Renal cell carcinoma metastases to the thyroid gland-8 cases reported.

OBJECTIVE: Clinically important, isolated metastases to the thyroid gland is a rare occurrence. Renal cell carcinoma (RCC) is the most common primary tumor site. We report on 8 cases of late onset metachronous thyroid metastases of RCC. DESIGN: Eight patients presented with metachronous thyroid metastases at a median of 12 years (range 9-18 years) after nephrectomy for RCC. Two patients had simultaneous lung and lymph node metastases, respectively. Four patients had been previously operated for other metastases 1 to 5 years earlier, three of them due to pancreatic metastases. The leading symptom was neck enlargement in all but one case. MAIN OUTCOME: Four total thyroidectomies, 3 subtotal resections, and 1 lobectomy were performed. Complete removal of metastases were achieved in all but one case. There was no postoperative morbidity. Six metastases were bilateral, two unilateral. The 4 year overall survival rate following metastasectomy was 53%, median survival from the date of nephrectomy was 21 years. CONCLUSION: Long-term survival can be achieved after resection of isolated metachronous RCC metastases to the thyroid gland. Total thyroidectomy is not required, unless it is necessary for complete metastasectomy.     

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.     

Operative Therapie des Nierenzellkarzinoms

The aim of surgical treatment for renal cell carcinoma is complete resection of the tumor. For localized renal cell carcinoma organ-sparing resection of the kidney tumor has become the gold standard, in particular for preservation of renal function with comparable oncological efficacy compared to radical nephrectomy. Crucial for the organ-sparing approach is currently the judgment of the surgeon whether a complete resection is possible. Organ-sparing renal tumor surgery can be performed with the appropriate expertise by minimally invasive laparoscopic, retroperitoneoscopic or robot-assisted (??da Vinci??) approaches. Alternatively various other treatment options, such as radical nephrectomy, percutaneous or laparoscopic thermal ablation or active surveillance are available. The therapeutic approach should be discussed individually with the patient and in addition to the oncologic issues, comorbidities, life expectancy and renal function must also be taken into account. For locally advanced renal cell carcinoma complete resection of the tumor is the method of choice. In metastatic renal cell carcinoma in the context of a multimodal treatment prior to systemic therapy cytoreductive nephrectomy is advised. The role of surgery in metastatic renal cell carcinoma remains unchanged in the era of targeted therapy. Patients with solitary or surgically manageable metastases should be considered for metastatic surgery with curative intent in order to avoid the toxicity of systemic therapy.     

Acquired cystic disease of the end-stage kidney

The development of multiple cysts in the previously noncystic chronically diseased kidneys of patients undergoing long-term dialysis appears to be associated with spontaneous renal bleeding and benign and malignant renal tumors. Two cases of acquired cystic disease with renal hemorrhage and adenocarcinoma are presented; metastases occurred in one patient and the other had bilateral carcinoma requiring bilateral nephrectomy. Combined data from 13 studies indicate acquired cystic disease occurs in one third of patients undergoing maintenance hemodialysis and is associated with adenocarcinoma in 4 percent of cases. Four cases of metastases and five deaths linked to acquired cystic disease have been reported. Eight of 24 patients with acquired cystic disease and clinical manifestations of renal bleeding had renal adenocarcinoma. Autopsy series indicate tumors associated with acquired cystic disease are usually benign but commonly bilateral and multiple. Cystic transformation of the end-stage kidney is more frequent after several years of hemodialysis. It is suggested that patients receiving dialysis treatments for more than three years have a baseline radiologic examination of the kidneys so that subsequent problems can be more easily identified and evaluated.     

11-year survival of a renal cell cancer patient following multiple metastasectomy

CASE REPORT: A renal cell cancer patient with late onset of multiorgan metastases showed an unusually long survival following surgical resection. Femoral metastasis appeared 11 years, and contra lateral kidney and adrenal gland metastasis 19 years after the primary nephrectomy, respectively. Following the resection of the femur and implantation of endoprosthesis and removal of adrenal gland and partial nephrectomy, the patient was disease-free 20 years after the first diagnosis of cancer. CONCLUSION: The long survival and successful treatment underline the importance and efficiency of radical metastasectomy even in the case of late onset multiorgan metastases of renal cell cancer. The life expectancies are better in the late onset of bone metastasis following the nephrectomy. The very late onset of metastases in this case shows however the importance of lifelong follow up.     

