eMedicine Specialties > Pediatrics: General Medicine > Endocrinology

Beckwith-Wiedemann Syndrome: Follow-up

Author: Robert J Ferry Jr, MD, Chief, Division of Pediatric Endocrinology and Metabolism, Le Bonheur Children's Medical Center, University of Tennessee Health Science Center at Memphis, and St Jude Children's Research Hospital; Field Surgeon (Medical Corps), 162nd Area Support Medical Company, Army National Guard
Contributor Information and Disclosures

Updated: May 21, 2009

Follow-up

Further Inpatient Care

  • Weaning from diazoxide mandates an inpatient fasting study to ensure that the child can maintain euglycemia.
  • The tumor most commonly associated with Beckwith-Wiedemann syndrome (BWS) is Wilms tumor.
    • Once Wilms tumor has been diagnosed in a child, evaluation for a partial nephrectomy is strongly encouraged.

      Gross nephrectomy specimen shows a Wilms tumor pu...

      Gross nephrectomy specimen shows a Wilms tumor pushing the normal renal parenchyma to the side.

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      Gross nephrectomy specimen shows a Wilms tumor pu...

      Gross nephrectomy specimen shows a Wilms tumor pushing the normal renal parenchyma to the side.

    • Children with Beckwith-Wiedemann syndrome who develop cancer and are screened in intervals of fewer than 4 months display an average Wilms tumor size of approximately 3.5 cm, as opposed to a size of 11-13 cm in children who are not screened for Wilms tumor.
    • Consideration for a partial nephrectomy is important because nonmalignant renal disease and metachronous Wilms tumor carry high risk of morbidity. Imaging findings and medical records of 152 neonates, infants, children, and adults with Beckwith-Wiedemann syndrome (age range, 1 d to 30 y; median age, 15 mo) were retrospectively reviewed by 3 radiologists.5
      • Correlation to available pathologic material revealed 38 (25%) of 152 patients with Beckwith-Wiedemann syndrome had 45 nonmalignant renal abnormalities, including medullary renal cysts (n=19, 13%), caliceal diverticula (n=2, 1%), hydronephrosis (n=18, 12%), and nephrolithiasis (n=6, 4%).
      • Thirty-three (87%) of the 38 patients with nonmalignant renal disease were asymptomatic.
      • Clinical manifestations of the remaining 5 patients included urinary tract infections (n=4) and flank pain due to obstructive stone disease (n=1).
      • Nonmalignant renal disease was mistaken for Wilms tumor in 2 patients, resulting in unnecessary nephrectomies.
      • Seven children (18%) had Wilms tumor and nonmalignant renal disease.
      • Children's Oncology Group is considering a submitted protocol for conducting the partial nephrectomy trial in children with Beckwith-Wiedemann syndrome and Wilms tumor.
  • The second most common cancer occurring in patients with Beckwith-Wiedemann syndrome is hepatoblastoma.

Further Outpatient Care

  • Routinely monitor somatic growth and development at 3-month intervals.

Inpatient & Outpatient Medications

  • Neonatal hypoglycemia in patients with Beckwith-Wiedemann syndrome tends to be transient. Attempts to taper diazoxide may be initiated in the outpatient setting after age 6 months and then completed with an inpatient fasting study within a few days of discontinuing diazoxide.

Transfer

  • Maintain airway and euglycemia (with intravenous dextrose) en route to a tertiary care center.

