An intracapsular nephrectomy for the acquired cystic disease-associated renal cell carcinoma in renal transplant allograft: A clinical case report

Rationale:Acquired cystic disease-associated renal cell carcinoma (ACKD-RCC) is a unique subtype of renal cell carcinoma (RCC) and is found exclusively in patients with end-stage renal disease. We report a case of intracapsular nephrectomy (ICAN) of renal allograft with ACKD-RCC. To our knowledge, this is the first case in Asia of ICAN of renal allograft to treat ACKD-RCC.Patient concerns:A 51-year-old male patient with a history of allogeneic kidney transplantation (23 years previously) presented with renal cystic degeneration of the transplanted kidney over the past 2 years.Diagnoses:ICAN was used to remove the cystic kidney.Interventions:The pathology report indicated clear cell renal cell carcinoma.Outcomes:Two years after surgery, computed tomography showed no tumor recurrence, and the patient''s creatinine level was 3.5 mg/dl under hemodialysis.Lessons:Removal of transplanted kidney with ACKD-RCC using ICAN is feasible to provide a mid-term tumor-free survival for the patient. Therefore, we consider nephrectomy as an early treatment for the nonfunctional cystic allograft kidney, in order to reduce the dosage of anti-rejection drugs, avoid the occurrence of transplanted kidney tumor, and provide the possibility for the patient an opportunity to receive a second kidney transplantation.     

Refining indications for contemporary surgical treatment of renal cell carcinoma metastatic to the pancreas

Background:

The pancreas is a rare location for metastatic disease, with only 2–11% of all pancreatic tumours being of non-primary origin. It is also uncommon for renal cell carcinoma (RCC) to metastasize to the pancreas (1–3% of cases) and, when it does, it typically occurs substantially after index nephrectomy. It is not known whether all pancreatic metastases need be resected because today''s chemo- and biological therapies are increasingly effective in controlling advanced disease.

Methods:

Six patients with a variety of symptoms are discussed. Four patients presented with recurrent gastrointestinal bleeding, ranging from occult to life-threatening in severity.

Results:

The four patients with gastrointestinal bleeding had RCC metastases that had eroded into the duodenum and were successfully controlled by palliative pancreaticoduodenectomy or completion pancreatectomy. The other two patients were treated using different chemotherapeutic or biological agents.

Conclusions:

Renal cell carcinoma metastases to the pancreas typically occur long after index nephrectomy. Although clinical presentation is variable, palliative resection should be reserved for those who develop complications, such as upper gastrointestinal bleeding, and, in other series, obstructive jaundice. Routine debulking resections do not appear to be indicated because current biological therapies effectively and reliably control disease over long periods.     

Metastatic renal cell carcinoma presenting as multiple pleural tumours

A 66-year-old man was admitted with dyspnoea. Chest X-ray and chest computed tomography (CT) demonstrated a left-sided pleural effusion and multiple tumours, suggesting malignant mesothelioma in the left pleural space, but there were no pulmonary lesions. However, abdominal CT revealed a right renal tumour. An ultrasonography-guided needle biopsy of the pleural mass provided evidence of metastatic renal cell carcinoma (RCC). The pleural lesions dramatically decreased in size following right radical nephrectomy and subsequent interferon-alpha treatment. While the thorax is a frequently affected site of RCC, sole pleural metastases are rare and are often secondary to lung involvement. Batson's plexus, a network of vertebral valve-less veins with multiple connections, is likely responsible for the contralateral pleural metastases of RCC.     

Extremely delayed solitary cerebral metastasis in patient with T1N0M0 renal cell carcinoma after radical nephrectomy: Case report and literature review

Rationale:Although renal cell carcinoma (RCC) is one of the common origins of brain metastasis, few cases of extremely delayed brain metastasis from RCC, more than 10 years after nephrectomy, have been reported. We present a rare case of extremely delayed brain metastasis from RCC, also performed a literature review to increase knowledge of the characteristics for extremely delayed brain metastasis from RCC.Patient concerns:A 72-year-old man presented with right-sided hemiplegia and dysarthria. The patient had a history of radical nephrectomy for RCC with stage T1N0M0 15 years earlier.Diagnosis:Magnetic resonance imaging with contrast revealed a 2-cm sized non-homogenous enhanced mass in the left frontal lobe with peritumoral edema. The pathological examination after surgery reported metastatic clear cell RCC.Interventions:A craniotomy for removal of the mass was performed at the time of diagnosis. Stereotactic radiosurgery was performed for the tumor bed 3 weeks after craniotomy, and then, chemotherapy was started 2 months after the SRS.Outcomes:Metastasis progressed to multiple organs 6 months after the craniotomy. The patient chose a hospice and no longer visited the hospital.Lessons:In cases with a history of nephrectomy for RCC, long period follow-up is necessary for monitoring RCC brain metastasis and pathologic diagnosis should be confirmed.     

