Results of surgical treatment of renal cell carcinoma with solitary metastasis

To determine the effect on survival of excision of a solitary metastasis from renal cell carcinoma, the records of 29 patients seen at our institute within the last 15 years (1972 to 1986) who underwent such an operation were reviewed. Metastasis was present at diagnosis in 11 of the 29 patients, while 18 had metastasis 2 months to 11 years after nephrectomy, with an average interval free of disease of 38 months. There were 13 pulmonary metastases, 6 bone lesions and 10 other lesions. The estimated over-all survival rate for this group was 41 per cent at 2 years and 13 per cent at 5 years after excision of the metastasis. Only 2 of the 29 patients currently are alive with no evidence of disease 42 and 53 months since excision of the metastasis. Neither the presence nor absence of a metastasis at diagnosis nor the interval between nephrectomy and the development of a metastasis in patients without metastatic disease at diagnosis appeared to influence survival after excision of the metastasis. Unlike previous reports, these results suggest that the beneficial effects of excision of metastatic renal cell carcinoma are limited to improved short-term survival postoperatively and that surgical cure of patients with metastatic renal cell carcinoma is a relatively uncommon event.     

小肾癌同期远处转移4例报告并文献复习

目的结合病例及文献就小肾癌同期发生远处转移相关因素、常见转移部位及诊断治疗策略做一介绍,提高对小肾癌同期发生远处转移的认识。方法回顾性分析西安交通大学第一附属医院泌尿外科肾癌患者临床资料,共发现4例小肾癌同期转移:患者均为男性,年龄40~68岁。影像学检查提示肾肿瘤直径均小于4cm,肺部、对侧肾上腺及全身多处骨骼发现转移病灶。所有患者临床诊断均为T1aN0M1。结果 4例患者分别行肾部分切除术、肾切除术、肋骨转移灶切除术、肾上腺转移瘤切除术及肾动脉栓塞术,术后给予分子靶向及细胞因子治疗;术后病理结果为透明细胞癌Ⅱ~Ⅲ级;术后随访:1例患者良好,未发现局部进展及转移病灶,1例失访,2例患者死亡,其中1例病情进展,死于多器官功能衰竭,另1例死亡原因不明。结论小肾癌同期远处转移并不罕见,特别是病理诊断为高度恶性,微血管侵犯及病理类型为肉瘤样、乳头状和嫌色细胞癌的患者。小肾癌同期发生远处转移者治疗效果远较无同期转移者差,预后主要取决远处转移部位、病理分级和病理类型。     

Solitary, late metastatic recurrence of renal cell carcinoma: Two extraordinary cases

Late recurrence of renal cell carcinoma (RCC) has been well documented in the literature. We present two extraordinary cases of solitary, late metastatic recurrence of RCC. The first is a case of a solitary, adrenal metastasis excised 38 years after nephrectomy and the second is a case in which two solitary metastatic deposits were resected 14 and 26 years after excision of the primary tumor. In each of these patients the solitary metastases were initially believed to be primary tumors at other sites; however, on histological examination they were found to be metastatic RCC recurrences. In patients with a previous history of RCC presenting with apparently new solitary lesions, metastatic RCC must first be excluded.     

Ring-enhanced malignant meningioma mimicking a brain metastasis from a renal cell carcinoma

We report a case of ring-enhanced malignant meningioma mimicking a solitary brain metastasis in a patient with renal cell carcinoma. This misleading situation is rarely encountered and has not been documented previously. Considering the low incidence of brain metastases from a renal cell carcinoma staged T1-2 without systemic metastases, a clinical diagnosis requires circumspection, and both primary and metastatic tumors should be considered when a solitary brain lesion is encountered.     

PULMONARY NODULES IN PATIENTS WITH A HISTORY OF RADICAL NEPHRECTOMY FOR RENAL CELL CARCINOMA

Background:
Nine patients with a history of radical nephrectomy for renal cell carcinoma underwent surgical removal of newly detected pulmonary nodules at the Hiroshima University Hospital. Six patients had metastatic lung tumors two patients had bronchogenic primary carcinomas and one had a granulomatous infection.
Methods:
To determine if any characteristics can distinguish a new primary carcinoma from metastatic renal cell carcinoma, we reviewed the nine patients described above. The patients with pulmonary metastases and those with new primary lung cancers did not differ in age, sex, history of smoking, clinical stage and pathological findings of the renal primary site, on the location and size of the pulmonary nodules.
Results:
Only the interval between the nephrectomy and the appearance of the new pulmonary lesion may be a predictive factor. This interval was 48 and 51 months for the patients with new primary lung cancers but varied from 0 to 39 months for the patients with metastatic renal cell carcinoma. A solitary nodule had an equal chance of being metastatic or primary. Conclusions: These results indicate that a solitary nodule that is detected at a longer inferval after radical nephrectomy may be a new primary lung cancer. Once new pulmonary nodules are identified in a patient with a history of radical nephrectomy for renal cell carcinoma, surgical excision is required for a final diagnosis before initiating therapy for metastases.     

