Pulmonary resection for metastatic renal adenocarcinoma: pathologic findings and therapeutic value

Renal cell carcinoma lung metastases surgery: pathologic findings and prognostic factors

BACKGROUND

Renal cell carcinoma metastases are more frequently located in the lungs, with surgical results better than in other anatomic locations. Prognosis is darkened by incomplete resection, short disease-free interval, and number of lung metastases (LM). Our purpose was to further review these prognostic factors and related renal cell carcinoma disease characteristics.

METHODS

From 1984 to 2005, 65 consecutive patients underwent surgery for LM in view of cure. Studied factors were age, sex, smoking habits, forced expiratory volume in 1 second, disease-free interval, adjuvant therapy, size and number of metastases, lymph node involvement, and renal cell carcinoma pathologic staging. These factors were compared with those of 23 patients with previously resected renal cell carcinoma and undergoing surgery for lung cancer during the same period.

RESULTS

There were 44 unilateral and 21 bilateral LM; 83 operations were performed, with no postoperative deaths. Lung metastases were classified in four subgroups: single metastasis (n = 23), multiple unilateral metastases (n = 8), LM and other organ metastasis (n = 13), and bilateral LM (n = 21). Five-year overall survival (37.2% when resection was complete) was not statistically different among subgroups nor dependent on age, sex, smoking, forced expiratory volume in 1 second, disease-free interval, and adjuvant therapy, but was significantly influenced by the size of LM and lymph node involvement (univariate and multivariate analyses). Lymph node involvement was less frequent than in patients operated on for lung cancer: respectively, 13 of 65 (20%) and 13 of 23 (56.5%; p = 0.0009). Intrathoracic metastatic spread was not related to a particular renal cell carcinoma pathologic tumor staging (pT) subgroup.

CONCLUSIONS

Size of LM and lymph node involvement are important prognostic factors. They suggest a metastatic mode of spread involving the renal lymphatic drainages and specific biologic characteristics acquired by selected tumor cells.

Solitary pulmonary metastases from renal cell carcinoma: comparison of high-resolution CT with pathological findings

PURPOSE

The aim of this study was to examine the radiographic features of solitary pulmonary metastases from renal cell carcinoma by comparing high-resolution CT (HRCT) findings with histopathological observations.

MATERIALS AND METHODS

Three thoracic radiologists retrospectively reviewed HRCT findings from eight patients who underwent surgery on the basis of the diagnosis of solitary pulmonary metastatic renal cell carcinoma. The histopathological diagnoses for six of these eight lesions were metastases from clear cell carcinoma of the kidney, one case was a metastasis from papillary renal cell carcinoma, and the remaining case was a metastasis from a poorly differentiated carcinoma including predominantly spindle cells, papillary cells, and clear cells.

RESULTS

The HRCT findings of all cases of clear cell carcinoma showed solid nodular lesions without ground-glass attenuation (GGA). The HRCT findings for one case of papillary renal cell carcinoma showed a lobulated nodule with a small amount of GGA in an area in the periphery and an air bronchogram. The HRCT findings of the remaining case of poorly differentiated carcinoma showed an ill-defined nodule with a GGA area and pleural indentations.

CONCLUSION

In brief, solitary pulmonary metastases from renal cell carcinoma may present as a smoothly marginated nodule, lobulated nodule, or a nodule with peripheral GGA.

Prognostic factors for survival after pulmonary resection of metastatic renal cell carcinoma

BACKGROUND

Pulmonary resection in metastatic renal cell carcinoma is an accepted method of treatment. The purpose of this study was to determine the clinical course, outcome, and prognostic factors after surgery.

METHODS

Between 1985 and 1999, 191 patients (145 men, 46 women) with pulmonary metastases from a renal cell carcinoma underwent surgical resection. Inclusion criteria for the study were the absence of primary tumor recurrence and other extrapulmonary metastases. Complete resection (CR) was achieved in 149 patients.

RESULTS

The overall 5-year survival rate was 36.9%. The 5-year survival rate after complete metastasectomy and incomplete resection was 41.5% and 22.1%, respectively. In patients with pulmonary or mediastinal lymph node metastases, we observed after complete resection a 5-year survival rate of 24.4%, whereas the rate was 42.1% in patients without lymph node involvement. A significantly longer survival was observed for patients with fewer than seven pulmonary metastases compared with patients with more than seven metastases (46.8% vs 14.5%). For surgically rendered complete resection (CR) patients with a disease-free interval of 0 to 23 months, the 5-year survival rate was 24.7% compared with 47% for those with more than a 23-month disease-free interval. By multivariate analyses, we showed that the number of pulmonary metastases, the involvement of lymph node metastases, and the length of the disease-free interval were all predictors of survival after complete resection.

