Case presentation (metastatic rcc)

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Published on June 26, 2014

Author: IhabSamy

Source: slideshare.net

Case Presentation Ihab Samy Lecturer of Surgical Oncology National Cancer Institute Cairo University 2012

 65 years old male patient presented with left iliac fossa mass since 2 weeks of gradual onset and progressive course. Change in bowel habits and drops of blood with defecation since then.  No previous history of operations,medications nor hospitalizations.  Examination revealed palpable lt. iliac fossa mass about 7X5 cm. PR  NAD  Labs were normal apart from Hgb. 10gm/dl and serum Albumin 3gm./dl CXR Free.

 CT Abdomen and pelvis with contrast revealed large sigmoid colon and upper rectal mass about 11x8 cm. +lt. lower pole small renal mass about 2x2 cm.  Inspite this large colonic mass , he was not obstructed and passed stools patched with irregular amouts of blood.  Patient was scheduled for Lower GI endoscopy and prescribed a regimen of Konakion , Kapron and Dicynone till the day of Colonoscopy.

Chest X-ray PA view

 However before the time of Colonoscopy he developed acute attack of bleeding per rectum which turned the case to be an emergency.  Exploratory laparotomy was done after an adequate short course of rehydration and electrolytes stabilization at the ICU.  Exploration through a lower midline incision revealed large mass involving from the mid- descending, sigmoid and upper rectum with large inf. Mesenteric LNs.

 The mass was resected along with the inf. Mesenteric nodes.  Hartmann’s procedure with terminal lt. hypochondrial colostomy was done.  The patients passed through a smooth PO course with good recovery and early ambulation without any detectable morbidities.  Discharged on the 7th PO day for follow up a week later

Pathology Report  Gross: Specimen 48 cm. long on opening showed a polypoid fungating whitish mass 12x10x4cm. Submucosal and muscle wall infiltation along the segment sparing in most parts the mucosa.  Microscopic: clear vacuolated multi-nucleated cells separated by fibrovascular stroma. CK and Vimentin +ve S-100 negative. However vimentin staining is more intense and profuse than CK. 13 from 13 Nodes showed reactive hyperplasia. SM –ve.

Clear Cell Carcinoma Uncertain whether primary or secondary

 Follow-up CT Abdomen and pelvis 3 weeks later  Noevidence of local tumor residue or recurrence. Stationary course of the previously noted lower pole Lt. renal mass.  Bone Scan  Free CXR and CT chest Free  Labs Normal

?  Putting in mind that the patient does not complain of any urinary tract symtoms.  Should we proceed for Lt Radical nephrectomy?  Putting in mind the position of the terminal colostomy  Should we release the terminal colostomy to have access to the Lt. Kidney? What type of incision should be done?  Putting in mind the (Hartmann’s)  Should we restore the bowel continuity)?  Should we protect the anastomosis with a loop ileostomy?

Uncommon sites of Metastases from RCC

 Solitary Pancreatic Metastasis of Renal Cell Cancer Treated by Pancreaticoduodenectomy: A Case Report E.E. Piccinini, MD; G. Ugolini, MD; G. Rosati, MD; N.C.M. Salfi, MD(*); S. Marroccu, MD; M. Del Governatore, MD; and A. Conti, MD; of the Istituto di Clinica Chirurgica III (*I Servizio di Anatomia Patologica), Policlinico Santa'Orsola, Universita degli Studi di Bologna, Italy.  Isolated RCC metastasis to the head of the pancreas detected six weeks after a left radical nephrectomy that was successfully treated by pancreaticoduodenectomy.  An adjuvant treatment with vinblastine plus alpha-interferon was prescribed. The patient is alive with no evidence of disease at 16 months of follow-up.

