Results of surgical treatment of renal cell carcinoma with solitary metastasis

A case report of liver infiltration from a large renal cell carcinoma: Diagnostic and management enigma

INTRODUCTION AND IMPORTANCE

Renal cell carcinoma is the most lethal malignancy of urinary tract. Invasion of right lobe of liver by Renal cell carcinoma is rare and possess a treatment challenge. Simultaneous nephrectomy with right hepatectomy has been proposed as a part of multi-modality treatment approach. But its safety and feasibility is not well established.

CASE PRESENTATION

We herein discuss a case of 30-year old female patient who underwent simultaneous nephrectomy with right hepatectomy along with single peritoneal metastasectomy for a huge Renal cell carcinoma of right kidney and infiltrating the right lobe of liver. Intra-operatively a single peritoneal nodule was present which came positive for malignancy on frozen section. Considering young age, good performance status and oligometastatic disease definitive procedure in the form of combined right nephrectomy and right hepatectomy was performed. She was discharged from the hospital on 6th post-operative day with an uneventful post-operative course.

CLINICAL DISCUSSION

The patients with locally advanced Renal cell carcinoma with involvement of adjacent organs require en block surgical resection in combination with targeted therapy and immunotherapy. The surgical management of patients with direct liver infiltration requires a right nephrectomy with some form of liver resection based on the extent of liver involvement to achieve a margin negative resection. In our case a plan of formal right hepatectomy was made as the tumor was infiltrating into segment VI, VII, and VIII.

CONCLUSION

The combined nephrectomy and right hepatectomy is safe and feasible for this type of huge RCC invading right hepatic lobe.

What You See Is Not What You Get: Frontal Sinus Metastasis From the Renal Cell Carcinoma

Metastatic neoplasms occurring in the nasal and paranasal sinuses are infrequent occurrences. In this study, we present one such case of a 61-year-old male patient with a known clear cell renal carcinoma presenting to us with signs and symptoms of acute sinusitis. The patient subsequently underwent CT and MRI examinations, which revealed a neoplastic mass in the right frontal sinus, which was surgically resected and was later confirmed histologically as a metastatic deposit from clear cell renal carcinoma. The patient is currently being treated with chemotherapy and radiotherapy and is doing well.

Atypical Metastasis to the Head and Neck Region: An Analysis of 11 Patients

Objective

We present 11 patients with distant metastases to the head and neck from an infraclavicularly located primary tumor and discuss the management strategies including the clinical presentation, treatment modalities, and prognosis.

Methods

The retrospective data of the pathology reports and operation notes of 1239 patients who had undergone any kind of oncological surgical intervention between 2005 and 2017 were analyzed. All of the 11 patients included in the study were evaluated in our department's tumor board, and all patients with an operable lesion had undergone surgery. Inoperable patients were treated with chemotherapy and/or radiotherapy.

Results

The average age of the patients was 64.3 (48-88) years. Primary tumors were located in the lung (2), breast (2), ovary (2), prostate (2), kidney (1), and colon (1) and the primary lesion could not be determined in one patient. The most common symptom was newly occurred painless swelling (9/11, 81.8%) at the metastatic site. Four patients without any other distant metastases were operated. Of these four patients, two died during follow-up due to systemic disease, and the other two are alive and disease-free. Three of the seven inoperable patients were treated with chemotherapy and the other four with radiotherapy. The prognosis of this group was worse.

Conclusion

Although metastasis to the head and neck is not common, it is vital to keep in mind while approaching a patient with a lesion at the head and neck region especially if there is a history of lung, breast, and genitourinary cancers. Despite the poor prognosis, diminishing the tumor burden would increase the treatment success.

Lung metastasectomy following kidney tumors: outcomes and prognostic factors from a single-center experience

Background

The lung is one of the sites most frequently affected by metastatic renal cell carcinoma (mRCC). Nonsurgical therapy for mRCC has limited efficacy, while the 5-year survival rates data published in literature after pulmonary surgery for metastasectomy, emphasize the role of surgery as the treatment that guarantees the best effectiveness in pulmonary resectable metastases.

Methods

From January 2000 to March 2016, 27 patients underwent pulmonary metastasectomy for metastatic renal cancer was retrospectively reviewed. Primary renal cancer was controlled in all patients and there was no other metastatic site in addition to the lung, at the time of metastasectomy. The aim of the study was to identify outcomes and prognostic factors in association with survival after complete pulmonary resection of metastases in a subgroup of patients with isolated pulmonary metastases from RCC.

Results

Five- and 10-year overall survival (OS) from first pulmonary metastasectomy was 75% and 59%, respectively. Independent prognostic factor influencing survival were: dimension of pulmonary metastases ≥2 cm (3-year survival: 67% vs. 100%; P=0.014) and disease free interval (DFI) ≥5 years (3-year survival: 94% vs. 28%; P=0.05). The only independent prognostic factors affecting DFI was the dimension of pulmonary metastases ≥2 cm (5-year DFI: 67% vs. 89%; P=0.03) at univariate analysis.