CONCLUSIONS

We conclude that pulmonary resection in metastatic renal cell carcinoma is a safe and effective treatment that offers improved survival benefit. Prognosis-related criteria are identified that support patient selection for surgery.

Solitary renal cell carcinoma metastasis to the hand: the need for wide excision or amputation

Metastatic renal cell carcinoma responds poorly to chemotherapy or radiation therapy and is associated with a dismal survival rate. In cases of a solitary acrometastasis, the literature supports complete resection of the lesion in an effort to prolong survival. We report a patient who presented with a solitary metachronous renal cell metastasis to the middle phalanx of the index finger. The lesion was correctly identified as a renal cell metastasis and aggressive surgical management was performed with curative intent.

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.

Pulmonary clear cell carcinoid tumor: another entity in the differential diagnosis of pulmonary clear cell neoplasia

A clear cell variant of primary pulmonary carcinoid tumor is described. The tumor arose in a 53-year-old woman who was incidentally found to have a solitary pulmonary nodule in the left upper lobe during routine chest roentgenography. Histologically, the tumor was composed of predominantly clear to lightly eosinophilic, polygonal cells with bland nuclei arranged in sheets and nests. Nuclear pleomorphism, necrosis, vascular invasion, and mitotic figures were not seen. The tumor cells were negative for oil-red-O and periodic acid-Schiff stains with and without diastase pretreatment on frozen and formalin-fixed sections, respectively. During immunohistochemical evaluation, the tumor cells were focally positive for cytokeratin and diffusely positive for neuron-specific enolase and chromogranin. Electron microscopy performed on paraffin block-retrieved tissue showed the presence of electron-dense, neurosecretory-type granules and variably sized vacuolated areas within the cytoplasm. the nature of which remained unclear. Intracytoplasmic glycogen or lipid were not identified. To our knowledge, this is the first report of pulmonary clear cell carcinoid tumor.

Pulmonary resection of metastatic renal cell carcinoma

Between 1965 and 1989, 96 consecutive patients (64 men and 32 women) underwent complete pulmonary resection for metastatic renal cell carcinoma. Median age was 63 years (range, 33 to 82 years). Median time between nephrectomy and pulmonary resection was 3.4 years (range, 0 to 18.4 years). Forty-eight patients had solitary metastasis, 16 had two, 18 had three, and 14 had more than three. Wedge excision was performed in 62 patients, segmentectomy in 3, lobectomy in 25, bilobectomy in 3, and pneumonectomy in 3. Fourteen patients had repeat thoracotomy for recurrent metastasis; 34 other patients also had complete resection of limited extrapulmonary disease. There were no operative deaths. Median follow-up was 3 years (range, 70 days to 19.0 years). Overall 5-year survival was 35.9%. Patients with solitary metastasis had a 5-year survival of 45.6% compared with 27.0% for patients with multiple metastases (p < 0.05). Patients with a tumor-free interval greater than the median of 3.4 years had a better survival (p = 0.05) than those with a tumor-free interval less than or equal to 3.4 years. Five-year survival for patients who underwent repeat thoracotomy or had complete resection of extrapulmonary disease did not differ from overall survival. We conclude that resection of renal lung metastasis is safe and effective, that patients with solitary metastasis have a better survival than those with multiple metastases, that resectable extrapulmonary disease does not necessarily contra-indicate pulmonary resection, and that repeat thoracotomy is warranted in selected patients with recurrent lung metastases.

Renal derived epistaxis

A solitary metastasis to the nose from a renal cell carcinoma is extremely rare. One such case is presented and the argument for aggressive therapy to these lesions is reviewed.

Renal cell carcinoma: resection of solitary and multiple metastases

Between 1985 and 1991, 23 patients underwent resection of pulmonary metastases from renal cell carcinoma, of whom 18 had previously received interleukin-2 based immunotherapies. Mean survival from exploration in all patients was 43 months. Survival after resection did not correlate with the number of nodules on preoperative tomograms, the number of nodules resected, or the disease-free interval. Patients who underwent complete resection of metastatic disease (n = 15), however, had a significantly longer survival (mean, 49 months; median not yet achieved) compared with patients with incomplete resection (median, 16 months) (p2 = 0.02). Two of the 15 patients who underwent curative resections are presently free of disease greater than 45 months after exploration. These data support surgical resection of isolated pulmonary metastatic disease from renal cell cancer.