树突状细胞免疫治疗用于局部进展性肾癌根治术患者效果观察

目的进一步提高局部进展性肾癌的治疗效果。方法将57例局部进展性肾癌患者随机分为观察组27例、对照组30例。两组均行肾癌根治术。观察组术后2周行树突状细胞（DC）免疫治疗。检测两组术前及术后8周外周血T淋巴细胞亚群CD4＋、CD8＋水平及CD4＋/CD8＋值,观察不良反应;随访1a、3a生存率。结果观察组术后CD4＋水平及CD4＋/CD8＋明显高于术前,CD8＋明显低于术前,P〈0.05;对照组上述指标与术前比较无显著差异。观察组未出现明显不良反应。观察组3a生存率明显高于对照组,P〈0.05。结论局部进展性肾癌患者根治术后DC免疫治疗可增强免疫功能,延长生存时间。     

Pancreatic metastasis of renal cell carcinoma

BACKGROUND: Renal cell carcinoma (RCC) is a common cancer, but pancreatic metastasis of RCC is unusual. Because of the rarity and peculiarity, pancreatic lesions from RCC me-tastasis were described mostly in case reports which highlight the importance of a systematic analysis of this clinical condi-tion.
DATA SOURCES: Data of 7 patients with pancreatic metasta-sis of RCC treated in the Peking Union Medical College Hospi-tal were extracted and 193 similar patients reported in the past 10 years from the literature were analyzed. Epidemiological, pathological and follow-up information were investigated. Po-tential prognostic factors were compared with corresponding data reported 10 years ago.
RESULTS: Multivariate Cox regression showed that asymp-tomatic metastasis and surgical procedure were independent factors associated with better survival. Compared with the data reported 10 years ago, follow-up of RCC patients has been emphasized in recent years, and atypical surgery is fre-quently used since it has similar effect as typical surgery on tumor resection while it is able to preserve more pancreatic function.
CONCLUSION: Surgical treatment should be an option as long as the pancreatic metastasis of RCC is resectable.     

Bilateral adrenal metastasis of renal cell carcinoma 4 years after radical nephrectomy: A case report and review of literature

Rationale:Renal cell carcinoma (RCC) almost metastasizes to every organ, the possibility of adrenal metastasis is relatively low in patients that have undergone radical nephrectomy, only a few cases of bilateral adrenal metastasis are reported on literature. Although surgical treatment of metastases from RCC is preferred and contributes to the rate of survival, it is considered challenging to manage such cases due to the rarity of bilateral metastasis to the adrenal glands.Patient concerns:A 64-year-old Manchus female presented with an incidental ultrasonic finding of a left adrenal mass 4 years after radical nephrectomy for left renal cell carcinoma.Diagnosis:Abdominal contrast enhanced CT scan revealed bilateral adrenal masses, suggesting metastatic lesion. Examinations indicated neither local recurrence nor distant metastasis anywhere have been detected by whole body Positron Emission Tomography/Computed Tomography (PET/CT) scan except high radioactive uptake in bilateral adrenal glands.Interventions:Metachronous bilateral adrenalectomy was taken and laparoscopic right adrenalectomy was first performed. She was discharged home on third postoperative day. Pathological examination revealed metastatic renal cell carcinoma. Two months later she was performed laparoscopic left adrenalectomy.Outcomes:The patient healed without obvious complications and no tumor recurrence.Lessons:Bilateral metastatic adrenal recurrence from RCC is very rare. Early diagnosis of adrenal metastasis is challenging because they are usually silent both anatomically and functionally. Surgical intervention is a wise option for these patients that may improve survival, and metachronous bilateral adrenalectomy is proved to be safe and effective.     

