Renal cell carcinoma of contralateral kidney with secondaries in gallbladder eight years after nephrectomy.
M KechridGhulam Hassan MalikSuleiman Al-MohayaJamil ShaikhJamal Al-WakeelHazem El GamalHeba FaroukA JasserMohammad Sabry Shetia
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Abstract:
A 55-year-old female underwent right nephrectomy for renal cell carcinoma (RCC). The histopathology showed clear cell carcinoma. There was no evidence of metastasis. After remaining asymptomatic for eight years, she developed pain in the right loin. Abdominal ultrasound, computerized tomography (CT) Scan and magnetic resonance imaging (MRI) were suggestive of a tumor mass in the right renal area, multiple tumor masses in the left kidney and a mass in the gallbladder. Cholecystectomy, left radical nephrectomy and right adrenal mass with excision of adjacent lymph nodes were performed. The histopathology from all sites was suggestive of RCC. She was maintained on hemodialysis. Two and half years later she died after surgical exploration for spinal cord decompression due to metastasis to the dorsal spine.Keywords:
Histopathology
Clear cell carcinoma
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Hypervascularity
Surgical oncology
Clear cell carcinoma
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Extremely rarely renal cell carcinoma metastasizes to the contralateral renal pelvis or ureter. A 42-year-old man had undergone left radical nephrectomy for renal cell carcinoma (pT1b, grade 2) in March, 2000. Fifteen months later, he complained of macroscopic hematuria. Computed tomographic scanning and retrograde pyelography showed a right renal pelvic tumor. Enucleation of pelvic tumor was performed and a parenchyma mass incidentally identified in the right kidney was also resected. Histopathological examination of each tumor revealed renal cell carcinoma identical to the primary tumors in the left kidney suggesting metastasis to renal pelvis and de novo tumor or metastasis in the right kidney.
Renal pelvis
Clear cell carcinoma
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症例は72歳，男性．1990年に左腎細胞癌の診断にて左腎摘出術を施行された．その際遠隔転移は見られず，以後経過観察されていた．2005年6月下旬，右腋窩に腫瘤を自覚し，7月4日精査のため当科に入院した．入院時右腋窩に小鶏卵大，弾性硬の腫瘤を触知し，エコーでは26×24mm，辺縁平滑で血管に富む腫瘤であった．血液検査上，腫瘍マーカーに大きな異常を認めなかった．胸部造影CTで同腫瘤は強い造影効果を認めた．腹部造影CTでは右腹直筋内および，膵鉤部にも造影される腫瘤を認めた．8月2日右腋窩腫瘤の切除生検を行った．組織所見が1990年に切除した左腎細胞癌と同様であったため，腎細胞癌の遠隔転移巣と診断した．全身状態良好であったため手術切除の適応と判断し，当院外科で膵および腹直筋の腫瘍核出術を施行した．切除病理標本はいずれも腎細胞癌由来の組織所見であった．その後の経過は良好であり，現在まで外来にて経過観察中である．本症例の経過は，根治術と考えられる腎細胞癌術後も長期にわたり全身の再発巣の有無を検索する必要性を示すものと考えられる．
Renal carcinoma
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Carcinoembryonic antigen
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We describe a case of bilateral renal cell carcinoma associated with chronic renal failure. A 49-year-old man was admitted to our hospital to initiate hemodialysis. He was found to have multiple renal cystic changes and a left renal mass by ultrasound. Computed tomographic (CT) scan showed a tumor 4 cm in diameter in the left kidney and another one 2 cm in diameter in the right kidney. Left nephrectomy was first performed and histopathological examination revealed renal cell carcinoma of mixed type and granular subtype. Six months after the operation, CT scan showed the mild growth of the tumor in the right kidney. Right nephrectomy was performed and histopathological examination revealed renal cell carcinoma of papillary type and granular subtype. The patient remains well on hemodialysis, with no evidence of recurrence or metastasis for 13 months after nephrectomy.
Chronic renal failure
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Bilateral renal cell carcinoma developing in a 55-year-old male receiving long-term dialysis is reported. The patient, who had undergone maintenance hemodialysis for 12 years, was admitted in July, 1986 for the purpose of extensive examination of a right renal mass. CT scan and ultrasonography demonstrated an enlarged bilateral kidney associated with multiple cysts, containing a solid mass in the right upper pole. The patients underwent right nephrectomy under the diagnosis of right renal tumor. The solid tumor 4 x 3 cm in size revealed a grade 1 to 2 renal cell carcinoma pathologically. Two small tumors were recognized in other portions of the kidney. Multiple cysts of varying sizes, the largest 2 cm in diameter, replaced the renal parenchyma. The cyst walls frequently contained hyperplastic changes. The patient has been subsequently followed up for 2 years and 9 months and underwent left nephrectomy for suspected left renal tumor. The surface of the left kidney was covered by numerous cysts. The result of pathological examination was renal cell carcinoma, which was recognized in a total of 7 regions of the left kidney. The patient remains well on hemodialysis, with no evidence of recurrence or metastasis.