Treatment of osseous metastases in patients with renal cell carcinoma

The records of 99 patients treated at one institution for osseous metastases secondary to renal cell carcinoma were reviewed. Patients were followed up for at least 24 months or until death. Survival was analyzed with respect to age, gender, disease-free interval, location of osseous metastases, number of osseous metastatic sites, resection of osseous metastases, and primary tumor resection. The mean age of the 72 men and 27 women was 60 years (range, 34-82 years) and the mean followup was 20 months (range, 2-81 months). Twenty-six patients (26%) had a solitary osseous metastasis, 47 patients (48%) had multiple osseous metastases, and 26 patients (26%) had additional visceral involvement such as the lung and brain at the time of diagnosis. In 49 patients (49%), the renal cell carcinoma was diagnosed concurrently with detection of the osseous metastasis. The presence of one osseous renal carcinoma metastasis, wide resection of the lesion, and a history of nephrectomy were identified as independent predictors of survival in patients with renal cell carcinoma. The eight patients who had wide resection of a solitary osseous metastasis in combination with a nephrectomy had a disease-specific survival rate of 100% (mean followup, 69 months; range, 24-76 months). Patients who present with these characteristics are candidates for aggressive surgical treatment with curative intent.     

Management of pancreatic metastases from renal cell carcinoma report of five cases

Pancreatic metastases from renal cell carcinoma are rare. In most cases metastases occur many years after nephrectomy. Solitary pancreatic metastases of renal cell cancer can be the only manifestation of tumor dissemination. Between 1995 and 2005 five patients after nephrectomy due to renal cell cancer were suspected of having malignant pancreatic tumor and underwent an operation. The histology revealed metastases of renal cancer. The intervals from primary renal tumor resection to recognition of metastases in the pancreas varied from 6-17 years. The prognosis of metastatic invasion to the pancreas is better than that of primary pancreatic carcinoma. Radical resection of the tumor is the treatment of choice for isolated solitary late metastases of renal cell cancer in the pancreas.     

Metastatic renal cell carcinoma mimicking a meningioma

We report a patient with renal cell carcinoma metastatic to the left trigone, which mimicked an intraventricular meningioma. The metastasis was recognized 1.3 years after removal of the primary tumor, a longer disease-free interval than any previously reported cases with brain metastases of renal cell carcinoma. The patient is now free of disease of years after resection and 17 years after the discovery of the primary tumor. Metastatic disease should be considered in all patients with prior resection of renal cell carcinoma who experience the onset of neurological disease, even after a prolonged disease-free interval. Long term survival is observed after the resection of solitary metastases, particularly if these appear after a prolonged disease-free interval.     

Solitary Pancreatic Metastasis from Renal Cell Carcinoma Concomitant with Early Gastric Cancer 17 Years After Nephrectomy: Report of a Case

The pancreas is an uncommon site for metastasis from renal cell carcinoma. We report the case of a 70-year-old man in whom a solitary pancreatic metastasis from renal cell carcinoma, found 17 years after nephrectomy, was successfully resected, combined with gastrectomy for early gastric cancer. We also discuss the relevant literature, including all the reports of pancreatic metastasis from renal cell carcinoma found in Medline. More than half the cases, like ours, were asymptomatic. A good prognosis can be expected once the pancreatic metastatic lesions are surgically excised, especially if it is a solitary metastasis. Therefore, surgical resection of pancreatic metastases is recommended to achieve the best chance of long-term survival. Special attention must be paid to the possibility of recurrence, even more than 10 years after nephrectomy for renal cell carcinoma, and imaging modalities should be part of the routine follow-up to detect metastases at an early stage.     

