Ventricular metastasis without atrial or caval involvement: a rare presentation

Right ventricular metastases from renal cell carcinoma without inferior vena cava (IVC) or right atrium involvement are rare. We discuss a 44-year-old male who presented with a left thigh mass, which was resected and the pathology revealed an epithelial sarcoma or a possible metastasis from another organ. His preradiotherapy cardiac evaluation showed mass in the right and left ventricles, which was confirmed by transesophagial echocardiogram. Computed tomography revealed a right renal mass in addition to the ventricular masses without any involvement of IVC or the atria. The patient underwent right radical nephrectomy without complications and systemic chemotherapy with interleukin-1 for metastatic renal cell carcinoma. He is doing well and follow-up echocardiogram showed significant reduction in the size of the cardiac metastases, even without surgical resection of these tumors. Thus, our article presents this unique case of asymptomatic ventricular metastases of renal cell carcinoma without any atrial or caval involvement and provides a new insight into the management of this syndrome.     

Cardiac metastasis from a renal cell carcinoma

A 59-year-old man developed an episode of syncope while he was driving. This resulted in a motor vehicle accident, and the patient sustained an open fracture of the left femur. Biopsy of the left femur fracture showed a metastastic renal cell carcinoma, and echocardiography revealed a right ventricular mass without contiguous vena caval or right atrial involvement. This is one of the few reported cases of renal cell carcinoma associated with syncope as an initial symptom.     

Simultaneous renal cell carcinoma of the kidney and transitional cell carcinoma of the bladder

Herein we report a rare combination of two urological tumors simultaneously: renal cell carcinoma of the kidney and transitional cell carcinoma of the bladder. A 67 year old male presented with hematuria. He was diagnosed with left renal cell carcinoma and transitional cell carcinoma of the bladder. Subsequently this patient underwent left nephrectomy (palliative) to control the pain and transurethral resection of bladder tumor. The clinical picture, radiographic and histological finding are presented, as well as the treatment offered.     

Renal Cell Carcinoma,Metastatic to the Left Ventricle

Left ventricular metastases from renal cell carcinoma without vena caval or right atrial involvement are extremely rare. Herein, we present the case of a 69-year-old man who had undergone radical nephrectomy for renal cell carcinoma in 1984. Eighteen years thereafter, we discovered metastatic disease in his left ventricle.When the metastasis was identified, the patient had no symptoms other than shortness of breath. He underwent surgical removal of a highly vascular mass from the left ventricular wall and resection of a nodule in the upper right pulmonary lobe. Upon pathologic examination, both tumors were metastatic renal cell carcinomas. The patient recovered uneventfully and was free of cardiac recurrence more than 6 years after the surgery. We describe our treatment of this patient and discuss some current approaches to the treatment of renal cell carcinoma that has metastasized to the heart.Key words: Carcinoma, renal cell/complications/pathology/secondary/surgery; coronary disease/etiology/surgery; heart neoplasms/diagnosis/secondary; heart ventricles; neoplasm invasiveness; time factors; treatment outcomeCardiac tumors are extremely rare, and metastatic disease that involves the heart is 20 to 40 times more frequent than are primary cardiac malignancies.¹ The most common secondary tumors of the heart originate from leukemia, melanoma, lung cancer, breast cancer, and lymphoma. Cardiac metastases from renal cell carcinoma (RCC), which are extremely rare, usually occur in either of 2 circumstances. First, advanced RCC characteristically extends into the renal vein and the inferior vena cava in 5% to 15% of patients, and into the right atrium in about 1% of patients, thereby obstructing venous return to the heart (1).^2,3 Second, there can be a primary tumor that metastasizes to the heart, which occurs in 10% to 20% of patients who are dying of widespread, systemic RCC. However, in the absence of either direct vena caval extension or systemic disease, involvement of the heart is extremely rare, with only 1 known report thereof in the medical literature.⁴ Here, we present the case of a 69-year-old man who experienced metastasis of RCC to the left ventricle and to the upper right lobe of the lung. We discuss our treatment of this patient, along with current surgical and therapeutic approaches to the treatment of RCC that has metastasized to the heart.     

