Pulmonary manifestations of renal cell carcinoma

Predictive factors of nivolumab plus ipilimumab treatment efficacy in metastatic renal cell carcinoma patients

OBJECTIVE

Nivolumab plus ipilimumab is a recommended first-line therapy regimen for metastatic renal cell carcinoma. However, it is not clear which patient characteristics are associated with its effectiveness.

METHODS

We retrospectively examined 67 metastatic renal cell carcinoma patients treated with nivolumab plus ipilimumab as a first-line therapy in multiple institutions from September 2018 to August 2022. We analyzed the relationships between survival outcomes and patient-related variables, including paraneoplastic symptoms. We also analyzed the relationships between changes in symptoms and parameters and outcomes.

RESULTS

Of the 67 patients, 32 patients had paraneoplastic symptoms. The median progression-free survival was 14.9 months and median overall survival was 43.3 months. The objective response rate was 49.25% (33 patients), including two patients with complete response. Patients with cytoreductive nephrectomy, bone metastasis, high C-reactive protein levels and paraneoplastic symptoms were significantly correlated with short progression-free survival in the univariate analysis. Multivariate analysis of these factors showed that the presence of paraneoplastic symptoms at treatment initiation remained an independent predictor of progression-free survival. Of the 32 patients with paraneoplastic symptoms at treatment initiation, 12 patients had symptomatic improvement and 20 did not. The 1-year progression-free survival rates were significantly longer in improved patients compared with those with no improvement.

CONCLUSIONS

Patients without cytoreductive nephrectomy and with bone metastasis, liver metastasis, high C-reactive protein levels and paraneoplastic symptoms were significantly correlated with shorter progression-free survival. The presence of paraneoplastic symptoms was an independent predictor of progression-free survival. Improvement in paraneoplastic symptoms may reflect the treatment efficacy of nivolumab plus ipilimumab.

Resolution of multiorgan sarcoid-like reaction after treatment of renal cell carcinoma

Sarcoid -like reactions (SLRs) can occur in several malignancies adjacent to primary tumour location or the draining lymph nodes. The presence of peritumoural and intratumoural SLR in patients suffering from renal cell carcinoma (RCC) has been reported in few instances. However, the association of RCC with SLR in spleen, liver and other organs in the absence of systemic sarcoidosis is very rare.We present an unusual case of a gentleman in his 30s, who presented with a lesion in the left kidney along with non-specific lesions (likely granulomatous) in liver, spleen and lungs. Partial Nnephrectomy specimen confirmed conventional/clear cell RCC. The histopathology revealed an extensive epithelioid granulomatous reaction affecting both peritumoural and intratumoural areas. Follow-up images demonstrated an almost complete resolution of lesions in the spleen, liver and lungs. Our case supports the hypothesis that non-caseating granulomas of SLR could be a manifestation of an immunologically mediated antitumour response.

Metastasectomy for extracalvarial renal cell carcinoma

Key Clinical Message

Palliative surgical resection of extra-calvarial metastatic lesions from renal cell tumors is crucial for controlling metastatic spread, improving quality of life, and preventing associated morbidity. Careful surgical planning, including selective preoperative embolization and controlled resection around critical structures such as the sagittal sinus, is essential for successful outcomes. Cranioplasty with Titanium mesh and bone cement post-resection can provide symptomatic relief, better cosmesis, and overall improved quality of life.

Abstract

Renal cell carcinomas are aggressive tumors with distant systemic disease. The calvarium appears to be an unusual and rare site for distant metastasis. The treatment modalities are challenging and out of the normal realm for the management of these tumors. We report a case of a 63-year-old woman with a previous history of nephrectomy who presented with symptoms of severe headaches, and swelling of bi-frontal and bi-parietal scalp regions due to multifocal extracalvarial disease. Preoperative bilateral superficial temporal artery embolization was performed to control the intraoperative bleeding. Surgical technique has been described with the critical steps involved, and a literature review has been conducted. Palliative tumor resection surgery was performed to improve the patient's quality of life as well as to confirm the histopathological diagnosis. Gross total resection of the extracalvarial metastatic tumor was achieved. Biopsy confirmed renal cell tumor with the clear cell subtype. The patient recovered well from her surgery with slow healing of the scalp wound. At 6-month follow-up, no recurrence of the extracalvarial disease was observed on serial imaging. Extracalvarial metastasis is a rare presentation in renal cell carcinoma. Considering the inherent radioresistant nature of the tumor, palliative surgical resection can be offered to control the metastatic spread, relieve agonizing pain symptoms, and to improve the quality of life. Preoperative embolization helps to decrease intraoperative blood loss. Moreover, palliative surgical resection of extracalvarial diseases helps to treat the metastasis as well as avoiding the associated morbidity that may occur if left untreated.