Metastatic renal carcinoma to the parotid gland

A case of renal carcinoma metastatic to the left parotid gland is presented. A 60-year-old male patient developed a painful mass in his left parotid region one and a half years after he had undergone a left nephrectomy operation for renal carcinoma. The mass was excised surgically. The histopathological diagnosis was metastatic renal carcinoma. From a review of the literature, it is apparent that unlike most of the cases reported, this one had a very aggressive nature. The clinical presentation of the metastasis, and the factors determining the prognosis in cases of metastatic renal carcinoma to the head and neck are discussed.

Salvage surgery for renal cell carcinoma

Complete surgical excision of solitary metastatic lesions in renal cell carcinoma has been reported to be associated with improved survival. An analysis of 65 outpatients undergoing excision of metastatic renal cell carcinoma is reviewed. In our series there was no significant difference among patients with solitary versus those with multiple metastasis. The overall 5-year survival was considerably lower than previously reported. We recommend that only patients with good performance status, who are participating in protocols with biological response modifiers, could potentially benefit from surgical removal of metastatic lesions.

Results of surgical treatment of renal cell carcinoma with solitary metastasis

To determine the effect on survival of excision of a solitary metastasis from renal cell carcinoma, the records of 29 patients seen at our institute within the last 15 years (1972 to 1986) who underwent such an operation were reviewed. Metastasis was present at diagnosis in 11 of the 29 patients, while 18 had metastasis 2 months to 11 years after nephrectomy, with an average interval free of disease of 38 months. There were 13 pulmonary metastases, 6 bone lesions and 10 other lesions. The estimated over-all survival rate for this group was 41 per cent at 2 years and 13 per cent at 5 years after excision of the metastasis. Only 2 of the 29 patients currently are alive with no evidence of disease 42 and 53 months since excision of the metastasis. Neither the presence nor absence of a metastasis at diagnosis nor the interval between nephrectomy and the development of a metastasis in patients without metastatic disease at diagnosis appeared to influence survival after excision of the metastasis. Unlike previous reports, these results suggest that the beneficial effects of excision of metastatic renal cell carcinoma are limited to improved short-term survival postoperatively and that surgical cure of patients with metastatic renal cell carcinoma is a relatively uncommon event.

Prognostic factors of adult metastatic renal carcinoma: a multivariate analysis

In order to define the prognostic factors for metastatic renal carcinoma, we reviewed 134 patients who were treated from 1971 through 1986. Survival rates were 72, 45, and 25% at 6, 12, and 18 months, respectively. Seventeen variables were tested using the logrank test. Improved survival was correlated with normal performance status, and an absence of fever, weight loss, hepatic metastasis, and lung metastasis (or, if lung metastasis was present, less than 2 cm in diameter and limited to one site), a disease-free interval, sedimentation rate less than 100, and renal surgery. Four variables retained significant value in the multivariate analysis: hepatic metastasis, lung metastasis, disease-free interval, and a variable combining the sedimentation rate and the weight loss (SWRL). Predictive survival rates based on these variables were calculated from the Cox model. Six subgroups of patients were identified. The estimation of survival is clinically of value for future phase II trials of chemotherapy in patients with adult metastatic renal carcinoma.

Benign clear cell (sugar) tumor of the lung. A light microscopic, histochemical, and ultrastructural study with a review of the literature

A case of a benign clear cell "sugar" tumor of the lung is reported. Light microscopy showed a uniform proliferation of clear cells filled with abundant glycogen. At the ultrastructural level, tumor cells were rich in free monogranular and rosette-forming glycogen, but no membrane-bound glycogen was demonstrated. Some cells showed plasma membrane interdigitations, microvilli, and macula occludens-type junctions. Many polymorphic secretory and sporadic haloed neurosecretory-like granules were observed, but argyrophil stains as well as a large set of immunohistochemical reactions specific for APUD derivation had negative results. A literature review of this puzzling entity with particular emphasis on the histogenetic hypotheses is presented, and a derivation from epithelial nonciliated bronchiolar (Clara) cells or epithelial serous cells is suggested.