Colon cancer with isolated metastasis to the kidney at the time of initial diagnosis

Blood-borne metastases to the kidneys from solid tumors have received little attention in the medical literature because they usually occur in a setting of advanced systemic disease, and renal involvement is a elatively minor cause of symptoms. Although the frequency of metastases to the kidney in cancer patients is 7–13% in large autopsy series, incidental discovery of a renal metastasis as the first manifestation of a primary tumor is a very rare event. The most common primary malignancy to involve the kidney is bronchogenic carcinoma, followed by breast and gastrointestinal cancers. In this article, we report a patient with left colon cancer and isolated metastasis to the right kidney at the time of initial diagnosis. Left hemicolectomy and right nephrectomy were performed. Adjuvant systemic chemotherapy consisting of 5-fluorouracil (5-FU) and folinic acid (FA) was given. 5-FU and FA were stopped after four cycles because metastases to the lung and liver occurred about 3 mo after the surgery during adjuvant chemotherapy. Capecitabine was started. The patient died 9 mo after the discovery of the isolated renal metastasis. Nephrectomy is more for diagnostic clarification in the setting of synchronous primary because it has no effect on survival and its effect on quality of life is minimal; as seen in our case, the other organ metastases rapidly occur and the survival is limited. Nephrectomy may also compromise the choice of chemotherapy agents that require renal clearance, thus a careful evaluation of renal functions is necessary if a nephrectomy is performed. In the matter of a decreased renal clearance, the doses of these drugs should be decreased or the choice should be reevaluated.     

Multiple metastases from renal carcinoma 15 years after nephrectomy

A 72-year-old man was admitted to our hospital complaining of an axillary mass. He underwent left total nephrectomy for renal cell carcinoma (RCC) 15 years previously (in 1990). Since further evaluation yielded no evidence of extra renal metastases, he was followed up in the outpatient clinic. On admission, there was a hard tumor in the right axilla. Ultrasonography demonstrated a vascular tumor with a smooth surface, 26 by 24mm. Laboratory findings were generally close to normal, including tumor markers. Chest contrast-enhanced dynamic CT showed that the tumor was enhanced. Furthermore, abdominal contrast-enhanced dynamic CT revealed some enhancing lesions within the right side of the rectus muscle of abdomen and pancreas head as well. Open simple axillary mass biopsy was performed on August 2 and the tumor was histologically confirmed as a metastasis of the RCC to the axillary. His overall status was normal, and he underwent an operation for the pancreas tumor and the tumor in the rectus muscle of the abdomen. On histological examination, both excised specimens were found to be metastases of RCC. During 2 years follow-up period in the outpatient clinic, additional metastasis has not been observed in any organ. Since this case confirms the potential of RCC for late and multiple distant metastases, careful long-term follow-up after radical nephrectomy is needed.     

Pancreatic metastasis from renal cell carcinoma 16 years after nephrectomy: a case report and review of the literature.

Two percent of all malignant pancreatic tumors are metastases from other primaries, with small cell lung cancer, colorectal cancer, breast cancer and hematological neoplasms being the commonest. Renal cell carcinoma (RCC) metastasizing to the pancreas is rare and occurs in 2.8% of patients with metastatic RCC. However, RCC is the most common primary leading to solitary pancreatic metastasis. Metastases often present many years after nephrectomy for primary RCC (median time of 8 years) and should therefore be looked for on surveillance or when patients present with upper abdominal symptoms. Complete surgical resection when possible offers the best chance for cure.     

Duodenal metastasis: an uncommon cause of occult small intestinal bleeding

Duodenal metastases are a very uncommon and peculiar cause of upper gastrointestinal bleeding. However, they should be considered in a patient presenting with upper gastrointestinal bleeding and a previous history of malignancy. The importance of recognising the unusual presentation of duodenal metastasis has to be emphasised. We describe two patients with upper gastrointestinal bleeding due to duodenal metastases. In the first patient a periampullary bleeding due to a metastasis of a renal cell carcinoma was detected five years after nephrectomy of the right kidney. In the second patient an occult bleeding caused by a duodenal metastasis of a melanoma was diagnosed. The first manifestation of this melanoma was eight years earlier.     

Synchronous esophageal and renal cell carcinoma

Multiple cancer associated with esophageal cancer is not uncommon; however, synchronous esophageal and renal cell carcinoma is very rare. Only three cases have been reported to date, and one of these patients was treated in our institution. We have since successfully treated another patient. Here, we report the two cases treated in our institution. In the first case, esophagectomy, nephrectomy, and reconstruction using a gastric tube were carried out in one stage. Post-operative renal function was temporarily impaired by the complications of anastomotic leakage and pyothorax but no hemodialysis was needed. In the second case, as the patient had undergone distal gastrectomy because of gastric cancer, we chose a two-stage operation, i.e. esophagectomy and nephrectomy as the first stage, followed by reconstruction using a colon substitute after 4 weeks, resulting in only slight renal dysfunction. Patients 1 and 2 are alive and well 7 years and 2 years after the operations respectively.     

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.     