Therapeutic options for different metastatic sites arising from renal cell carcinoma: A review

Renal cell carcinoma (RCC) stands among the top 10 malignant neoplasms with the highest fatality rates. It exhibits pronounced heterogeneity and robust metastatic behavior. Patients with RCC may present with solitary or multiple metastatic lesions at various anatomical sites, and their prognoses are contingent upon the site of metastasis. When deliberating the optimal therapeutic approach for a patient, thorough evaluation of significant risk factors such as the feasibility of complete resection, the presence of oligometastases, and the patient's functional and physical condition is imperative. Recognizing the nuanced differences in RCC metastasis to distinct organs proves advantageous in contemplating potential treatment modalities aimed at optimizing survival outcomes. Moreover, discerning the metastatic site holds promise for enhancing risk stratification in individuals with metastatic RCC. This review summarizes the recent data pertaining to the current status of different RCC metastatic sites and elucidates their role in informing clinical management strategies across diverse metastatic locales of RCC.

Endobronchial localization - arena of two tumors: a case report

The lung is a common arena for metastases of tumors with different localization, but endobronchial localization of metastases is very rare. The most common tumors with endobronchial localization of metastasis are renal, breast, and colorectal cancer. We report a man presenting with cough and hemoptysis. Endobronchial biopsy showed renal cell carcinoma and micro-invasive bronchogenic squamous cell carcinoma. Endobronchial metastases from renal cell carcinoma are rare. The squamous cell lung cancer is one of the most common cancers in men, but the combination of renal cell carcinoma and micro-invasive squamous cell carcinoma with endobronchial localization is a casuistic case.

Renal Cell Carcinoma Presenting as Syncope due to Saddle Pulmonary Tumor Embolism

Pulmonary embolism (PE) is defined as the obstruction of the pulmonary artery or one of its branches by a blood clot, tumor, air, or fat emboli originating elsewhere in the body. A saddle PE occurs when the obstruction affects the bifurcation of the main pulmonary artery trunk. We present a case of a 46-year-old man who presented to our hospital due to an episode of syncope. Computed tomography angiography (CTA) of the chest showed extensive PE and abdominal CT scan showed a large 8 cm left renal mass with inferior vena cava (IVC) thrombus. Emergent embolectomy, left total nephrectomy, and IVC tumor removal were performed yielding the diagnosis of clear cell renal cell carcinoma (RCC). Interestingly, our patient did not experience any symptoms related to his RCC until the diagnosis of PE due to syncope, and the asymptomatic tumor was found out to be the possible cause of this PE due to the presence of tumor cells constituting the tumor embolus. It is thus recommended to improve the early screening process for RCC. Besides, clinicians should pay attention to patients presenting with uncharacteristic symptoms of RCC who might present with symptoms of saddle PE.

The roles and mechanisms of circular RNAs related to mTOR in cancers

BACKGROUND

Circular RNAs (circRNAs) are stable molecules with covalently closed structures that have an irreplaceable role in the occurrence, progression, and even treatment of plenty of cancers. Mammalian/mechanistic target of rapamycin (mTOR) is a key regulator in cancers and plays several biological functions, such as proliferation, migration, invasion, autophagy, and apoptosis.

METHODS

All data were collected through PubMed and CNKI, using terms including "circRNA," "mTOR," "caner," "signaling pathway," "biomarker," "diagnosis," "treatment." Articles published in Chinese and English were included.