Solitary liver metastasis of chromophobe renal cell carcinoma 20 years after nephrectomy treated by hepatic resection

A small proportion of patients with metastatic renal cell carcinoma have operable liver metastases, as there is often multiple dissemination within the liver and to other organs. We present a case of a solitary liver metastasis found incidentally 20 years after radical nephrectomy for a chromophobe renal cell carcinoma. The patient underwent a liver resection with tumor-free margins and recovered uneventfully. Time will tell if this was oncologically successful.     

Late pancreatic metastasis from renal carcinoma

The appearance of solitary late metastases of renal cell carcinoma has seldom been documented. A male patient, who 5 years ago underwent left radical nefrectomy for renal cell carcinoma, presented with a solitary pancreatic metastasis (an uncommon site of metastasis for renal cell carcinoma), which was successfully treated with partial pancreatectomy. The diagnostic, treatment and prognostic implications of solitary late metastases are discussed.     

Evaluation of bone metastases from renal cell carcinoma

Forty-two cases of bone metastasis from renal cell carcinoma were examined. Thirty of the cases had bone metastases at the time of renal cell carcinoma. Bone metastasis appeared after treatment of the primary site in 12 cases. Fifteen cases had only bone metastasis and another 27 had metastasis in multiple organs. The total cause-specific survival curve of these patients was 10% at 5 years. All patients with bone metastases died of cancer within 5 years after the bone metastases had developed. There was no significant difference in the survival rate between patients with bone metastases and patients with lung metastases. We investigated the prognostic value of laboratory studies in bone metastases of renal cell carcinoma. However, no significant markers were detected for bone metastases. The 6 patients were treated with decompressed laminectomy (2), wide resection (3) and excision of the metastatic lesions (3). The quality of life was improved in all the patients although they died of cancer.     

Adrenalectomy for metastatic adrenal tumors

The indications for adrenalectomy in cases of metastatic adrenal tumor remain controversial. To clarify indications and outcomes of adrenalectomy for adrenal metastasis, we performed a retrospective review of all 8 patients who underwent adrenalectomy for adrenal metastasis between 1990 and 2006 in Asahikawa Medical College Hospital. The Primary tumor was renal cell carcinoma in 2 cases, and eccrine poro carcinoma, rectal cancer, lung cancer, melanoma, bladder cancer and cancer of unknown origin in 1 case each. Open adrenalectomy was performed in all cases, including 1 case that was converted from laparoscopic adrenalectomy. Of the 4 patients with solitary adrenal metastasis, 3 were considered tumor-free after adrenalectomy, while the remaining patient was not due to unresectable primary tumor. Of the 3 patients with complete resection, one remained alive as of 88 months after adrenalectomy but was then lost to follow-up, and the other 2 patients remain alive 12 and 7 months after adrenalectomy. Of the 2 patients with other resectable metastasis who were tumor-free after removal of all metastases, one was alive 31 months postoperatively and the other died 23 months after operation. The remaining 2 cases with other unresectable metastasis died within 6 months after adrenalectomy. At least in cases of solitary adrenal metastasis, adrenalectomy can be effective if other valid methods are unavailable.     

Pancreatic metastasis of renal cell carcinoma: presentation, treatment and survival

PURPOSE: The pancreas is an uncommon site of metastasis from renal cell carcinoma, comprising 2% of pancreatic tumors removed in sizable series of operations. To our knowledge the role of operative resection in the setting of metastatic malignancy to the periampullary region has not yet been defined. We reviewed the records of 6 women and 2 men who underwent pancreatic resection due to malignancy and analyzed various prognostic factors. MATERIALS AND METHODS: Between 1985 and 1995, 269 patients underwent pancreatic resection for malignancy at our hospitals, including 150 (56%) for pancreatic duct cancer, 65 (24%) for carcinoma of the ampulla, 27 (10%) for distal bile duct cancer, 19 (7%) for duodenal carcinoma and 8 (3%) for renal cell carcinoma metastasis. We reviewed the records of these latter 8 cases, and analyzed demographics, primary tumor type, disease-free interval, resection type, concomitant other organ resection, histological examination of the specimen, morbidity, adjuvant therapy and survival. RESULTS: Pancreatic metastasis of renal cell carcinoma was managed by duodenopancreatectomy in 5 patients and total pancreatectomy in 3. There were no perioperative deaths. Mean tumor size in cases of a solitary pancreatic metastasis was 4 cm. (range 1.5 to 8). In the 3 patients treated with total pancreatectomy there were 2, 5 and 3 pancreatic metastases, respectively. Pathological examination revealed negative lymph nodes in all cases. Mean survival was 48 months. At study end 6 patients were alive at 24, 26, 30, 46, 84 and 88 months, while 2 died at 13 and 70 months, respectively. CONCLUSIONS: We advocate aggressive surgical resection when possible. Surgical removal of metastatic lesions prolongs survival but radical lymph node dissection is not mandatory. We also recommend careful long-term followup of patients with a history of renal cell carcinoma.     