 A 51 year old man presented  Upper and lower gastrointestinal endoscopy showed polypoid gastric masses in the cardia, fundus, and antrum.  Biopsies revealed the pathology described below.  CT scan additionally demonstrated an enlarged lymph node in the gastrohepatic ligament.  The patient had a subsequent gastrectomy, esophagojejunostomy.  Diagnosis: Metastatic Renal Cell Carcinoma, clear cell type

 Renal cell carcinoma (RCC), with metastases in the maxillary sinus extending to the oral cavity with mediastinal lymphadenopathy. Jain V, Shergill GS, Gupta K, Bhandari RK. Case report: Renal cell carcinoma: Unusual metastases. Indian J Radiol Imaging 2000;10:249-51 Renal cell carcinoma is the third most frequent primary infraclavicular tumor after lung and breast carcinoma to metastasize to the head and neck. it is the most frequent infraclavicular primary tumor to metastasize to the nasal cavity and paranasal sinuses (40-50%)

 Rt. Renal cell carcinoma with secondaries in the opposite suprarenal. Deodhar SD, Mehendale VG, Bhave GG. Renal cell carcinoma with unusual metastases (A case report). J Postgrad Med 1978;24:55-7  The left suprarenal was markedly enlarged, 10 cm x 7.5 cm, well capsulated, having a variegated consistency.  Cut surface showed greyish white lobulated tumour deposit completely replacing the normal suprarenal tis-sue (Autopsy)

 Renal Cell Carcinoma Presenting as Metastasis to Scrotum and Spermatic Cord Panda P, Sharma S, Chandel UK, Jaswal KS, Jhobta A, Bhatia V. Renal Cell Carcinoma Presenting as Metastasis to Scrotum and Spermatic Cord. Online J Health Allied Scs. 2012;11(1):21  Skin is a rare site of metastasis compared to other organs.  Cutaneous metastasis of RCC implies poor prognosis.  Metastatic tumor of the spermatic cord from RCC usually presents as a painless mass or swelling.

 Thus renal cell carcinoma is characterized by its varied presentation and variable clinical course.  It is the most unusual and unpredictable cancer. Like tuberculosis and syphilis, it is one of the great mimics in clinical medicine.  Recognizing the unusual presentation and natural history of an RCC can have a profound effect on patient management.

Unusual Metastases in Renal Cell Carcinoma: A Single Institution Experience and Review of Literature  Cynthia Villarreal-Garzaa, b, Sandra I. Perez-Alvareza, Ivan R. Gonzalez-Espinozaa, Eucario Leon-Rodrigueza  Background: To report location and management of atypical metastases from renal cell carcinoma (RCC) in the Instituto Nacional de Ciencias Medicas e Investigacion Salvador Zubiran (INCMNSZ) in Mexico City.  Methods: Between 1987 to 2009, 545 patients with RCC were retrospectively identified at the INCMNSZ. Patients with unusual metastases confirmed by histopathology were analyzed. Epidemiological, clinical, diagnosis, treatment and outcome data were reviewed.  Results: Sixty patients developed 98 unusual metastases secondary to RCC. The group was comprised of 35 men (58.3%), with a median age of 60 years at diagnosis. Metachronous unusual metastases with primary renal cancer were observed in 37 individuals (61.7%). Median time from primary RCC diagnosis to the first unusual metastasis was 16.5 months. Median survival from diagnosis of the first unusual metastasis to death was 5.0 months (CI 95%: 2.8-7.2 months). Patients with an initial solitary metastatic lesion in an unusual site (28.3%) had a better survival compared to patients who primarily presented with multiple metastases, 17.0 (CI 95%: 6.1-27.9) Vs 3.0 months (CI 95%: 0.9-5.1), p = 0.001. Unusual metastasis resection (21 patients) improved survival, 25.0 (CI 95%: 5.1-44.9) Vs 3.0 months (CI 95%: 0.8-5.2), p < 0.0001. No survival difference was observed between localization of unsual metastases (p = 0.72).  Conclusions: In patients with advanced RCC we suggest an individual diagnostic and surgical approach to achieve complete resection with disease-free margins, even in the presence of unusual metastatic sites, multifocality, or history of metastasectomy. These strategy might provide not only palliation for symptoms, but an opportunity for meaningful disease free and overall survival.

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