RESULTS

In this review, the expression, function, and mechanism of circRNA-associated mTOR in cancers were described. CircRNA-associated-mTOR can regulate the progression and therapy of a variety of cancers in multiple signaling pathways, such as phosphatidylinositol-3-kinase (PI3K)/protein kinase B (Akt)/mTOR, mitogen-activated protein kinase (MAPK)/mTOR, and AMP-activated protein kinase (AMPK)/mTOR axis. These cancers including esophageal carcinoma (circLPAR3, ciRS-7), gastric cancer (circNRIP1, hsa_circ_0010882, hsa_circ_0000117, hsa_circ_0072309, and circST3GAL6), colorectal cancer (hsa_circ_0000392, hsa_circ_0084927, hsa_circ_0104631, and circFBXW7), liver cancer (circC16orf62, hsa_circ_100338, hsa_circ_0004001, hsa_circ_0004123, hsa_circ_0075792, hsa_circ_0079299, and hsa_circ_0002130), pancreatic cancer (circ-IARS and circRHOBTB3), renal carcinoma (ciRS-7), bladder cancer (circUBE2K), prostate cancer (circMBOAT2 and circ-ITCH), ovarian cancer (circEEF2, circRAB11FIP1, circMYLK, and circTPCN), endometrial cancer (hsa_circ_0002577 and circWHSC1), lung cancer (circHIPK3, hsa_circ_0001666), thyroid cancer (hsa_circ_0007694 and hsa_circ_0008274), glioma (circGFRA1, circ-MAPK4, circPCMTD1, and hsa_circ_0037251), osteosarcoma (circTCF25), leukemia (circ-PRKDC), and breast cancer (hsa_circ_0000199, circUBAP2, and circWHSC1).

Surgical treatment in malignant pleural effusion

Malignant pleural effusion can be described as the presence of exudate in the pleural space, accompanied by the detection of cancer cells in pleural fluid or tissue, which is the indicator of the disease in its advance stages, and survival time of these patients ranges between 3 and 12 months. Treatment options for malignant pleural effusion vary from observation in asymptomatic patients to pleurectomies or even extrapleural pneumonectomies in severe cases.

A case of renal cell carcinoma with microscopic pulmonary tumor embolism proven by surgical lung biopsy

Pulmonary tumor embolism (PTE) is difficult to diagnose before death. We report the case of a 75-year-old man with microscopic PTE of renal cell carcinoma who was diagnosed by surgical lung biopsy. He visited our hospital because of dyspnea on exertion. Chest computed tomography (CT) showed multiple micronodules and ground glass opacities. Steroid therapy was started as therapeutic diagnosis for IgG4-related pulmonary disease. However, he was admitted our hospital due to progressive respiratory failure. Pathological findings of a lung biopsy obtained by video-assisted thoracic surgery showed PTE of renal cell carcinoma without embolization of large pulmonary arteries. He received palliative medicine and died four months after the surgical lung biopsy. In cases of multiple micronodules in chest CT findings and worsened respiratory symptoms, PTE should be considered in the differential diagnosis.

Intractable Cough Associated With Renal Cell Carcinoma

Renal cell carcinoma (RCC) is known to cause abdominal pain, hematuria, flank pain, fevers, night sweats, and weight loss, but its association with paraneoplastic syndromes such as intractable cough is rare. Here, we present the case of an 86-year-old female who presented with a persistent dry cough for two months. Computed tomography (CT) of the abdomen and pelvis with contrast revealed large left renal mass consistent with renal cell carcinoma spreading through Gerota’s fascia and metastatic to regional lymph nodes. Biopsy of the mass tested positive for renal cell carcinoma markers. Ultimately, the patient was deemed a nonsurgical candidate and treated with immunotherapy. In this case study, we discuss the rare but important clinical findings leading to the possible diagnosis of paraneoplastic cough secondary to RCC.

Recurrent Large Volume Malignant Pleural Effusion in a Patient With Renal Cell Carcinoma

Malignant pleural effusion (MPE) due to renal cell carcinoma (RCC) is extremely rare, accounting for only 1%-2% of all malignant pleural effusions. This paper presents a case report of a 56-year-old male who presented with a chief complaint of bilateral flank pain with dyspnea and was diagnosed with RCC via immunopathologic pleural fluid analysis and who persistently had recurrent large volume pleural effusion.

A 56-year-old male who had a recent admission for dyspnea secondary to a right-sided pleural effusion underwent thoracentesis and returned to the hospital for his worsening shortness of breath. He was found to have recurrent pleural effusion. Thoracentesis studies revealed an exudative pleural effusion positive for malignant cells showing adenocarcinoma, which had an immunopathologic profile (WT-1 and PAX8) favoring an adenocarcinoma of kidney origin. The patient underwent chest tube placement, followed by chemical pleurodesis with 4.3 L of bloody fluid drained immediately. Subsequent x-rays taken while the chest tube was in place showed worsening reaccumulating pleural effusion. A repeat CT scan showed a large right pleural effusion with loculated collections. The patient then underwent right video-assisted thoracoscopic surgery, which revealed a loculated effusion with pleural carcinomatosis that was biopsy-positive for RCC.