Metastatic renal cell carcinoma to head of the pancreas successfully treated by left nephrectomy and pancreatoduodenectomy

We describe a patient with renal cell carcinoma with synchronous metastasis to the head of the pancreas who underwent left nephrectomy and pancreatoduodenectomy. The 57-year-old man was referred to us because of jaundice. Computed tomography of the abdomen showed irregular masses in the left kidney and head of the pancreas. Endoscopic retrograde cholangiopancreatography revealed a filling defect at the head of the pancreas. Renal angiography demonstrated the hypervascular nature of the lesion. No other tumor lesions were discovered. The patient underwent left nephrectomy and pancreatoduodenectomy. Postoperative histopathologic examination revealed clear cell-type renal cell carcinoma in both the renal and pancreatic lesions. At follow-up 3 years later, the patient was alive without evidence of recurrent disease. We present a rare case and assess the role of aggressive surgical management for this unusual problem.     

A rare combination consisting of primary hyperaldosteronism and glucagonoma

A 59-yr-old man with multiple pancreatic tumors is presented. Previously, he had undergone left adrenalectomy for primary hyperaldosteronism and left nephrectomy for renal cell carcinoma at the ages of 39 and 55 yr, respectively. This time, 3 yr after removal of renal cancer, two solid lesions in the pancreas associated with hyperglucagonemia were detected. Under a diagnosis of pancreatic metastasis from renal cell carcinoma or islet cell tumor of the pancreas, distal pancreatectomy with splenectomy and enucleation of the tumor in the pancreas head were performed. Microscopically, a glucagonoma, measuring 2.3 mm in diameter, was detected among five pancreatic metastases from renal cell carcinoma. Four years after surgery, the patient remains well, without signs of recurrence despite multiple pancreatic metastases. This is the first report of such a rare combination consisting of aldosterone-secreting adrenal adenoma and glucagonoma.     

Multiple late asymptomatic pancreatic metastases from renal cell carcinoma: diagnosis by endoscopic ultrasound-guided fine needle aspiration biopsy with immunocytochemical correlation

We describe a patient who presented with multiple asymptomatic masses detected in the pancreas. Twelve years prior to this presentation, he underwent a left radical nephrectomy for stage I renal cell carcinoma. CT-guided biopsy was unsuccessful. Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) biopsy was performed. Adequate material was obtained for various immunocytochemical stains that supported the diagnosis of renal cell carcinoma metastatic to the pancreas. The patient was referred for appropriate therapy. This case illustrates that metastasis to the pancreas from renal cell carcinoma can present years after the original diagnosis. We conclude that EUS-FNA can provide tissue diagnosis from pancreatic masses, especially when other modalities have failed.     

A case of von Hippel-Lindau disease with bilateral pheochromocytoma,renal cell carcinoma,pelvic tumor,spinal hemangioblastoma and primary hyperparathyroidism

A rare case of von Hippel-Lindau (VHL) disease with bilateral pheochromocytomas, right renal cell carcinoma, right pelvic carcinoma, spinal hemangioblastoma and primary hyperparathyroidism is described. A 78-year-old woman had a history of hypertension from her forties. She suffered from headache and body weight loss. Abdominal CT revealed bilateral adrenal tumors and right external renal tumors enhanced in early stage. MIBG scintigraphy exhibited a high accumulation of tracer in both adrenal glands. On the basis of the radiographic findings and endocrinological results, the patient was diagnosed as having bilateral pheochromocytomas and right renal cell carcinoma. A bilateral adrenectomy was performed, followed by surgery for resection of the renal cell carcinoma. The other resected right kidney showed a clear cell subtype that was determined to be renal cell carcinoma, and proved that the pelvic tumor was transient cell carcinoma. Spinal MRI showed spinal hemangioblastoma. von Hippel-Lindau (VHL) gene mutation for the patient was found. We diagnosed the patient as VHL because of the existence of spinal hemangioma and a VHL disease gene. Parathyroid echo revealed a hypoechoic space on the back of the left lobe, and serum calcium and intact PTH to be elevated. The patient was diagnosed as primary hyperparathyroidism. We report the first case of a patient with VHL disease complicated with bilateral pheochromocytomas, right renal cell carcinoma, right renal pelvic carcinoma and primary hyperparathyroidism. The life expectancy of affected individuals has been less than 50 years. Since the prognosis may be improved by an early diagnosis, affected individuals with VHL complexes should undergo cranial, spinal MRI and abdomen CT. The families may benefit from presymptomatic detection of affected gene carriers and the exclusion of at-risk family members by negative test results.     