Deterrence/Prevention

  • Screening for cancer is warranted if early identification of the tumor leads to improved survival and/or decreased morbidity associated with cancer treatment. The 2 most common cancers associated with Beckwith-Wiedemann syndrome (Wilms tumor and hepatoblastoma) meet these criteria.
  • The authors recommend screening for cancer in children with Beckwith-Wiedemann syndrome, despite the observation that cancer does not develop in most children with Beckwith-Wiedemann syndrome. Cancer develops in approximately 1 in 10 children with Beckwith-Wiedemann syndrome; however, this risk is high enough to warrant cancer screening. The risk of cancer is age-dependent; the risk is higher in patients younger than 4 years, lower in patients aged 5-10 years, and near the baseline risk of cancer in the general population in patients older than 10 years.6
  • Prenatal ultrasonography permits early detection of severely affected patients with Beckwith-Wiedemann syndrome. More critically, prenatal diagnosis allows physicians to anticipate the most serious health consequences associated with Beckwith-Wiedemann syndrome, namely, hypoglycemia and abdominal tumors.
  • The length of screening intervals for ultrasonographic examination is not well established; however, the authors believe that screening in intervals fewer than 4 months is appropriate. Screening for Wilms tumor using abdominal ultrasonography at intervals no less frequently than every 4 months was been shown in one large series to detect every case of early-stage Wilms tumor.
  • A false perception is that the screening interval can be increased from 3 months to 6 months to 12 months as a child becomes older. This is not true because Wilms tumor grows too fast to justify screening every 6-12 months. In fact, the authors have several patients who underwent screening every 6 months and were found to have late-stage Wilms tumor.
  • Using routine abdominal ultrasonography to identify tumors has proven cost effective because physical examination (eg, palpation), even by experienced professionals or well-trained parents, is ineffective for early (small) tumors, which are most amenable to resection. However, in the absence of reliable ultrasonography, physical examination is the next best screening test available.
  • Repeated ultrasonography remains highly effective for detection of abdominal masses, despite its high cost compared with the cost of physical examination. In patients with tumors identified by ultrasonographic screening, the average size of the tumor was 4 cm, as opposed to 12 cm when palpation alone was used. Prenatal genetic testing is not commercially available.
  • As with Wilms tumor, hepatoblastoma can be identified using abdominal ultrasonography. However, abdominal ultrasonography does not view the entire liver. Fortunately, alpha-fetal protein (AFP), a protein generated by fetal liver, is a suitable marker for hepatoblastoma. At birth, AFP levels are high and then gradually decline to adult levels by age 10-11 months. However, most infants with hepatoblastoma do not display a declining AFP measurement; rather, their AFP level rapidly increases. In a small case series of 5 patients with Beckwith-Wiedemann syndrome, early stage hepatoblastoma (stage 1) was identified by elevated AFP level after serial evaluation for a maximum 8 weeks.7
    • AFP levels that increase dramatically but do not continue to drop during the first year of life are worrisome. For example, an AFP level that increases from 18 ng/mL to 180 ng/mL warrants further investigation, as does an AFP level that does not decline by the time the infant is aged 6 months. When such situations occur, the authors recommend repeating the AFP measurement in about 2 weeks and considering imaging studies (eg, liver ultrasonography, CT, MRI). Reports describe several children with Beckwith-Wiedemann syndrome in whom AFP measurements were elevated yet imaging studies did not initially reveal the tumor.
    • Hepatoblastoma is also a fast-growing cancer. Because of the fast growth, the authors recommend AFP measurement every 6 weeks and ultrasonography of the liver and kidney every 12 weeks. Liver and renal ultrasonography can be performed at the same time. Unlike the risk of Wilms tumor, the risk of hepatoblastoma declines after 4 years of age; thus, screening with AFP is recommended in patients as old as 4 years. The authors see no value in conducting liver ultrasonography after age 4 years.
  • As with all screening programs, the physician and family must consider the risk-benefit ratio for the child. The authors recommend screening with AFP level until age 4 years and with ultrasonography until age 8 years, based on the observation that most but not all hepatoblastomas and Wilms tumor occur by these ages. The decision to screen beyond these ages is individual, weighing benefits against the risks. The major risk of screening is misdiagnosis of cancer that results in inappropriate surgery. The authors have experienced 3 such incidents. A cost-effective model describing the costs and benefits of screening for cancer was conducted in this population. Although imperfect, the model, coupled with available data, strongly favors screening for Wilms tumor and hepatoblastoma.8
  • Children with Beckwith-Wiedemann syndrome can develop other cancers, including neuroblastoma, rhabdomyosarcoma, or adrenocortical carcinoma. Fortunately, these cancers are rare in children with Beckwith-Wiedemann syndrome, and screening for these has no proven benefit.

Complications

  • Medical and surgical complications are possible with treatment of abdominal tumors.

Prognosis

  • Prognosis is fair and depends primarily on the status of the airway and on aggressive prevention of hypoglycemia.

Patient Education

  • Instruct parents and caregivers how to perform monthly palpation for abdominal masses. Any unusual finding should prompt professional evaluation.

Miscellaneous

Medicolegal Pitfalls

  • Regular physical examination is necessary to screen for abdominal tumors.