This report presents a rare case displaying how RCC pleural carcinomatosis can cause a patient to present with dyspnea secondary to a pleural effusion, which was revealed to be RCC upon fluid cytology and immunohistopathology studies. This case demonstrates that RCC can cause recurrent large volume MPE, which has not been widely reported in contemporary literature.

A case of pulmonary tumor embolism diagnosed with respiratory distress immediately after FDG-PET/CT scan

Acute distress immediately following an ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scan is an exceedingly rare event. We report a case whose condition was suddenly deteriorated in the nuclear medicine laboratory, and whose diagnosis was confirmed by FDG-PET/CT. A 67-year-old woman with left renal cell carcinoma (RCC) suddenly complained of dyspnea and tachycardia just after undergoing FDG-PET/CT. PET/CT images showed increased FDG uptakes in the left renal vein, inferior vena cava, right atrium, and bilateral hila. She was diagnosed with a massive tumor embolism from the inferior vena cava to both pulmonary arteries, and urgently underwent tumor embolectomy. FDG-PET/CT was helpful for diagnosing the tumor embolism and differentiating it from bland thromboembolism in this patient with RCC.

Collision tumors of the lung: A case report of urothelial carcinoma metastasizing to renal cell carcinoma with heterotopic ossification

Collision tumors are rare entities that consist of at least two or more histologically and ontologically distinct tumor types within the same organ. It is still not well understood how collision tumors form; yet, three main theories have been proposed to explain the pathogenesis, including the “random collision effect,” “field cancerization,” and “tumor-to-tumor carcinogenesis.” Collision tumors have been encountered in various body organs, including the lung. They either consist of a metastasizing tumor colliding with primary cancer or distinct primary or metastatic cancers colliding together. Here, we describe a rare case of collision tumors of the lung that consists of two metastatic carcinomas, namely renal cell carcinoma and urothelial carcinoma of the bladder. We propose that the urothelial carcinoma disseminated into several pre-existing pulmonary metastases of renal cell carcinoma with heterotopic bone formation. The possible mechanisms underlying the development of this peculiar tumor are discussed.

Sarcoid-like reaction associated with renal cell carcinoma - A case report

Renal cell carcinoma (RCC) is a highly vascular tumor, which may spread to the lungs and other organs. It often presents with localized or systemic manifestation, including paraneoplastic syndromes. Sarcoidosis is a systemic granulomatous inflammatory disease characterized by non-caseating granulomas that typically afflicts the respiratory system. In the absence of any evidence of systemic sarcoidosis they are referred to as sarcoid-like reactions. Non-caseating epithelioid granulomas, also regarded to sarcoid-like granulomas have been described in association with certain malignancies such as carcinomas of the breast, colon, seminoma, and Hodgkin's lymphoma. However, sarcoid like reaction associated with renal cell carcinoma is uncommon. Herein we present a rare case of a patient with renal cell carcinoma with mediastinal lymphadenopathy initially thought to metastatic disease, though revealed a sarcoid-like reaction with review of literature.

Sampling pleural nodules with an EBUS scope: A novel application

Convex endobronchial ultrasound transbronchial needle aspiration (C-EBUS-TBNA) has become an essential modality for diagnosis and staging of hilar, mediastinal, and central pulmonary lesions. A Trans-thoracic pleural biopsy is the accepted practice for diagnosing pleural nodules. However, the diagnostic yield of a pleural biopsy is limited and surgical procedures pose a greater risk. We report a unique case of using a C- EBUS scope for the diagnosis of pleural nodules and mediastinal lymph node metastasis in a man with metastatic renal cell carcinoma.

Sarcoidosis: a review for the internist

Sarcoidosis is a systemic granulomatous lung disease of unknown origin affecting people of any age, mainly young adults. The disease is extremely heterogeneous with an unpredictable clinical course. Different phenotypes have been identified: an acute syndrome can be distinguished from subacute and chronic variants. About 20% of patients are chronically progressive and may develop lung fibrosis. Sarcoidosis usually involves the lungs and thoracic lymph nodes, although the skin, eyes, bones, liver, spleen, heart, upper respiratory tract and nervous system can also be affected. No reliable indicators of clinical outcome are available, and there is no single serological biomarker with demonstrated unequivocal diagnostic and prognostic value. Diagnosis requires histological confirmation although a presumptive diagnosis may be acceptable in special conditions. This review examines the diagnostic approach to sarcoidosis involving a multidisciplinary team of specialists in which the internist has the task of identifying all pulmonary and extrapulmonary localizations of the disease and of managing complications and comorbidities.