Clinical Study of Renal Cell Carcinoma with Brain Metastasis

Background:
The clinical outcome of patients with renal cell carcinoma with brain metastasis was analyzed.
Methods:
Nine patients (median age, 60 years) with primary renal cell carcinoma and distant metastasis, including brain metastasis, were treated. The median time to the development of brain metastasis was 15 months after the initial visit. Patients with poor performance status or progressive disease were treated with interferon or conservative therapy alone. Patients with good performance status and other well-controlled metastatic foci were treated either with radiotherapy, or by tumorectomy of brain metastasis, or both. The median follow-up was 26 months after the initial visit.
Results: The 1-year, cause-specific survival rate was 17%. Of the 5 patients treated with α-interferon alone, all died of disease after the treatments, without improvement of performance status, 1 to 4 months after the diagnosis of brain metastasis. Two of 4 patients who underwent radiotherapy were treated with a combination of γ-knife and tumorectomy of brain metastasis. They remained alive 10 and 22 months after diagnosis of brain metastasis. The 2 patients who underwent the combination treatment of γ-knife and tumorectomy showed improvement of their performance status after these treatments for brain metastasis.
Conclusion:
Brain metastasis is an unfavorable prognostic factor in renal cell carcinoma. Although a larger number of patients would be necessary to demonstrate the definitive effects of γ-knife treatment, our results suggest that the combination of γ-knife and tumorectomy of brain metastases may be recommended for selected patients with good performance status and other well-controlled metastatic foci.     

Prognostic factors in patients who survived more than 10 years after undergoing surgery for metastatic brain tumors: report of 5 cases and review of the literature

BACKGROUND: Although the overall prognosis of patients with metastatic brain tumors is dismal, a small number survive longer than 10 years after craniotomy. We report 5 patients who survived for more than 10 years after undergoing treatment for metastatic brain tumor. METHODS: The 5 patients who survived for more than 10 years after undergoing craniotomy were among 56 consecutively treated patients with solitary metastatic brain tumors. We retrospectively examined their clinical course, treatment, and variables associated with their longer survival and compared these 5 patients with other reported cases of metastatic brain tumor. RESULTS: The histologic tumor types and the sites of origin of the primary tumor varied: two were from lung cancer and one each was from colon cancer, renal cell, and cervical carcinoma of the uterus. Common features among the long-term survivors were: systemic disease was absent, the metastatic tumor was located in the non-eloquent area of the non-dominant hemisphere, they were in good neurologic condition before surgery, there was a long interval between the diagnosis and treatment of the primary lesion and the diagnosis of the brain metastasis, and the patients received postoperative irradiation/chemotherapy. CONCLUSION: Aggressive surgical treatment may be justified in young patients with a solitary metastatic brain tumor, as long as they are free of active systemic metastases.     

Surgeon's role in the management of solitary renal cell carcinoma metastases occurring subsequent to initial curative nephrectomy: An institutional review

Background: Solitary metastases from a primary renal cell carcinoma (RCC) occur in <10% of patients with metastatic RCC. To date, the benefit of surgically resecting such apparently solitary lesions has not been well documented. Materials and Methods: Forty-one patients (25 men, 16 women) with metastatic renal cell carcinoma treated by surgical excision of solitary metastases (1970–1990) were retrospectively reviewed. They comprised 9% of patients with metastatic hypernephroma seen during this period. All patients had undergone previous curative nephrectomy with a median disease-free interval of 27 months. Patients with skeletal, spinal cord, and lymph node metastases were excluded. Results: Mevtastases were intrathoracic (n=20), intracranial (n=7), and intraabdominal or in the extrapleural chest wall soft tissue (n=10). Three patients had metastases to the thyroid gland and one had a solitary metastasis to an index finger. Median follow-up was 3.2 years. Complete resection was possible in 36 patients (88%) with a single lesion excised in 23 of these 36 patients (64%). There was no operative mortality. Predicted survival from the date of complete resection of metastases was 77%, 59%, and 31% at 1, 3, and 5 years, respectively, with a median survival of 3.4 years. One patient is alive without evidence of recurrent tumor 93 months from the first of 12 complete surgical resections. Varying adjuvant therapy was used in 50% of the patients. An increased histological tumor grade of the metastatic lesion relative to the original RCC was the only significant prognostic indicator identified. Disease-free interval and number of resected lesions were not significantly associated with patient survival. Conclusion: A small fraction of renal cell carcinoma patients are candidates for potentially curative surgical resection of solitary metastatic lesions. Excision of such lesions may contribute to prolonged survival in selected instances. The results of this study were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, California, March 18–21, 1993.     

