Metastasis from renal cell carcinoma to thyroid presenting as rapidly growing neck mass

INTRODUCTION

Renal cell carcinoma (RCC) is commonly known as the “internist''s tumor” because of its unpredictable behavior. Metastasis to the thyroid gland is rarely found in clinical practice.

PRESENTATION OF CASE

We report a rare case of non-thyroid malignancies NTM from renal cell carcinoma 1.5 years after radical nephrectomy in a 58-year-old man with a rapidly growing neck mass.

DISCUSSION

Malignant melanoma, breast carcinoma, lung, and skin cancer are the most common sources of non-thyroid malignancies (NTM). Although metastases of NTMs to the thyroid gland are uncommon in clinical practice, it should be considered in patients with a history of prior malignancy and a new thyroid mass.

CONCLUSION

Isolated thyroid metastasis should be considered in patients with a previous history of cancer and newly developing thyroid mass.     

Combined robotic lobectomy and adrenalectomy for lung cancer and solitary adrenal metastasis

Background and Objectives:

Surgical resection of isolated adrenal metastasis in primary lung cancer is associated with improved survival. We report a combined robotic lobectomy and adrenalectomy for resection of a primary lung cancer and metastasis to the adrenal gland.

Methods:

A 69-year-old male with a significant smoking history and shortness of breath was found to have a 3-cm left upper lobe mass with an enlarged left adrenal gland measuring 1.5cm. The adrenal gland was biopsied confirming metastatic poorly differentiated carcinoma, likely lung cancer. Computed tomography, positron emission tomography, and mediastinoscopy revealed no evidence of disease outside the adrenal gland.

Results:

Following induction chemotherapy, the patient underwent combination robotic lobectomy, lymphadenectomy, and adrenalectomy while in the same lateral decubitus position. Thoracic and urologic oncology teams performed their respective portions of the operation. Overall operative time was 4 hours, and length of hospital stay was 3 days. Estimated blood loss was 150mL with no narcotic requirements beyond the first postoperative day. Final pathology revealed large cell carcinoma of the lung with metastasis to the adrenal. All surgical margins were negative.

Conclusions:

Combination robotic lobectomy and adrenalectomy is feasible and can be associated with a short convalescence, minimal pain, and an oncologically sound approach.     

Primary intraosseous ACC of mandible of possible salivary origin: A rare clinical entity

INTRODUCTION

Adenoid cystic carcinoma (ACC) is a malignant tumor mainly of salivary origin which is well known for its deceptively benign histologic appearance characterized by indolent, locally invasive growth with high propensity for local recurrence and distant metastasis.

PRESENTATION OF CASE

An unusual case of a 23-year-old woman was reported in our hospital. After investigations, it showed that it is a second primary intraosseous lesion of mandible that occurred subsequently after ACC of parotid gland. After diagnosis was established, resection of tumor and reconstruction with a free fibula flap was performed. Ten months follow-up showed no signs of recurrence or metastasis.

DISCUSSION

Among the salivary neoplasms, adenoid cystic carcinoma is very rare and intraosseous lesions are even rarer. We found a total of 26 cases of primary ACC of the mandible reported in the literature. Pain and swelling were the most frequent symptoms.

CONCLUSION

This case illustrates two key facts. First, not all cystic lesions are necessarily metastatic or recurrence. Second is, even though the exact origin of this tumor is unknown, central salivary gland tumors should be considered in the differential diagnosis of cystic lytic lesions in the mandible.     

Unusual presentation of follicular carcinoma thyroid with special emphasis on their management

INTRODUCTION

Follicular carcinoma of thyroid usually behaves in an indolent manner with low metastatic potential. Distant metastases as initial presentation is rare in follicular carcinoma; especially in young patients.

PRESENTATION OF CASE

We report the clinical, pathological features and the management of three different cases of follicular carcinoma of the thyroid with unusual presentations at the time of diagnosis. First case presented as thyroid abscess, second case with a large skull swelling in a pre-exiting goiter and the third case with a swelling in the sternum.

DISCUSSION

Follicular carcinoma of thyroid is the second category of well-differentiated thyroid cancer that constitutes about 10% of all thyroid malignancies. Blood borne metastasis is common with spread to lung, bone and other solid organs. In less than 10% cases of follicular carcinoma, there is evidence of lymphatic involvement. The patients’ presentations above are highly unusual.

CONCLUSION

Recognizing these cases has a significant impact on clinical decision-making and prognosis of the patients. Treatment in these patients should be individualized and an alternative therapeutic approach should be considered.     