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We describe a case of bilateral synchronous renal cell carcinoma. A 70-year-old female was admitted to our department because of further examination for bilateral renal masses. Computed tomographic scanning and ultrasound examinations revealed bilateral solid enhanced renal masses, and bilateral renal cell carcinomas were suspected. First, partial left nephrectomy was performed. On the 21th day after the first operation, we confirmed the recovery of the left kidney, and performed right nephrectomy laparoscopically. The histopathological diagnosis revealed bilateral renal cell carcinomas. The patient is alive with no metastatic lesions and no recurrence at 16 months after the operations.
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In patients with either bilateral renal malignancies or with carcinoma occurring in a solitary kidney, the principle of en bloc removal of the tumor-bearing kindey cannot be applied.Recently we have performed surgical enucleation in two cases of asynchronous bilateral renal cell carcinoma.Case 1. A 60-year-old woman was hospitalized with diangosis of left renal tumor 10 years tumor 10 years after right nephrectomy for renal cell carcinoma. The tumor was enucleated while occluding the renal vessles. Pathological examination revealed that the tumor (a nodule of 35g) was renal cell carcinoma of grade I and perfectly covered by pseudocapsule. Hemodialysis was not required. The patient has been well for more than 11 months postoperatively and Ccr is 65ml/min.Case 2. A 62-year-old man with slight elevation of serum GOT and GPT level was examined by CT, which revealed a space occupying lesion in the left kidney. He had undergone nephrectomy for renal cell carcinoma of right kindey 11 years ago. Three nodules of 56g, 6g and 3g were removed by in situ enucleation. They were renal cell carcinoma of grade II and there was no malignant penetration of the pseudocapsule pathologically. After surgery hemodialysis was required 10 times for 21 days. Renal function has been refined gradually and the patient is well with 47.3ml/min of Ccr at 4 months postoperatively.Before this report of 2 cases there were 22 cases of asynchronous bilateral renal cell carcinoma in Japanese literature. Of the 24 cases with renal cell carcinoma in the residual sole kidney, enucleation and partial nephrectomy for conserving renal tissue were performed in 8 and 2 cases, respectively. These 10 cases were alive from 3 to 42 months postoperatively. Hemodialysis after radical nephrectomy was done in 5 patients and various kinds of treatment, such as irradiation, chemotherapy and immunotherapy, were given to 9 cases, but the results were not satisfactory.Our experience and the satisfactory results achieved after surgical enucleation and partial nephrectomy suggest that these techniques have significant applicability in these patients.Although radical nephractomy must be considered as the optimum curative therapy for patients wiht localized renal cell carcinoma and a normal opposite kidney, enucleation and partial nephrectomy are the treatment of choice when localized low grade renal cell carcinoma is present in a solitary kidney.
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An 81-year-old female presented with abdominal discomfort. Computed tomography scan showed a 26 x 22 mm tumor in the left kidney and 43 x 37 mm tumor in the right kidney. Clinical diagnosis was bilateral renal cell carcinoma, left; cT1a, right; cT1bN0M0. We planned primary unilateral partial nephrectomy, followed by secondary contralateral radical nephrectomy. Left partial nephrectomy was performed and 4 months later, laparoscopic right renal nephrectomy was performed without serious postoperative renal dysfunction. Pathological diagnosis of both tumors was chromophobe renal carcinoma. The patient has been doing well without any evidence of recurrence or metastasis.
Chromophobe cell
Distant metastasis
Clear cell carcinoma
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A 61-year-old female presented with gross hematuria and left flank pain. The arteriogram and CT scan revealed a large left renal tumor and multiple small right renal metastatic tumors. A chest X-ray and Ga scintigram showed no other metastatic lesions. A left radical nephrectomy and a right renal bench surgery were performed at the same time. The right multiple tumors were enucleated and the right kidney was autotransplanted into the right iliac fossa. The postoperative course was uneventful and the patient was free of tumor with good renal function. Renal preservation surgery was considered more beneficial for this patient than bilateral nephrectomy followed by hemodialysis.
Iliac fossa
Bilateral Nephrectomy
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