Inferior vena cavectomy for renal cell carcinoma with intracaval tumor thrombus

Excision of the inferior vena cava for renal cell carcinoma with intracaval tumor thrombus is infrequently performed. Herein the authors report a 60-year old woman with a right renal cell carcinoma and massive occluding tumor thrombus of the inferior vena cava. Following a negative metastatic workup, this patient underwent surgery to remove the tumor and thrombus. Thrombectomy occurred via excision of the affected portion of inferior vena cava and proximal left renal vein. Reconstruction of the vena cava was not undertaken. The patient did not suffer any morbidity during recovery in hospital. Her renal function was normal upon discharge. All resection margins were negative for tumor. This experience is compared to those reported in the literature. Postoperative morbidity may be minimized by careful patient selection. Suitable patients should have a right-sided tumor with an occlusive subhepatic vena caval tumor thrombus.     

Simultaneous occurrence of metastasizing carcinoid tumour of the gallbladder and chromophobe renal cell carcinoma in a young man

Carcinoid tumour is an endocrine neoplasia described for the first time in 1888 and rarely observed in the extrahepatic bile ducts. Gallbladder carcinoid tumour was first reported by Joel in 1929. An endoluminal gallbladder lesion, with a bizarre echogenicity, and a mass in the upper pole of the left kidney were found in a 27 year-old man. The patient underwent a cholecystectomy with partial hepatectomy and a polar renal resection. Histological examination revealed a typical gallbladder carcinoid tumour with regional lymph nodal metastasis and a renal cell carcinoma, with morphological and histochemical features of the chromophobe type. This is a distinctive, rare variant, often described in the literature in association with other neoplastic and non-neoplastic diseases. To our knowledge, this is the first report of gallbladder carcinoid tumour with an unexpected aggressive behaviour in a very young patient, with concurrent renal cell carcinoma, chromophobe variant.     

Renal cell carcinoma with skull base metastasis preceded by paraneoplastic signs in a chronic hemodialysis patient

A 59-year-old man who had received chronic hemodialysis developed left occipital pain and hypoglossal nerve palsy. He was diagnosed as having skull base metastasis from renal cell carcinoma related to acquired cystic kidney. Retrospective analysis revealed the patient had had elevated serum C-reactive protein and alkaline phosphatase levels before the symptoms appeared. Radiotherapy to the skull base relieved the pain. Finally he died with generalized metastases. Serum interleukin-6 levels measured during admission had been elevated, and interleukin-6 mRNA was detected in the autopsy specimen of renal cell carcinoma. Interleukin-6 might be involved in the etiology of paraneoplastic signs.     

Unexpected outcome after sclerotherapy of simple renal cyst

ABSTRACT: BACKGROUND: Simple renal cysts usually have benign clinical features. We report a rare case of papillary renal cell carcinoma (RCC) associated with a large recurrent simple cyst following sclerotherapy. Case Presentation A 47-year-old Japanese woman received minocycline sclerotherapy for a large (9 cm in diameter) simple left renal cyst in May 2005. The cyst regrew, and second-line sclerotherapy with ethanol was performed in November 2005. Three years later, she developed papillary RCC on the wall of the recurrent renal cyst. Radical nephrectomy was performed, but the patient died of metastatic disease 15 months after surgery. CONCLUSION: Malignant transformation from recurrent simple renal cyst to RCC may occur in the years following sclerotherapy, underscoring the need for long-term follow-up. Key words: papillary renal cell carcinoma, simple renal cyst, sclerotherapy, malignant transformation.     

