Royal College of Surgeons in Ireland - Medical University of Bahrain

Wilms tumor (nephroblastoma) is the most common renal malignancy in pediatric population, typically diagnosed before the age of 5. Vascular extension into the inferior vena cava (IVC) is seen in approximately 4-10 % of cases, but intracardiac extension, particularly into the right atrium, is exceedingly rare. Managing such advanced tumors in resource-limited settings presents major diagnostic and surgical challenges.

Herein a rare case of a 3-year-old boy presenting with a giant Wilms tumor exhibiting extensive intravascular spread. Preoperative CT scans of the chest and abdomen revealed significant invasion into the IVC with thrombus extending into the right atrium. The patient underwent neoadjuvant chemotherapy, which led to marked tumor and thrombus reduction. Intraoperatively, the tumor was found adherent to the colon and left common iliac artery but was dissected without arterial injury. A massive intravascular thrombus was identified, forming a wandering thrombus, with evidence of collateral venous drainage indicating longstanding IVC obstruction. Cavotomy was performed, and the IVC was completely transected without hemodynamic compromise due to collateralization. The surgery was uneventful, and the patient recovered in the Pediatric Intensive Care Unit (PICU).

This case highlights the complexity of managing extensive Wilms tumor thrombus with intracardiac involvement in a low-resource environment. It underscores the role of neoadjuvant chemotherapy and surgical planning in achieving curative resection.

Multidisciplinary coordination, preoperative chemotherapy, and understanding of collateral circulation allowed successful management of this rare and complex Wilms tumor case in a resource-constrained setting.

Plexiform schwannoma a rare subtype of schwannoma. Often presenting equally in males and females, especially in childhood. Although the causes are still unidentifiable, plexiform schwannomas are common in the head and neck regions. Hence, we present a case of plexiform schwannoma in a 14-year-old male with an uncommon location, specifically in the sole of the foot. Histopathological examination revealed features characteristic of plexiform schwannoma, including Antoni A and B areas, Verocay bodies and strong S100 positivity. The lesion was excised completely to reduce the risk of recurrence. Although these schwannomas are considered mostly benign, histological and immunohistochemical examination are necessary to rule out more sinister pathologies and guide management.