Surgery for renal carcinoma metastases

During the last few years, the increasing use of diagnostic imaging (especially ultrasound) has allowed a remarkable rise in the detection of asymptomatic, early-stage renal neoplasms, possibly treatable by radical surgery. Renal cell carcinoma, however, is still the renal neoplastic condition with the highest mortality rate, due in most cases to the presence of distal metastases. Because of a lack of agreement on an efficient systemic therapeutic approach, surgery is generally considered to be the most suitable option to remove metastases: it is technically easy to perform, it can increase survival and the patient's psychological compliance, though metastasectomy is unlikely to cure the metastatic patient. In our experience, we studied 1475 patients who underwent surgery for renal cell carcinoma from 1983 on. 304 (20%) developed a metastasis; 4 subjects only (5.4%) out of the 74 having multiple metastatic anatomical sites were long-surviving. 39 subjects (16.9%) out of the 230 having single-site metastases are currently disease-free (mean follow-up: 80 months from diagnosis): 33 out of the 111 patients who underwent metastasectomy, 4 out of the 57 who received a medical therapy, 1 out of the 14 being administered radiotherapy, and 1 out of the 48 who were cared under palliative purposes only. Therefore we concluded that, in case of single-site (lung or adrenal) metastases, surgery is the most suitable and advisable therapeutic approach, being the only option able to achieve survival even for a small amount of patients. New biologic drugs are currently under investigation, which can interfere with tumor proliferation and angiogenesis: the study results are still preliminary, nevertheless these drugs open the way to a multimodal medical option of treatment for metastatic renal cell carcinoma.     

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.     

Bilateral transitional cell carcinoma of the kidney: a case report

Bilateral nephrectomy for transitional cell carcinoma of the renal pelvis is a rare procedure. We report two cases of bilateral nephrectomy for transitional cell carcinoma. Both patients were placed on dialysis. A review of the literature revealed three other cases of transitional cell carcinoma treated with bilateral nephrectomies. Based on our experience and the review of current literature, we recommend a waiting period of 2 years on dialysis post-operatively before proceeding to transplantation.     

Primary angiosarcoma of the kidney: case report and literature review

The primary angiosarcoma of the kidney is a rare tumor. We report a case of angiosarcoma of the right kidney in a man of 60 years. The CT-scan appearance is the one of a solid tumor compatible with renal cell carcinoma. Histological examination of the piece of nephrectomy straightens diagnosis and reveals the angiosarcomatous nature. In this patient with bone and lung synchronous metastasis, evolution has been a lightning death in less than three months. The literature review confirms the high potential of malignancy of these tumors (metastases almost constant and very short survival in spite of local and systemic treatment).     

Surgical treatment of malignant tumors of the right heart

Seven patients with malignant cardiac tumors were treated surgically in the Department of Cardiothoracic Surgery of the University of Tokyo between 1981 and 2000. Their treatments and outcomes are summarized and discussed. The ages of the patients ranged from 21 to 70 years old (mean: 49.5+/-15) and there were three males and four females. The histopathological diagnoses were hepatocellular carcinoma (HCC), spindle cell sarcoma, round cell sarcoma, osteosarcoma, renal cell carcinoma, and leiomyosarcoma. In four of the cases, the tumor extended or metastasized from other organs, while in the other three cases it originated in the heart. Before the cardiac operation, an above-knee amputation, left nephrectomy, transarterial embolization, or extended right hepatic lobectomy had been performed to treat the primary site of the tumor. Tumor resection using cardiopulmonary bypass was performed in every case. The NYHA classification of heart failure was significantly improved (preop: 3.3+/-0.8, postop: 1.9+/-0.7 [P<0.001]). The mean survival period of the patients who died was 8.8+/-7.0 months. A patient with renal cell carcinoma is still alive after 87 months of follow-up. In summary, surgical treatment of malignant tumors of the right heart can improve the QOL in patients with cardiac failure. However, its effectiveness was temporary in all cases except one case of renal cell carcinoma.     

Contribution of endoscopic ultrasound to the diagnosis of pancreatic metastases from renal carcinoma. Apropos of two cases

Pancreatic metastases represent 2% of pancreatic tumors. The neoplasms most frequently metastasizing to the pancreas are breast, lung, melanoma and kidney tumors. We present the cases of two patients with pancreatic metastases from renal carcinoma diagnosed 4 and 8 years after the diagnosis and surgical treatment of the primary renal tumor. In both patients, endoscopic ultrasound was useful in the detection and characterization of these pancreatic lesions and allowed fine-needle aspiration for cytological study to be performed.     

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.     

Unusual upper gastrointestinal bleeding due to late metastasis from renal cell carcinoma: a case report

A case of recurrent massive upper gastrointestinal bleeding originating from metastatic renal cell carcinoma is reported. A 63-year-old woman underwent right nephrectomy 9 years previously and experienced no recurrence during follow-up. A gradually enlarging ulcerative tumor over the bulb of the duodenum and four subsequent episodes of massive bleeding from this tumor occurred between June 2001 and March 2002. The patient underwent surgery in April 2002 for intractable bleeding from the tumor. Renal cell carcinoma metastasis to the duodenum was confirmed from the surgical specimen. Upper gastrointestinal bleeding due to malignancy is very rare and the duodenum is the least frequently involved site. Furthermore, a solitary late renal cell carcinoma metastasis 9 years after a nephrectomy is extremely uncommon. This case suggests that life-long follow-up of renal cell carcinoma patients is necessary, owing to unpredictable behavior and the possibility of long disease-free intervals. In nephrectomized patients suffering from gastrointestinal bleeding, complete evaluation, especially endoscopic examination, is indicated. The possibility of late recurrent renal cell carcinoma metastasis to the gastrointestinal tract should be kept in mind, although it is rare. If the patient is fit for surgery, metastatectomy is the first choice of treatment.     

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.