Ovarian metastases from cancer of the lung: problems in interpretation--a report of seven cases

Seven women, 26 to 66 (average 42) years of age, from whom ovarian tumors were removed before (three cases), synchronously with (three cases), or less than 1 year after (one case) the discovery of a pulmonary neoplasm are the subjects of this report. The ovarian tumor was unilateral in six cases and bilateral in one case and was unassociated with intraabdominal spread. The lung tumors, which were similar to the ovarian tumors on microscopic examination, were central in six cases and peripheral in one; three of them were small cell undifferentiated carcinomas, two large cell undifferentiated carcinomas, one a poorly differentiated adenocarcinoma, and one an atypical spindle cell carcinoid tumor. In each case the question of the primary site of the tumor had been raised clinically. The histological similarity of the ovarian and pulmonary tumors in all the cases to well-recognized forms of pulmonary neoplasia as well as additional clinical and pathological features of the cases led to an interpretation of a pulmonary origin of the tumors in all the cases.

Pulmonary resection of metastatic renal cell carcinoma

Over a ten-year period, 44 patients with known primary renal cell cancer underwent thoracotomy for pulmonary metastases. The median postthoracotomy survival for all patients was 33 months. The five-year survival was 27 percent. Postthoracotomy survival was significantly better in those patients with a disease free interval of greater than 24 months and patients with metastatic lesions greater than or equal to 3 cm. No difference in survival was detected in patients with one versus more than one lesion or in patients undergoing complete resection versus incomplete resection or biopsy only. Age, sex, grade of tumor, or location of the pulmonary metastasis had no influence on survival.

The clinical course and prognosis of patients with renal adenocarcinoma with solitary metastasis

The present investigation describes a series of 25 patients with solitary metastasis from a renal adenocarcinoma. Forty-eight percent of the patients had metastatic foci in bones, 24% in the lungs, and 28% in a variety of organs. Radiotherapy was the treatment for 64% of the patients, surgery for 36%. Disease control after treatment was obtained in 88% of the patients. The 5-year survival rate was 39%. Sixteen of 25 patients died after a mean survival time of 36 months; 9/25 patients are still living 28-126 months after treatment. Women survived significantly better than men. Patients with normal pre- and post-treatment erythrocyte sedimentation rate (ESR) survived significantly longer than patients with elevated ESR. A definite relationship between ESR and disease activity was demonstrated in 64% of the patients. We concluded that solitary metastases in bones can be treated with radiotherapy; even if 64% of the patients die there is significant clinical remission to be obtained after aggressive treatment. Furthermore, ESR seems to be an important indicator of prognosis and disease activity.

Renal adenocarcinoma presenting as a solitary metastasis: contribution of electron microscopy to diagnosis

Two patients, presenting with single mass lesions involving the posterior fossa and temporal bone, respectively, are reported. Clinically, both were thought to have primary tumors in those locations, hemangioblastoma in one and glomus jugulare paraganglioma in the other. Morphologic evaluation was compatible with adenocarcinoma of renal origin and large renal tumors were subsequently found in both patients. Electron microscopy was useful in eliminating the possibility of a primary tumor in those respective locations by demonstrating focal, but conspicuous dense arrays of microvilli at intercellular areas or along the free surfaces of plasma membranes. Microvilli do not, by themselves, signify any specific primary organ site. However, taken in the clinical and histologic contexts of a given case, ultrastructural observations can assist in establishing a definitive diagnosis.

A case report of a thymoma associated with a renal adenocarcinoma

We report a case of renal adenocarcinoma and a solitary lung lesion thought to be metastatic disease. Further evaluation revealed the lung lesion to be a benign thymoma. This is the first case of such an association reported in the English literature.

The histologic spectrum and significance of clear-cell change in lung carcinoma

We reviewed 348 consecutive cases of lung carcinoma to determine the incidence and significance of clear-cell carcinoma. Areas composed of clear cells were common in all types of lung carcinoma except small cell carcinoma. The clear cytoplasm in most cases contained glycogen. We found only one tumor fulfilling the World Health Organization (W.H.O.) criteria for clear-cell carcinoma. There were 14 other tumors which contained over 50% clear cells and therefore could be considered clear-cell carcinomas by some published criteria. Ten of these tumors also showed foci of epidermoid differentiation while four showed gland formation. The prognosis of tumors containing even large areas of clear cells does not appear to differ from that reported for the common lung carcinomas. We feel that clear-cell carcinoma should not be considered a distinct clinicopathologic entity. Rather, tumors composed even predominantly of clear cells should be classified according to the major W.H.O. categories.