Review on renal cell carcinoma and pregnancy: A challenging situation

Renal mass imaging modalities: does body mass index (BMI) matter?

PURPOSE

Accurate measurement of renal mass size is crucial in the management of renal cancer. With the burdensome cost of imaging yet its need for management, a better understanding of the variability among patients when determining mass size remains of urgent importance. Current guidelines on optimal imaging are limited, especially with respect to body mass index (BMI). The aim of this study is to discern which modalities accurately measure renal mass size and whether BMI influences such accuracy.

METHODS

A multi-institutional chart review was performed for adult patients undergoing partial or radical nephrectomy between 2018 and 2021, with 236 patients ultimately included. Patients were categorized by BMI (BMI 1: 18.5-24.9, BMI 2: 25-29.9, BMI 3: 30-34.9, and BMI 4: ≥ 35). The greatest mass lengths were compared between the pathology report and the following: computerized tomography (CT), renal ultrasound, and magnetic resonance imaging (MRI).

RESULTS

The difference between greatest length on CT with contrast and MRI were significantly different when compared to pathologic measurement. BMI groups 3 and 4 were found to have a significant difference in size estimates compared to BMI 2 for CT with contrast. No difference was found between size estimates by BMI group for any other imaging modality.

CONCLUSION

CT with contrast becomes less accurate at estimating mass size for patients with BMI > 30. While contrast-enhanced CT remains a vital imaging modality for tissue enhancement in the context of unknown renal masses, caution must be used for mass size estimation in the obese population.

Pregnant patient with Xp11.2/transcription factor E3 translocation renal cell carcinoma: a case report and literature review

MiT family translocation renal cell carcinomas (tRCCs) primarily include Xp11.2/transcription factor E3 (TFE3) gene fusion-associated renal cell carcinoma (Xp11.2 tRCC) and t(6;11)/TFEB gene fusion-associated RCC. Clinical cases of these carcinomas are rare. Fluorescence in situ hybridization can be used to identify the type, but there are no standard diagnostic and treatment methods available, and the prognosis remains controversial. Herein, we present a case of a patient with Xp11.2 tRCC at 29 weeks of gestation. The baby was successfully delivered, and radical surgery was performed for renal cancer at the same time. This is a unique and extremely rare case. We have described the case and performed a literature review to report the progress of current research on the treatment and prognosis of pregnant patients with Xp11.2/TFE3 translocation renal cell carcinoma. This study aims to contribute to improving the diagnosis and treatment of Xp11.2 tRCC in pregnant patients.

Eosinophilic Variant of Chromophobe Renal Cell Carcinoma During Pregnancy: A Multidisciplinary Approach and Successful Management in a Tertiary Hospital in Mexico

Renal cell carcinoma (RCC) is rarely diagnosed during pregnancy and its management represents a challenge as it necessitates considerations for the well-being of both the mother and the developing fetus. Diagnosis can be challenging and is often an incidental finding during routine imaging, which can lead to difficult decision-making. The choice of the ideal imaging study in these cases is a matter of debate. When the tumor is detected at an early stage, radical nephrectomy is indicated. However, there is still controversy regarding whether it should be performed conventionally or laparoscopically, as both techniques have their risks and benefits. In this context, our primary objective was to provide adequate surgical treatment for the patient, while safeguarding fetal health. Here, we present a patient with a history of recurrent miscarriages, in whom a renal tumor was incidentally diagnosed during pregnancy. Adding to the uniqueness of this case, the patient was diagnosed with an eosinophilic variant of chromophobe RCC through histopathological analysis. Our aim is to highlight the controversies surrounding diagnostic and treatment methodologies and to present the surgical techniques employed in this unique situation. This case underscores the importance and need for a multidisciplinary approach, which, in our instance, resulted in favorable outcomes for both maternal and neonatal health.

Prognosis, counseling, and indications for termination of pregnancy

As the coincidence of pregnancy and cancer rise, clinicians must be prepared to counsel their patients on the complex relationship between maternal and fetal health. In most types of cancer, maternal prognosis mirrors that of non-pregnant women. However, challenges associated with the timing of diagnosis and treatment can present additional risks. Consequently, pregnant cancer patients must be counseled early and effectively with regard to how their pregnancy status affects treatment options and the range of expected outcomes for both mother and fetus. Some patients choose to terminate pregnancy after such counseling, though the specific course of action depends on the cancer in question, the stage at diagnosis, and the personal priorities and values of the patient.

Etiologies, Gross Appearance, Histopathological Patterns, Prognosis, and Best Treatments for Subtypes of Renal Carcinoma: An Educational Review

Of all primary renal neoplasms, 80-85% are renal cell carcinomas (RCCs), which develop in the renal cortex. There are more than 10 histological and molecular subtypes of the disease, the most frequent of which is clear cell RCC, which also causes most cancer-related deaths. Other renal neoplasms, including urothelial carcinoma, Wilms' tumor, and renal sarcoma, each affect a particular age group and have specific gross and histological features. Due to the genetic susceptibility of each of these malignancies, early mutation discovery is necessary for the early detection of a tumor. Furthermore, it is crucial to avoid environmental factors leading to each type. This study provides relatively detailed and essential information regarding each subtype of renal carcinoma.

Renal Tumors in Pregnancy: A Case Report Focusing on the Timing of the Surgery and Patient Positioning

Management of renal mass during pregnancy is challenging. There is no consensus regarding the fundamental timing issues (which trimester) of the interventions and patient positioning during the procedures. We present three pregnant women with renal mass and their management, focusing on patient positioning and timing of surgical intervention. All patients were positioned supine with a 30-degree rotation to the left lateral without signs of compromising fetal circulation. This report's three major takeaway points are the following: (1) Renal mass biopsy might be more beneficial in pregnant women than the normal population (unless CT findings suggest vascular angiomyolipomas) to achieve a definite diagnosis and avoid unnecessary interventions during pregnancy. (2) Surgical interventions, if indicated, should be performed as soon as possible and are applicable in all trimesters of pregnancy. (3) A minimum of 15-degree left lateral tilt (for both right- and left-sided renal masses) can provide enough venous return during the nephrectomy.