Metastatic basaloid-squamous cell carcinoma of the esophagus treated by 5-fluorouracil and cisplatin

Basaloid squamous cell carcinoma （BSC） of the esophagus is a rare malignant disease. We report here a patient with recurrent esophageal BSC, who was successfully treated by systemic chemotherapy containing 5-fluorouracil （5-FU） and cisplatin （CDDP）. A 57-year-old woman was diagnosed as having SCluamous cell carcinoma of the esophagus upon endoscopic examination. Curative esophagectomy with lymph node dissection was performed under the thoracoscope. The pathological diagnosis of the surgical specimen was BSC. Five months after operation, the patient was diagnosed as having a recurrence of the BSC with metastases to the liver and spleen, and a right paraclavicular lymph node. She was given systemic chemotherapy consisting of continuous infusion of 800 mg/d of 5-FU and 3 h infusion of 20 mg/d of CDDP for 5 consecutive days every 4 wk. The metastatic lesions in the spleen and right paraclavicular lymph node disappeared, and the liver metastasis was apparently reduced in size after 2 courses of chemotherapy. The tumor regression was seen over 6 courses, with progression afterwards. Although subsequent treatment with CPT-11 and CDDP was not effective, docetaxel and vinorelbine temporarily controlled the tumor growth for 2 mo. 5-FU and CDDP combination may be useful for the patients with advanced BSC.     

Pylorus-preserving pancreatoduodenectomy is applicable to patients with carcinoma of the head of the pancreas: Studies of lymph node metastasis and quality of life

Metastases to the regional lymph nodes of the stomach were studied in patients in whom carcinoma of the head of the pancreas had been resected (51 standard pancreatoduodenectomy and 26 total pancreatectomy). Involvement of gastric lymph nodes was rare (1.3%–3.9%), except of the subpyloric lymph nodes (9.1%). Carcinoma in the five patients with positive gastric lymph nodes, with the exception of the subpyloric nodes, was clinically far advanced: four of the five had liver metastasis or peritoneal dissemination. This suggests that, in terms of preservation of the regional gastric lymph nodes, only subpyloric node involvement has any significance with respect to surgical treatment of carcinoma of the head of the pancreas. There was no significant difference in survival rates after curative resection between standard pancreatoduodenectomy (n=44) and pylorus-preserving pancreatoduodenectomy (n=17). In the patients who underwent the pylorus-preserving pancreatoduodenectomy for various kinds of periampullary diseases (n=47), postoperative recovery of gastric and small bowel function was temporarily prolonged compared to that after shandard pancreatoduodenectomy (n=44). However, the former group were able to take significantly more calories 6 weeks after the operation. Our study indicates that the pylorus-preserving pancreatoduodenectomy with subpyloric lymph node dissection is applicable to the treatment of patients with carcinoma of the head of the pancreas from the viewpoints of both extent of operation and quality of life.     

Results of duodenopancreatectomy for solitary pancreatic metastasis from renal cell carcinoma

The pancreas is an uncommon site of metastasis from renal cell carcinoma. We present five patients with solitary pancreatic metastasis from renal cell carcinoma located in the head of the pancreas, treated by duodenopancreatectomy. There were no perioperative deaths. Mean survival was 48 months; three patients were alive at the end of the study (at 27, 46, and 88 months, respectively) and two patients died, at 13 and 70 months. The 3- and 5-year survival rates of our patients together with 22 previously reported patients were 86% and 68%, respectively. We advocate aggressive surgical treatment when the metastatic disease is limited to the pancreas.     

Management of metastatic renal cell carcinoma in the era of targeted therapies

Background: Metastatic renal cell cancer is associated with poor prognosis and survival and is resistant to conventional chemotherapy. Therapeutic targeting of molecular pathways for tumour angiogenesis and other specific activation mechanisms offers improved tumour response and prolonged survival. Aims: To conduct a retrospective audit of metastatic renal cell carcinoma patients treated with targeted therapies. Methods: Data were extracted from clinical records of patients undergoing targeted treatment between 2005 and 2009 at two hospital sites. Data collected included pathology, systemic therapy class, toxicity and survival. Univariate and multivariate survival analyses were performed. Results: Sixty‐one patients were treated with 102 lines of therapy with a median overall survival (OS) of 23 months, median time to failure of first‐line treatment (TTF1) of 10 months and median time to failure of second‐line treatment (TTF2) of 5.2 months. Time from first diagnosis to treatment >12 months was significantly associated with improved OS, longer TTF1, TTF2 and response to first‐line anti‐vascular endothelial growth factor receptor tyrosine kinase inhibitors (anti‐VEGF TKI) therapy. Variables associated with tumour biology, natural history and the systemic inflammatory response were associated with improved OS and TTF1. Development of hypertension was predictive of anti‐VEGF TKI outcome. Toxicities were as expected for each drug class. Conclusions: Survival and toxicity outcomes from two Australian sites are comparable to published data. The adverse event profile differs to conventional chemotherapy. Clinicians caring for patients with metastatic renal cancer will need to become familiar with these toxicities and their management as these agents enter widespread use.     