Isolated nasopharyngeal metastasis from hepatocellular carcinoma

INTRODUCTION

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, the incidence of which parallels that of areas with high prevalence of chronic hepatitis. HCC commonly metastasizes to the lungs, lymph nodes, adrenals and bones with the overall prognosis of metastatic HCC being dismal.

PRESENTATION OF CASE

We herein with present a case of a 70-year-old male who was referred to our institution with history of nasal obstruction and nasal bleeding which on further evaluation was diagnosed to have an isolated metastasis to nasopharynx from liver primary.

DISCUSSION

Extrahepatic metastasis in HCC occurs in about 30–50% of patients, the commonest site being the lung. Rare sites of extrahepatic metastasis from HCC to the ovaries, kidneys, skeletal and cardiac musculature and brain have been reported. Unusual sites of metastasis in the head and neck area like the mandible have also been documented. With the changing trends in the treatment modalities, these patients are often treated using target therapy.

CONCLUSION

This article presents an unusual isolated metastasis to nasopharynx from HCC in the absence of disseminated disease. This case report illustrates the distinctive pathological features of metastatic HCC.     

Primary squamous cell carcinoma of breast with ipsilateral axillary lymph node metastasis: An unusual case

Introduction

Pure squamous cell carcinoma of the breast [SCCB] is rare.

Presentation of Case

We report a case of primary squamous cell carcinoma of breast with ipsilateral axillary lymph node metastasis in a 58year old woman.

Discussion

It is a breast carcinoma entirely composed of metaplastic squamous cells that may be keratinized, non-keratinized or spindled. The pure squamous cell carcinoma usually present with central cystic cavity, which we found in our case, also supported by immunohistochemical evidence.

Conclusion

Although a rare breast cancer subtype, SCCB is of considerable interest due to its pathological heterogeneity and differences in clinical behavior and less reported occurrence of nodal metastasis.     

The Management of Spinal Metastases from Renal Cell Carcinoma

INTRODUCTION

Osseous metastases occur in 50% of patients with renal cell carcinoma; of these, 15% occur in the spine. The treatment options for spinal metastases secondary to renal cell carcinoma are limited. This paper considers the current management options available for spinal metastases secondary to renal cell carcinoma.

PATIENTS AND METHODS

A review of four patients with spinal metastases secondary to renal cell carcinoma.

RESULTS

The presentation of four cases highlighting the current management options for spinal metastases secondary to renal cell carcinoma.

CONCLUSIONS

Historically, spinal metastases from renal cell carcinoma have been poorly managed; however, as the treatment of the primary disease improves, better treatment of the secondary disease is needed. Cement augmentation, used alone for prophylactic stabilisation or in conjunction with a posterior decompression and fixation, provides a useful addition in the management of these patients optimising their chance to remain ambulant, continent, and pain-free.     

Single Incision Laparoscopic Pancreas Resection for Pancreatic Metastasis of Renal Cell Carcinoma

Background:

Transumbilical single incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain, reduced need for analgesia, and thus accelerated recovery. Herein, we report the first transumbilical single incision laparoscopic pancreatectomy case in a patient who had renal cell cancer metastasis on her pancreatic corpus and tail.

Methods:

A 59-year-old female who had metastatic lesions on her pancreas underwent laparoscopic subtotal pancreatectomy through a 2-cm umbilical incision.

Results:

Single incision pancreatectomy was performed with a special port (SILS port) and articulated equipment. The procedure lasted 330 minutes. Estimated blood loss was 100mL. No perioperative complications occurred. The patient was discharged on the seventh postoperative day with a low-volume (20mL/day) pancreatic fistula that ceased spontaneously. Pathology result of the specimen was renal cell cancer metastases.

Conclusion:

This is the first reported SILS pancreatectomy case, demonstrating that even advanced surgical procedures can be performed using the SILS technique in well-experienced centers. Transumbilical single incision laparoscopic pancreatectomy is feasible and can be performed safely in experienced centers. SILS may improve cosmetic results and allow accelerated recovery for patients even with malignancy requiring advanced laparoscopic interventions.     

The value and role of low dose methylene blue in the surgical management of hyperparathyroidism

Introduction

Methylene blue (MB) has been used in the identification of abnormal parathyroid glands in surgery for hyperparathyroidism. Its efficacy and safety profile have been questioned recently and this study sought to demonstrate such aspects in a unit where its use is routine.