Diagnosis and Treatment of Renal Cell Carcinoma During Pregnancy

Renal cell carcinoma during pregnancy is extremely rare, but it is the commonest urological malignancy reported in pregnancy. Currently, no uniform domestic or international diagnostic or treatment criteria exist for these patients, so their diagnosis and treatment are challenging for urologists. The health and reproductive needs of these patients have improved in recent years because of the continuous development of medical technology. This article reviews the epidemiology, risk factors, diagnosis, treatment, and prognosis of renal cell carcinoma during pregnancy.

Sex and Gender Differences in Kidney Cancer: Clinical and Experimental Evidence

Simple Summary

Kidney cancer is a frequent malignant tumor that accounts for approximately 5% of all cancer incidences. It affects both males and females, but males are twice as likely to develop kidney cancer than females. Evidence shows that this discrepancy takes root in individual differences, such as genetics or pathologies that affect the patient. It is then reflected in the clinical characteristics of the tumors, as males have larger and more aggressive tumors. Understanding the sex- and gender-based differences in kidney cancer is essential to be able to offer patients individualized medicine that would better cover their needs in terms of prevention, diagnosis and treatment.

Abstract

Sex and gender disparities have been reported for different types of non-reproductive cancers. Males are two times more likely to develop kidney cancer than females and have a higher death rate. These differences can be explained by looking at genetics and genomics, as well as other risk factors such as hypertension and obesity, lifestyle, and female sex hormones. Examination of the hormonal signaling pathways bring further insights into sex-related differences. Sex and gender-based disparities can be observed at the diagnostic, histological and treatment levels, leading to significant outcome difference. This review summarizes the current knowledge about sex and gender-related differences in the clinical presentation of patients with kidney cancer and the possible biological mechanisms that could explain these observations. Underlying sex-based differences may contribute to the development of sex-specific prognostic and diagnostic tools and the improvement of personalized therapies.

Wunder-women: Systematic review of causes, treatment and outcomes of Wunderlich syndrome during pregnancy

Objective:

The objective of this article is to conduct a contemporary literature review on Wunderlich syndrome, or spontaneous renal haemorrhage (SRH), among pregnant women to describe contemporary aetiology, investigations and management patterns.

Methods:

A systematic review of MEDLINE and CENTRAL in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. All articles, including case reports and case series on SRH published from 2000 to 2016, were included. Full-text manuscripts describing SRH among pregnant women were reviewed for clinical parameters, which were collated and analysed.

Results:

Twenty cases of SRH in pregnant women were identified. The median age and gestation were 32.1 years and 26.5 weeks, respectively, with SRH most commonly occurring in the third trimester (nine patients; 45%) and due to renal neoplasm, specifically angiomyolipoma (AML; 12 patients; 60%), followed by renal artery aneurysm (RAA; five patients; 25%). Surgical intervention (55%) was most commonly used for acute SRH. Foetal demise was not uncommon (15%).

Conclusions:

SRH in pregnant women is an uncommon but complex urological and obstetric emergency with potentially catastrophic consequences. A multidisciplinary approach is key to timely diagnosis and appropriate management considering the well-being both of mother and foetus. Pre-emptive diagnosis and intervention may reduce complications.

Level of evidence:

4

Renal cell carcinoma diagnosed during pregnancy: a case report and literature review

Diagnosing cancer during pregnancy is uncommon. Although pregnancies with concomitant malignancies have been reported, urological tumours are possibly the most rarely identified tumours during pregnancy. Renal cell carcinoma appears to be the most common urological malignancy during pregnancy. In this case report, we discuss successful management of a patient who was diagnosed with renal cell carcinoma during the antenatal period.

Peculiarities and management challenges of advanced renal cell carcinoma incidentally discovered in pregnancy

Our aim is that urologists, gynecologists, nephrologists, and general practitioners will be reminded that diagnosis of renal malignancies sometimes require a high index of suspicion as they may remain asymptomatic in advanced stages; even as they can also rarely co‐exist with and cause peculiar challenges in pregnancy.

Renal cell carcinoma with inferior vena cava thrombus extending to the right atrium diagnosed during pregnancy

Only one case of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus diagnosed and treated during pregnancy has been reported in the literature. In that report, the tumor thrombus extended to the infrahepatic IVC (level II tumor thrombus). In the present case, a 37-year-old woman with lupus anticoagulant antibodies was diagnosed with RCC and IVC tumor thrombus extending to the right atrium (level IV tumor thrombus) at 24 weeks of pregnancy. The fetus was safely delivered by cesarean section at 30 weeks of gestation. At 4 days later, an open right radical nephrectomy and IVC and right atrial thrombectomy were performed on cardiopulmonary bypass (CPB) once the patient's hemodynamic status had been optimized. Fetal and maternal concerns included the risk of a thromboembolic event (due to increased hypercoagulability from pregnancy, active malignancy, and lupus anticoagulant), intraoperative hemorrhage risk (due to extensive venous collaterals and anticoagulation), and fetal morbidity and mortality (due to fetal lung immaturity). Standardized guidelines for treatment of RCC with or without IVC tumor thrombus during pregnancy are unavailable due to the infrequency of such cases. Treatment decisions are therefore individualized and this case report may inform the management of future patients diagnosed with RCC with level IV tumor thrombus during pregnancy.