Surgical treatment of osseous metastases in patients with renal cell carcinoma.

Forty-five patients who underwent surgical treatment for osseous metastases secondary to renal cell carcinoma between 1980 and 1998 were reviewed. The diagnosis was confirmed histologically in all patients. The mean age of the 34 men was 61.5 +/- 9 years and of the 11 women 55.2 +/- 17.6 years. The most common locations of the metastases were the spine (15 patients), the pelvis (eight patients), and the femur (11 patients). In 21 patients, the renal cell carcinoma was diagnosed when the osseous metastasis was detected. The time from diagnosis of the primary tumor to metastasis in the remaining patients ranged from 0 to 23 years (mean, 3 +/- 5 years). At presentation, 19 patients had a singular lesion. Nine patients had multiple osseous metastases and 17 patients had additional visceral involvement. In seven patients, a wide or radical resection was done; in 35 patients, a palliative procedure was done; and in three patients, only a diagnostic procedure was done. For the whole group, the survival was 49% after 1 year, 39% after 2 years, and 15% after 5 years. Only the extent of the disease and the latency period between primary tumor diagnosis and first detection of osseous metastasis could be identified as independent factors of survival. Nine patients with solitary metastasis to the bone more than 12 months after resection of the primary tumor showed a 5-year survival of 54%.     

Total cleidectomy for a solitary metastasis of the clavicle

The clavicle is a fairly common site of metastases of renal cell carcinoma. We report the cases of two patients with undiagnosed renal cell carcinoma who were first seen for shoulder pain secondary to a solitary clavicular metastasis. Wide resection was performed in both cases. Functional and cosmetic results were good, with no shoulder pain or neurovascular deficits. We suggest wide surgical resection of a solitary bony metastasis from renal cell carcinoma, associated with appropriate systemic treatment, because the survival may be increased.     

Clinical study of brain metastasis of renal cell carcinoma.

OBJECTIVES: To evaluate the natural history and the efficacy of treatments for renal cell carcinoma (RCC) with brain metastasis, we reviewed 18 patients with this disease. METHODS: Out of 325 cases with RCC treated at Osaka University Hospital from 1957 to 1993, 18 (5.5%, male:female ratio 16:2) cases developed brain metastases. Median follow-up was 44 months after the initial treatment of the primary lesion. Twelve patients had surgical resection of brain metastases (surgical group), and 7 of them received adjuvant radiotherapy. Six patients with poor performance status were treated with supportive therapy alone (nonsurgical group). RESULTS: Of 18 RCC patients with brain metastasis, 16 were male and 2 female. All brain metastases except for 1 case were symptomatic. Median interval between the initial treatment of the primary lesion and the diagnosis of brain metastasis was 19 months. The most frequent metastatic site prior to brain was the lung, which was detected in 7 cases (38.9%). Median survival of the entire group, measured from the onset of brain metastasis, was 9.5 months. One-year survival rate after the diagnosis of brain metastasis was 43.2% (64.8% in surgical group, 0% in nonsurgical group), 3-year 18.5% and 5-year 0%. Among 109 metastatic RCC, 14 patients were treated by lymphokine-activated killer (LAK) therapy. Out of 14 metastatic RCC patients treated by LAK therapy, 3 (21.4%) developed brain metastases. On the other hand, out of 95 metastatic RCC patients without LAK therapy, 15 (15.8%) had brain metastases. There was no significant difference in the rate of brain metastases between these two groups. CONCLUSION: There was a trend for prognosis of the surgical group to be better compared to that of the nonsurgical group, although it is not statistically significant. The optimum treatment for brain metastasis of RCC remains undefined, but our data suggested surgical resection in selected patients might contribute to prolonged survival of patients with brain metastasis. LAK therapy was not necessarily the risk factor of the brain metastasis.