Methods

Prospective data collected over six years in a single surgeon’s practice were interrogated to identify factors affecting MB staining, side effects suffered and unusual cases where the dye was invaluable in locating the diseased gland.

Results

A total of 98 patients underwent MB infusion. Of these, 77 cases (78.6%) stained positively with MB and 21 (21.4%) did not. Six patients suffered side effects but there were no cases of neurotoxicity. No positive predictive factors of dye uptake were found. MB was particularly useful in cases of intrathyroidal and ectopic glands as well as improving efficiency in both targeted and open parathyroidectomy.

Conclusions

This series shows that when used correctly, MB is efficacious in locating diseased parathyroid glands, with similar sensitivity rates to preoperative ultrasonography and radionucleotide imaging. Adverse effects were much lower than published previously, which may be attributed to the low dose of MB used (3.5mg/kg).     

Vascular Anomalies During Laparoscopic Renal Surgery: Incidence and Management of Left-Sided Inferior Vena Cava

Background:

Left-sided inferior vena cava (IVC) is an unusual abnormality that may be clinically significant during renal surgery.

Methods:

We report the unique case of a patient with a centrally located left renal mass who underwent laparoscopic radical nephrectomy. During the hilar dissection, unusual vascular anatomy was encountered. The patient was noted to have a left-sided inferior vena cava with multiple renal veins and anomalous tributaries. Laparoscopic radical nephrectomy was performed without complication.

Discussion:

The embryology of a left-sided inferior vena cava is reviewed, and the safety and feasibility of a laparoscopic approach is discussed.     

Laparoscopic Resection of Solitary Adrenal Metastasis from Lung Carcinoma: A Case Report

Background and Objectives:

Patients with adrenal metastases from bronchogenic carcinoma are considered incurable and any surgical treatment is usually excluded. A review of the few cases of adrenalectomy for metastases from lung cancer that have been reported in the literature shows that good results can be achieved in selected patients. We propose a laparoscopic approach to perform the adrenalectomy in these patients.

Methods:

A right laparoscopic adrenalectomy for metastasis from lung adenocarcinoma was performed. The right adrenal was resected using the anterior transperitoneal laparoscopic approach.

Results:

The tumor was resected in total. The operating time was two hours. One year after surgery the patient remains well.

Conclusions:

The current indications for laparoscopic adrenalectomy can include the removal of small metastatic adrenal lesions in selected cases.     

Adrenal Schwannoma

Background:

Adrenal schwannomas are very rare tumors that are difficult to diagnose preoperatively. We report the case of a left adrenal schwannoma incidentally discovered in a 55-year-old man during a postoperative checkup for a cutaneous malignant melanoma.

Methods:

The biological evaluation was unremarkable, and the radiological examination revealed the adrenal mass that was first considered a metastatic lesion. Adrenalectomy was performed by the laparoscopic approach.

Results:

The postoperative course was uneventful. Histological examination established the correct diagnosis of schwannoma, which was also confirmed by immunohistochemical staining.

Conclusions:

A nonsecreting adrenal mass can be easily misjudged, especially in the context of a recently operated on malignancy. Unilateral adrenal metastasis needs pathological confirmation, as it can dramatically affect prognosis. Unusual tumors of the adrenal gland may be found incidentally, and a malignant context will generate difficulties in establishing the right management. Complete laparoscopic excision is the treatment of choice whenever feasible and will also clarify pathology.     

Spontaneous regression of adrenal metastasis from renal cell carcinoma after sunitinib withdrawal: case report and literature review

Background

The spontaneous regression of metastatic renal cell carcinoma is a rare phenomenon, with an estimated incidence of <?1%. We report a case of post-nephrectomy renal cell carcinoma adrenal metastasis, followed by the spontaneous regression of the metastasis after withdrawal of sunitinib.

Case presentation

The patient was a 55-year-old male with clear cell type renal cell carcinoma who previously underwent a left laparoscopic radical nephrectomy. After 51 months of follow up, a recurrence in the left renal fossa was observed and subsequently excised. Four months after excision, an abdominal Computerized tomography (CT) identified an adrenal metastasis of 1.6 cm. The patient was treated with sunitinib. However, the treatment was discontinued because of gastrointestinal side effects and fatigue. Eleven months after the discontinuation of sunitinib treatment, a progression in the adrenal metastasis growth (5.7 cm) was observed, whereas 16 months after the discontinuation, a regression of the adrenal metastasis growth (3.4 cm) was observed. During subsequent follow-ups, a gradual reduction in the size of the adrenal metastasis (1.8 cm) was observed. After 44 months from the discontinuation of sunitinib treatment, the patient was still alive and followed up in the outpatient department.