Special Concerns

  • Refer the child to an early childhood intervention program to reduce the risk of permanent developmental delays. Speech and occupational therapies are particularly important in light of macroglossia.
  • Commercial assays cannot detect all forms of IGF and IGF-binding proteins. The authors are happy to discuss and provide their IGF-related assays with clinicians caring for patients with Beckwith-Wiedemann syndrome (BWS).
  • Beckwith-Wiedemann syndrome has features of fetal overgrowth, organomegaly, and risk of embryonal tumors, which often overlap other conditions; however, Beckwith-Wiedemann syndrome can often be differentiated with its features of exomphalos and posterior helical pits.
    • Wilms tumor, aniridia, genitourinary defects, and mental retardation (WAGR) syndrome carries a more than 50% prevalence of Wilms tumor (compared with 5% in patients with Beckwith-Wiedemann syndrome) and is differentiated from Beckwith-Wiedemann syndrome because it is associated with 11p13 deletion or mutation of the WT1 tumor suppressor gene, aniridia, and genitourinary defects.
    • 11p trisomy is similar to Beckwith-Wiedemann syndrome because of its associated feature of fetal overgrowth but is differentiated because of associated features of a high forehead with frontal upsweep of hair, beaked nose with wide central nasal bridge, chubby cheeks, and severe mental retardation.
    • Simpson-Golabi-Behmel syndrome is similar to Beckwith-Wiedemann syndrome because of its prenatal and postnatal overgrowth, neonatal hypoglycemia, risk of embryonal tumors, and splenomegaly. Differentiating features include syndactyly, 13 ribs, slight obesity, cataract, retinal detachment, pectus excavatum, intestinal malrotation, Meckel diverticulum, hypospadias, advanced bone age, X-linked inheritance, high early perinatal and infant mortality, and cryptorchidism.
    • Sotos syndrome (cerebral gigantism) is similar to Beckwith-Wiedemann syndrome because of its autosomal dominance and macrocephaly but is differentiated by advanced bone age, neonatal hypotonia, normal growth hormone production, rapid early growth, hypothyroidism or hyperthyroidism, arm span greater than height, dolichocephaly, alveolar ridge exostoses, and generalized neonatal edema.
    • Weaver syndrome is similar to Beckwith-Wiedemann syndrome because of its features of accelerated growth, advanced bone age, and macrocephaly but is differentiated by camptodactyly, serrated gums, clinodactyly of fifth digit, and cryptorchidism.
    • Klippel-Trenaunay-Weber syndrome is similar to Beckwith-Wiedemann syndrome because of its association with mental retardation and seizure but is differentiated by glaucoma and Kasabach-Merritt syndrome. The combination of macrosomia, obesity, macrocephaly, and ocular abnormalities (MOMO) may have overlapping features with Beckwith-Wiedemann syndrome of macrosomia and macrocephaly but is differentiated by its associated morbid obesity and ocular abnormalities.
 


More on Beckwith-Wiedemann Syndrome

Overview: Beckwith-Wiedemann Syndrome
Differential Diagnoses & Workup: Beckwith-Wiedemann Syndrome
Treatment & Medication: Beckwith-Wiedemann Syndrome
Follow-up: Beckwith-Wiedemann Syndrome
Multimedia: Beckwith-Wiedemann Syndrome
References
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Further Reading

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Keywords

Beckwith-Wiedemann syndrome, BWS, exomphalos, macroglossia, congenital exomphalos, congenital macroglossia, gigantism syndrome, EMG syndrome, Wilms tumor, omphalocele with macroglossia, hepatoblastoma, organomegaly, hypoglycemia, anterior abdominal wall defects, helical indentations, organ overgrowth, nephromegaly, hemihypertrophy, genitourinary abnormalities, embryonal tumors, adrenocortical neoplasias, treatment, diagnosis

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Contributor Information and Disclosures

Author

Robert J Ferry Jr, MD, Chief, Division of Pediatric Endocrinology and Metabolism, Le Bonheur Children's Medical Center, University of Tennessee Health Science Center at Memphis, and St Jude Children's Research Hospital; Field Surgeon (Medical Corps), 162nd Area Support Medical Company, Army National Guard
Robert J Ferry Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Diabetes Association, American Medical Association, Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, Society for Pediatric Research, and Texas Pediatric Society
Disclosure: Nutropin Speakers Bureau Honoraria Speaking and teaching; Genotropin Speakers Bureau Honoraria Speaking and teaching; Eli Lilly & Co. Grant/research funds Independent contractor; MacroGenics, Inc. Grant/research funds Independent contractor; Ipsen, S.A. (formerly Tercica, Inc.) Grant/research funds Independent contractor

Medical Editor

Phyllis W Speiser, MD, Chief of Pediatric Endocrinology, Schneider Children's Hospital; Professor of Pediatrics, New York University School of Medicine
Phyllis W Speiser, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, Endocrine Society, Lawson-Wilkins Pediatric Endocrine Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Barry B Bercu, MD, Professor, Departments of Pediatrics, Molecular Pharmacology and Physiology, University of South Florida College of Medicine, All Children's Hospital
Barry B Bercu, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Federation for Clinical Research, American Medical Association, American Pediatric Society, Association of Clinical Scientists, Endocrine Society, Florida Medical Association, Lawson-Wilkins Pediatric Endocrine Society, Pituitary Society, Society for Pediatric Research, Society for the Study of Reproduction, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD, Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas and Arkansas Children's Hospital
Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, and Southern Society for Pediatric Research
Disclosure: Genentech, Inc. Honoraria Speaking and teaching; Pfizer, Inc. Honoraria Consulting

 
 
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