Metastatic carcinoma of the gallbladder from renal cancer presenting as intraluminal polypoid mass

Summary We report a rare case of secondary involvement of the gallbladder by metastatic renal cell carcinoma. A 71-year-old man was diagnosed as having a polypoid mass within the gallbladder when he underwent right nephrectomy for a renal cell carcinoma. A preoperative diagnosis of simultaneous carcinoma of the gallbladder was made, and extended cholecystectomy with regional lymphadenectomy was performed five months after the initial operation.Postoperative histological examination of the polypoid mass within the gallbladder and a pancreatic mass excised during the second surgery revealed these resected tumors to be identical to the clear cell type of renal cell carcinoma. We feel that this case presents synchronous involvement of the gallbladder and pancreas by metastatic renal cell carcinoma of the right kidney.     

Prognostic factors for overall survival in patients with clear cell metastatic renal cell carcinoma: Model development and external validation with Memorial Sloan Kettering Cancer Center model and the international metastatic renal cell carcinoma database consortium model

To develop a new prognostic model for the overall survival of patients with clear cell metastatic renal cell carcinoma (mRCC) using Korean Renal Cancer Study Group (KRoCS) database and compared it with 2 renowned prognostic models: the Memorial Sloan Kettering Cancer Center (MSKCC) and the international metastatic renal cell carcinoma database consortium (IMDC) models.Data of 790 patients diagnosed with mRCC and receiving targeted therapy as their first-line treatment were pooled to this study. Data from 4 hospitals (n = 619) were used to develop the new model and those from other 5 hospitals (n = 171) were used for external validation. After detecting prognostic factors in multivariable Cox proportional-hazards regression analysis, patients were classified into 3 risk groups, favorable (0), intermediate (1–2), and poor (3 and more) by the number of prognostic factors.Seven variables such as more than 2 metastasis sites, no prior nephrectomy, Eastern Cooperative Oncology Group performance status ≥2, low hemoglobin, high serum corrected calcium, high neutrophil, high serum alkaline phosphatase were identified as prognostic factors for poor overall survival. Also, risk groups were categorized into 3 groups; median overall survival was 61.1 months in favorable, 26.5 months in intermediate, and 6.8 months in poor group. KRoCS ranked the first in all 3 statistical parameters including akaike information criterion (AIC), concordance index and generalized R² among other prognostic models.We developed the KRoCS model and validated it externally with demonstrating its superiority over MSKCC and IMDC models. The KRoCS model can provide useful information for counseling patients with clear cell mRCC regarding life-expectancy.     

Fulminant hepatic failure in nonmetastatic renal cell carcinoma

Summary Paraneoplastic manifestations including reversible abnormal serum liver biochemistry are known to occur in at least one third of patients with renal cell carcinoma. This hepatic dysfunction has always been regarded as benign in nature and attributed to reactive nonspecific hepatitis. In contrast to this belief, we report here a more devastating course of an asymptomatic patient with nonmetastatic renal cell carcinoma which ranged from mere serum liver biochemistry derangement to a fatal end with fulminant hepatic failure within 10 days. To our knowledge, this is the first report of such a case.     

Resection of renal metastases to the pancreas: a surgical challenge

BACKGROUND: Metastasis to the pancreas from renal cell carcinoma (RCC) is distinctly uncommon. Most cases are detected at an advanced stage of the disease and are thus unsuitable for resection. A solitary RCC metastasis to the head of pancreas is rarely encountered and, although it is potentially amenable to surgical resection, surgeons may be hesitant to perform pancreatoduodenectomy. CASES OUTLINES: Two patients with a solitary RCC metastasis to the head of pancreas were treated by pancreatoduodenectomy, while a third with multiple RCC metastases declined any treatment. Two of the patients were asymptomatic, and one presented with anaemia and mild abdominal pain. Computed tomography (CT) and angiography were used to exclude other metastases and to assess resectability of the pancreatic tumour. All three patients are still alive, those with resectable disease at 2 years and 9 years and the one with irresectable disease at 4 years. DISCUSSION: Isolated RCC metastasis to the pancreas is a rare event. Patients present either on follow-up imaging or with symptoms such as mild abdominal pain, weight loss, jaundice, anaemia or gastrointestinal bleeding (whether occult or overt). Dynamic spiral CT can visualise the tumour and exclude distant metastasis. Angiography often reveals a highly vascularised tumour and will help to assess resectability. In the absence of widespread disease, pancreatic resection can provide long-term survival in metastatic RCC, although few cases have been reported with lengthy follow-up. The prognosis is better than for pancreatic adenocarcinoma.