Conclusions

Sunitinib is a multi-targeted inhibitor of vascular endothelial growth factor (VEGF) receptors. This compound reduces tumor angiogenesis and has been approved worldwide for the treatment of advanced renal cell carcinoma. To our knowledge, this is the fourth case of the spontaneous regression of metastatic renal cell carcinoma after the discontinuation of sunitinib treatment.

     

Synchronous gist,colon and breast adenocarcinoma with double colonic polyp metastases

INTRODUCTION

Long term survivors of breast cancer are at risk of developing distant metastasis years after the initial treatment. We report a case of breast adenocarcinoma with colonic polyp metastases, as well as synchronous primary colonic adenocarcinoma and a gastric GIST.

PRESENTATION OF CASE

An 83 year old female underwent colonoscopy for rectal bleeding. This showed a primary colonic adenocarcinoma, a pedunculated polyp in the ascending colon and two polyps in the sigmoid colon. A staging CT scan did not show distant metastasis, but revealed a small gastric GIST which was managed conservatively. A right hemicolectomy showed a T3N0 colonic adenocarcinoma and a polyp contained metastatic adenocarcinoma from a breast primary. The patient had undergone surgery 30 years ago for an invasive lobular carcinoma. Further clinical assessment demonstrated an impalpable grade II Invasive ductal carcinoma in the contralateral breast. She was started on hormonal treatment and at 18 months follow-up, she was well with stable disease.

DISCUSSION

Invasive lobular cancer is the most common histological type of breast cancer that metastasizes to the colon. There is no consensus on the management of breast cancer metastasis to the gastrointestinal tract. Co-existence of a GIST and an adenocarcinoma at two separate locations is uncommon. These are two different cancer entities and it is unclear whether these two are related by as causal relationship.

CONCLUSION

This is a rare case of three distinct tumours; association between them is unlikely. However, the case highlights the importance of a multidisciplinary approach to cancer treatment.     

Neuroendocrine breast carcinoma metastatic to the liver: Report of a case and review of the literature

INTRODUCTION

Primary neuroendocrine breast carcinoma (NEBC) is a rare entity of breast cancer.

PRESENTATION OF CASE

We herein report a case of right hepatectomy for a NEBC liver metastasis.

DISCUSSION

Little is known about its evolution, bilologic behavior and optimal treatment. Its malignant potential has been addressed in few reports, with cases of metachronous metastases in diverse sites, even years following treatment of the breast primarily.

CONCLUSION

Treating this kind of cancer implies both breast and hepatic surgery.Primary neuroendocrine breast carcinoma (NEBC) is a rare entity of breast cancer. Little is known about its evolution, biologic behavior and optimal treatment. Its malignant potential has been addressed in few reports, with cases of metachronous metastases in diverse sites, even years following treatment of the breast primarily. We herein report a case of right hepatectomy for a NEBC liver metastasis.     

Phyllodes tumor metastasis to the tonsil with synchronous undifferentiated carcinoma

INTRODUCTION

Breast tumor metastasis to the tonsil is extremely rare.

PRESENTATION OF CASE

A 54-year-old woman underwent resection of a breast malignant phyllodes tumor and later presented with metastasis to the lung and the left tonsil. She underwent left lower lobectomy and resection of the left tonsillar tumor. She subsequently developed undifferentiated carcinoma of the right tonsil. She underwent resection of the right tonsillar tumor and chemotherapy was started. The central venous catheter became infected with methicillin-resistant Staphylococcus aureus. Finally, she died.

DISCUSSION

To the best of our knowledge, this is the first reported case of a phyllodes tumor metastasizing to the tonsil. Furthermore, morphological and immunohistochemical study revealed that the right tonsillar tumor was irrelevant to the phyllodes tumors.

CONCLUSION

We report a case of phyllodes tumor metastasis to the left tonsil which developed undifferentiated carcinoma in the other side of tonsil later. Breast tumor metastasis to the tonsil is rare but it should be considered as a possible diagnosis.     

Breast carcinoma metastasis to meningioma in the thoracic spine: A case report and review of the literature

Context

Systemic metastasis to a primary tumor of the central nervous system is uncommon. Breast carcinomas metastasizing to a possibly preexisting meningioma in the spine are reported very rarely.

Study design

Case report.

