.: Renal diseases, Philadelphia, 1950, Lea & Febiger, Publishers, p. 433. 3. Robertson, D. M., Kipkie, G. F., and Berry, N. E.: Urogenital tract tumors occurring in unusual age groups: Report of two cases, J. Urol. 82: 26, 1959. 4. Hara, S., Bradley, D. V., Brown, H. P., and Crump, E. P.: Hypernephroma in a threeyear-old negro boy, Amer. J. Dis. Child. 116: 559, 1968. 5. Boyd, C. S., and Lisa, J. R.: Primary carcinoma of the kidney in childhood. Review of literature, case report with necropsy, J. PEDIAT. 5: 608, 1934. 6. McCurdy, G. A.: Renal neoplasms in childhood, J. Path. Bact. 39: 623, 1934. 7. Scruggs, C. D., and Ainsworth, T.: Renal cell carcinoma in children: Review of the literature and report of two cases, J. Urol. 86: 728, 1961. 8. Nicholls, M. F.: Carcinoma of the kidney in an infant, Proc. Roy. Soe. Med. 29: 372, 1936. 9. Nicholls, M. F.: The behavior of tumors, J. Roy. Coll. Surg. Edin. 5: 253, 1960. 10. Kaplan, J. H., Hadley, H. L., and Bergman, R. T.: Hypernephroma in an 8-year-old child, Calif. Med. 76: 297, 1952. 11. Hempstead, R. H., Dockerty, M. B., Priestley, J. T., and Logan, G. B.: Hypernephroma in children: Report of two cases, J. Urol. 70: 152, 1953. 12. Beattie, J. W.: Hypernephroma in seven-yearold white girl, J. Urol. 72: 625, 1954. 13. Carlson, H. E.: Hypernephroma in children, Trans. South Central Sect. Amer. Urol. A. 1955, p. 9. 14. Johnson, S. H., and Marshall, M.: Primary kidney tumors of childhood, J. Urol. 74: 707, 1955. 15. Currie, J. A.: Hypernephroma in a child of five years, S. Aft. Med. J. 29: 730, 1955. 16. Del Pobil y Bensusan, J. P.: Hipernefroma en una nina de once anos, Cirg. Ginecol. Urol. 9: 128, 1955. 17. Clinton-Thomas, C. L., and Robinson, T. M.: Adenocarcinoma of the kidney in childhood: Report of a case and a review of the literature, Brit. J. Urol. 28: 132, 1956. 18. Reiser, M. P., and Creevy, C. D.: Hypernephroma in infancy and childhood, Minn. Med. 39: 539, 1956. 19. Stout, G.: Carcinoma of kidney in a boy aged fourteen years, Brit. J. Urol. 29: 147, 1957. 20. Mogg, R. A.: Rare renal tumors: With special reference to those occurring in children, Brit. J. Urol. 29: 287, 1957. 21. Klinger, M. E., and DeLeon, V. M.: Hypernephroma in a child, Amer. J. Surg. 94: 966, 1957. 22. Hogan, J. F., and Simons, C. E.: R e n a ! ~ l l adenocarcinoma in a five-year-old girl with reduplicated collecting system and ectopic ureter opening into urethra, J. Urol. 78: 212, 1957. 23. Marcial-Rojas, R. A., Rodriguez-Lucca, B., and Alonso, R.: Renal cell adenocarcinoma in

3 68

24, 25. 26.

27.

Dehner, Leestma, and Price

Children. Report of a case, Amer. J. Dis. Child. 96: 744, 1958. Nourse, M. H., and Yurdin, D. H.: Renal celI carcinoma in children, J. Urol. 82: 21, 1959. Cresson, S. L., and Pilling, G. P.: Renal tumors, Pediat. Clin. N. Amer. 6: 473, 1959. Woodward, W. W.: Clear cell renal tumor: Report with commentary of an example found in a boy aged 11 years, Brit. J. Urol. 33: 63, 1961. Borovoy, B., and Rome, L. P.: Hyper-

The Journal of Pediatrics March 1970

28. 29. 30. 31.

nephroma in a 10-year-old child, Amer. J. Dis. Child. 105: 85, 1963. Holtz, F.: Renal cell carcinoma in a child: Report of a case simuIating glomerular nephritis, Univ. Mich. Med. Bull. 29': 49, 1963. Marcus, R., and Watt, J.: Renal carcinoma in children, Brit. J. Urol. 53: 351, 1 9 6 6 . Kay, S.: Renal carcinoma. A 10-year study, Amer. J. Clin. Path. 50: 428, 1968. Fetter, T. R., and Snyder, A. I.: Survival study in renal cell carcinoma, Surg. Gynec. Obstet. 117: 7, 1963.