Renal cell carcinoma presenting as Henoch–Schönlein purpura with leukocytoclastic vasculitis, hematuria, proteinuria and abdominal pain

Some infectious, rheumatic, allergic diseases, and malignancies have been associated with leucocytoclastic vasculitis (LCV). LCV and cancer occur most frequently in patients with hematological malignancies such as lymphomas and leukemias. There have been a few prior cases reported of LCV associated with renal cell carcinoma (RCC). A 25-year-old male patient was referred from the department of dermatology and nephrology because of recurrent petechiae on both lower legs for several months; the patient also had a tumor of the left kidney. The findings on the skin biopsy were compatible with the diagnosis of LCV. The patient was diagnosed as having Henoch–Schönlein purpura (HSP) with LCV. A CT scan performed due to abdominal pain revealed a mass on the upper pole of the left kidney. A partial nephrectomy of the left kidney including the tumor was performed. The pathology report was consistent with a clear cell type of renal cell carcinoma, Fuhrman’s grade 2; the tumor measured 0.9 × 0.8 cm and focal segmental glomerulosclerosis was noted in non-neoplastic regions. Here, we report a case of LCV associated with RCC presenting as HSP. This case illustrates the importance of evaluating patients for an underlying malignancy when HSP or LCV is diagnosed.     

An autopsy case of autoimmune pancreatitis after a 6-year history of steroid therapy accompanied by malignant dissemination of unknown origin

Little is known about the long-term outcome of autoimmune pancreatitis (AIP), and whether AIP possesses malignant potential. We report herein a 68-year-old Japanese AIP patient who rapidly developed systemic malignant dissemination of unknown origin, resulting in death. The patient was diagnosed histopathologically as having AIP in 1999. After a 6-year history of 5 mg/day of prednisolone therapy, a sudden onset of abdominal pain and convulsive seizure occurred, and the patient died on the tenth hospital day owing to diffuse peritoneal disseminations and metastases in the bilateral lungs and brain. Autopsy disclosed that the primary site was renal cell carcinoma, detectable only by autopsy, originating in the left kidney. On microscopy, metastatic cells obtained from the brain, lung, and peritoneum were composed of pleomorphic malignant cells identical to those from the renal cell carcinoma. Unexpectedly, abundant IgG4-positive plasma cell infiltration, suggesting high activity of AIP in pancreatic parenchyma and around dilated bile ducts, was still observed.     

Changes in the mass and function of the left ventricle after renal transplantation]

We undertook a study of cardiac function in 13 patients with end-stage renal disease with conventional echocardiography. Measurements in systolic and diastolic function were assessed before and after renal transplantation. Improvement in left ventricular mass was observed (mu +/- SD) from 362.4 +/- 150.2 to 178.4 +/- 62.4 (p less than 0.001), also in left ventricular mass index (left ventricular mass/body surface) from 229 +/- 86.3 to 115.6 +/- 41.3 (p less than 0.001), ejection fraction from 0.44 +/- .196 to 0.64 +/- .165 (p less than 0.01) and velocity of circumferential fiber shortening (mu +/- SD) from 19.5 +/- 11.04 to 31 +/- 11.6. Renal transplantation procedure induce favorable modifications in left ventricular functions. If cardiac dysfunction is present in a end stage renal disease patient, it should be not considered a contraindication for transplantation. We were unable to demonstrate that hemoglobin values play an important role in the development or maintenance left ventricular dysfunction. A prospective, larger and longer trails are needed to clarify the risk factors associated with cardiovascular morbid event.     

Posttraumatic infarction with a surgically treated floating thrombus of the left ventricle. Apropos of a case

Forty-two days after severe thoracic trauma which had led to thrombosis of the left renal artery and to nephrectomy, a 22 year old patient developed anterior wall infarction. Echocardiography and coronary and left ventricular angiography showed distal occlusion of the left anterior descending artery and the presence of a large, mobile thrombus at the left ventricular apex. The thrombus was removed surgically without any complications but a small thrombus adherent to the ventricular scar was observed postoperatively. After a discussion on the different possible physiopathological mechanisms, the authors conclude that the patient probably suffered primary myocardial contusion which led to secondary occlusion of the LAD artery, late myocardial infarction and extension of the initial intraventricular thrombus. This case illustrates the value of two-dimensional echocardiography in the detection and follow-up of ventricular thrombosis.     