Findings

A 69-year-old female was referred to us with progressive gait disturbance. She had undergone a total mastectomy for carcinoma of the right breast 11 years previously. A magnetic resonance imaging of the thoracic spine showed an intra- and extradural spinal cord tumor. The patient underwent resection of the tumor via laminectomy from T2 to T4. After the operation, the patient''s neurological status improved significantly, and she was able to walk without assistance. Histological examination showed the tumor to be a fibrous-type meningioma within a metastatic breast cancer tumor. The patient underwent 40 Gy radiation treatment for local control of the tumor. However, the tumor recurred locally 7 months after the surgery. The patient died of carcinomatous pleurisy 13 months after the surgery.

Conclusion

This case illustrates that a primary meningioma in the thoracic spine can be a recipient of breast cancer metastasis, which may alter the treatment strategy.     

Intestinal Injury Secondary to an Umbilical Piercing

Background:

Body piercing has become increasingly popular throughout the world and may cause unanticipated complications during surgery.

Methods:

We describe the case of a 35-y-old woman with hepatocellular carcinoma who underwent a diagnostic laparoscopy for metastatic disease evaluation.

Results:

An early intestinal injury occurred upon abdominal entry and introduction of pneumoperitoneum. The injury was secondary to a single adhesion between the abdominal wall and small bowel caused by a previous umbilical piercing.

Conclusions:

Umbilical piercing can lead to unanticipated intraoperative complications even if it is removed prior to surgery. Surgeons performing laparoscopy should be aware of potential pitfalls associated with these art forms.     

Synchronous multifocal medullary and papillary thyroid microcarcinoma detected by elastography

INTRODUCTION

A few cases of concomitant medullary and papillary carcinoma in the same thyroid nodule have been described in the literature. However, the presence of multiple foci of both types of malignancy in the same gland is very rare.

PRESENTATION OF CASE

A 39 year-old female with multiple thyroid nodules, elevated serum calcitonin levels and elastographic findings suggestive of thyroid malignancy, underwent total thyroidectomy and central neck dissection. Histology revealed the presence of one focus of medullary and one focus of papillary carcinoma on each thyroid lobe. Subsequently, the patient underwent treatment with radioactive iodine.

DISCUSSION

This is the third case of synchronous multifocal medullary and papillary thyroid carcinoma reported in the literature. Several theories for the simultaneous development of these malignant entities have been proposed.

CONCLUSION

Ultrasound elastography can be a useful, noninvasive tool in the assessment of thyroid nodules.     

Videothoracoscopic Resection of a Mediastinal Parathyroid Adenoma

Objective:

The conventional approach to resection of anterior mediastinal masses is median sternotomy. Advances in thoracoscopy have made it possible to perform excision of mediastinal parathyroid adenoma using minimally invasive techniques.

Methods and Procedures:

A 67 year old female was found to be hypercalcemic on routine chemistry analysis. Calcium levels were consistently elevated (range between 10.2-12.4) with an intact parathyroid hormone (PTH) of 721 (normal less than 54). Preoperative sestamibi parathyroid scan showed a focal area of intense increased uptake in the anterior mediastinum. CT scan of the chest showed a 2 cm soft tissue nodular mass in the anterior mediastinum. Initial intraoperative PTH level was 575.

Results:

The patient was placed in a left lateral decubitus position with double lumen intubation and single lung ventilation. Four right-sided thoracic ports were placed (two 10 mm, two 5 mm). A parathyroid adenoma was excised with the thymus gland using the Autosonic shears (U.S. Surgical Corporation). The operative time was 1.5 hours with minimal blood loss and no intraoperative complications. Pathology confirmed an enlarged parathyroid gland (4.2 grams), consistent with adenoma. A repeat intraoperative PTH level 10 minutes following excision of the parathyroid adenoma was 122, which confirmed that all hyperfunctional parathyroid tissue was removed. The patient had an uneventful recovery and was discharged on the first post-operative day.

Conclusions:

This video demonstrates the technical aspects of resection of a mediastinal parathyroid adenoma by a videothoracoscopic approach.

• JSLS. 1998 Oct-Dec; 2(4): 389–392.
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• Use of a Video System with Twin Cameras and Picture-in-a-Picture for Laparoscopic Surgery

1998 Oct-Dec; 2(4): 389–392.

Use of a Video System with Twin Cameras and Picture-in-a-Picture for Laparoscopic Surgery

Dennis L. Fowler, MD Copyright and License information DisclaimerCopyright notice