Multiple circular pleural metastases of renal cell carcinoma

A 91-year-old woman was admitted with persistent pyrexia, anorexia and weight loss. A chest radiograph showed multiple circular masses of various sizes. Chest computed tomography revealed multiple pleural tumors without any lung lesion. The ultrasound-guided biopsy specimens demonstrated diffusely-proliferated tumor cells with clear or vacuolated cytoplasm, which were positive for CD10, PAX8, vimentin and CAM5.2, but were negative for mesothelial cell markers such as HBME-1 and thrombomodulin. These findings indicated metastatic clear cell carcinoma of the kidney, and a solitary renal tumor was observed on abdominal computed tomography. It has been reported that pleural metastases constituted 12% of patients with progressive renal cell carcinoma, and most of the pleural metastases occurred secondary to lung metastasis. This was a rare case of renal cell carcinoma with an unusual chest image via an intriguing metastatic pathway, which was limited to pleura.

Acute cor pulmonale due to pulmonary tumour thrombotic microangiopathy from renal cell carcinoma

We report the case of a previously healthy man who presented with subacute dyspnoea after a long drive. He developed hypoxic respiratory failure, thought secondary to a massive pulmonary embolism and was treated with tissue plasminogen activator but died in the hospital despite aggressive medical measures. Autopsy revealed pulmonary tumour thrombotic microangiopathy (PTTM) from papillary renal cell carcinoma. PTTM is a rare clinicopathological syndrome that clinically results in symptoms of dyspnoea and right heart failure. Pathologically, a localised paraneoplastic process evolves from tumour microemboli in the pulmonary arterioles, resulting in fibrocellular proliferation and narrowing of the vessels, causing subacute right heart failure. To our knowledge, this is the first case of PTTM due to papillary renal cell carcinoma.

Pulmonary manifestations of urothelial carcinoma of the bladder

Urothelial carcinoma (Transitional cell carcinoma) of the bladder is the pre-dominant histological type of bladder cancer in the United States and Europe. Patients with bladder cancer usually present with painless hematuria. The diagnosis is often delayed, as the symptoms are similar to various other benign conditions such as urinary tract infection, prostatitis or renal calculi. In some patients, the metastatic lesions will cause the initial presenting symptoms. We conducted a MedLine/PubMED search identifying all relevant articles with "pulmonary manifestations", "urothelial bladder cancer", "manifestations of bladder cancer" or a combination of these terms in the title. The pulmonary manifestations of urothelial carcinoma of the bladder include metastatic disease including cavitary lesions, endobronchial, pleural, or lymph node metastasis pleural effusion and chylothorax. Pulmonary embolism and tumor embolism is another manifestation of this cancer. Intravesical Bacillus Calmette-Gurin therapy for bladder cancer has been associated with a range of adverse effects including the systemic spread of Bacilli Calmette-Guérin immunotherapy affecting the lungs. Other drugs used to treat bladder cancer can be associated with drug-related pneumonitis. Other rare manifestations include a sarcoid like reaction and systemic granulomatous disease to Bacilli Calmette-Guérin therapy. In this review we discuss the various pulmonary manifestations of urothelial carcinoma of the bladder. A high index of suspicion with these presentations can lead to an early diagnosis and assist in instituting an appropriate intervention.

Pulmonary Manifestations of Solid Non-Pulmonary Malignancies

The lungs are a common site of metastatic disease. Pulmonary metastases develop due to local blood flow and cellular or biochemical properties of tumor cells. Metastases develop from any type of malignancy and may occur via hematogenous, lymphatic, aerogenous, and/or direct spread. Metastatic disease may present with symptoms indistinguishable from primary lung cancer, including dyspnea, hemoptysis, and chest pain. Radiographically, these may present as parenchymal lung disease, mediastinal lymphadenopathy, airway obstruction, or pleural and vascular disease. No part of the thorax is spared from metastatic potential. This review highlights complications of non-pulmonary solid malignancies based on sites of anatomic metastases.