Prevalence and correlates of left ventricular hypertrophy in the African American Study of Kidney Disease Cohort Study

African Americans with hypertensive renal disease represent a high-risk population for cardiovascular events. Although left ventricular hypertrophy is a strong predictor of adverse cardiac outcome, the prevalence and associated factors of left ventricular hypertrophy in this patient population are not well described. The African American Study of Kidney Disease Cohort Study is a prospective, observational study that is an extension of the African American Study of Kidney Disease randomized clinical trial that was conducted from 1994 to 2001 in African Americans with hypertension and mild-to-moderate renal dysfunction. Echocardiograms and 24-hour ambulatory blood pressure monitoring were performed at the baseline visit of the cohort. Of 691 patients enrolled in the cohort study, 599 patients had interpretable baseline echocardiograms and ambulatory blood pressure data. Left ventricular hypertrophy was defined using a cut point for left ventricular mass index >49.2 g/m(2.7) in men and >46.7 m/m(2.7) in women. The majority of patients had left ventricular hypertrophy (66.7% of men and 73.9% of women). In a multiple regression analysis, higher average day and nighttime systolic blood pressure, younger age, and lower predicted glomerular filtration rate were associated with left ventricular hypertrophy, but albuminuria was not. These data demonstrate a striking prevalence of left ventricular hypertrophy in the African American Study of Kidney Disease Cohort and identify potential targets for prevention and therapeutic intervention in this high-risk patient population.     

Symptomatic renal metastases of bronchial carcinoma

Renal metastasis from carcinoma of the lung is rarely a clinical problem. Autopsic series however prove that the kidney is a frequent metastatic organ (20%). We report the case of a 43-years-old male patient affected with a squamous cell carcinoma of the lung, with bilateral renal extension. These secondary localizations were detected through a left flank pain prior to a systemic inflammatory response syndrome. The absence of hematuria (even microscopic) contrasted with the importance of the lesions. The age, along with the poor general state of our patient and the absence of any CT specificity justified an exploratory lobotomy. The pathologic analysis of the renal biopsies confirmed the metastatic nature of the lesion.     

Pulmonary arteriovenous fistula in a patient with renal cell carcinoma.

Arteriovenous (AV) fistulas are common in renal cell carcinoma. These are usually small and asymptomatic. Case reports have previously described symptomatic fistulas in primary renal cell tumour or, less commonly, bone metastases. The current study describes a patient with lung metastases from renal cell carcinoma who developed a symptomatic pulmonary AV fistula. The patient presented with debilitating progressive shortness of breath, which resolved after coiling of the pulmonary AV fistula. Supporting radiographs include a unique ventilation-perfusion finding of perfusion tracer in the kidney that is diagnostic of a pulmonary shunt. This is the first report of a pulmonary fistula from renal cell carcinoma. This rare complication of renal cell carcinoma reflects its diverse clinical presentations and unique tumour biology.     

Simultaneous resection of pancreas and liver metastases from different metachronous primary cancers

Resection of a pancreatic head tumor and partial resection of the liver for metastatic lesions were carried out simultaneously in a 72‐year‐old woman. The patient had a history of two previous operations, right nephrectomy for renal cell carcinoma (clear cell type), done 14 years previously, and an Autincloss procedure for cancer of the left breast (solid tubular carcinoma); (T1N0M0; stage I) done 7 years previously. At the current presentation, preoperative radiographic examination showed a hypervascular tumor in each of the pancreatic and hepatic lesions, but with different patterns. On the basis of histological findings in the two resected specimens, it was difficult to establish whether the hepatic tumor originated from the renal cell carcinoma or the breast cancer, but postoperative immunohistochemical studies for carcinoembryonic antigen (CEA), estrogen receptors, and gross cystic disease fluid protein (GCDFP)‐15 showed that the pancreatic tumor had metastasized from the renal cell carcinoma, and the liver tumor from the breast cancer. The immunohistochemical investigation of different markers thus proved to be useful in making the final diagnosis of metastatic lesions from different and metachronous cancers.