Conclusions

Considering the good results based on high long-term efficacy and low morbidity after metastases surgical resection, we always recommend metastasectomy in patients with technically resectable metastases, especially in case of long DFI and reduced dimension of pulmonary lesions.

Metastatic Renal Cell Carcinoma Presenting as a Paranasal Sinus Mass: The Importance of Differential Diagnosis

Metastases in the paranasal sinuses are rare; renal cell carcinoma is the most common cancer that metastasizes to this region. We present the case of a patient with a 4-month history of a rapidly growing mass of the nasal pyramid following a nasal trauma, associated with spontaneous epistaxis and multiple episodes of hematuria. Cranial CT scan and MRI showed an ethmoid mass extending to the choanal region, the right orbit, and the right frontal sinus with an initial intracranial extension. Patient underwent surgery with a trans-sinusal frontal approach using a bicoronal incision combined with an anterior midfacial degloving; histological exam was compatible with a metastasis of clear cell renal cell carcinoma. Following histological findings, a total body CT scan showed a solitary 6 cm mass in the upper posterior pole of the left kidney identified as the primary tumor. Although rare, metastatic renal cell carcinoma should always be suspected in patients with nasal or paranasal masses, especially if associated with symptoms suggestive of a systemic involvement such as hematuria. A correct early-stage diagnosis of metastatic RCC can considerably improve survival rate in these patients; preoperative differential diagnosis with contrast-enhanced imaging is fundamental for the correct treatment and follow-up strategy.

Treatment for liver metastasis from renal cell carcinoma with computed-tomography-guided high-dose-rate brachytherapy (CT-HDRBT): a case series

PURPOSE

To retrospectively analyze the clinical outcome of patients with hepatic metastases from renal cell carcinoma who were treated with computed-tomography-guided high-dose-rate brachytherapy (CT-HDRBT).

METHODS

Ten patients (7 men and 3 women; median age 72 ± 7.9 years) with a total number of 16 hepatic metastases from histologically proven renal cell carcinoma were treated with CT-HDRBT after discussing the case in an interdisciplinary tumor conference. All patients had underwent nephrectomy before CT-HDRBT. Three patients had extrahepatic manifestations (2 lung and 1 bone). Six patients had received immunotherapy or targeted therapy before CT-HDRBT. Follow-up included gadoxetic acid (Gd-EOB-DTPA) enhanced MRI two times within 6-8 weeks and after that every 3 months after treatment to evaluate treatment efficacy.

RESULTS

Mean follow-up time was 21.6 ± 13.7 months. One patient developed local and systemic (pulmonary and osseous) progression after 10.8 months which was treated with targeted therapy and died 20.3 months after CT-HDRBT. None of the remaining nine patients developed local progression or died during the follow-up period. Five patients developed systemic progression (3 pulmonary, 1 osseous and 1 locally at the site of nephrectomy) after an average of 19.7 ± 5.5 months.

CONCLUSIONS

CT-HDRBT is a viable alternative to hepatic resection of liver metastases from renal cell carcinoma in selected patients.

Evaluation of a new prognostic score (Munich score) to predict long-term survival after resection of pulmonary renal cell carcinoma metastases

BACKGROUND

The aim of this single-center study was to analyze factors predicting long-term outcomes following surgical resection of pulmonary metastases in patients with renal cell carcinoma.

METHODS

Two hundred two consecutive patients entered the study. Overall survival was analyzed by the Kaplan-Meier method. Multivariate analysis was performed using Cox regression models.

RESULTS

In 175 cases (87%), curative resection of the pulmonary metastases was achievable, with median survival of 43 months. Multivariate analysis revealed complete metastasectomy (R0), metastasis size >3 cm, positive nodal status of the primary tumor, synchronous metastases, pleural infiltration, and tumor-infiltrated hilar or mediastinal lymph nodes as independent prognostic factors for survival. On the basis of these findings, a new scoring system (the Munich score) was established to predict survival, which discriminates 3 groups with low, intermediate, and high risk for poor outcomes (median survival, 90, 31, and 14 months, respectively, P < .001).

CONCLUSIONS

The aim of the Munich score is to define patients with low, intermediate, and high risk for poor survival and will help identify patients who may benefit from further adjuvant therapy.

Surgical treatment of renal cell cancer liver metastases: a population-based study

BACKGROUND

To evaluate outcomes of surgical treatment in patients with hepatic metastases from renal-cell carcinoma in the Netherlands, and to identify prognostic factors for survival after resection. Renal-cell carcinoma has an incidence of 2,000 new patients in the Netherlands each year (12.5/100,000 inhabitants). According to literature, half of these patients ultimately develop distant metastases with 20% involvement of the liver. Resection of renal-cell carcinoma liver metastases (RCCLM) is performed in only a minority of patients. Hence, little is known about outcome of resectable RCCLM.

METHODS

Patients were retrieved from local databases of the Netherlands Task Force for Liver Surgery (14 centers) and from the Dutch collective pathology database. Survival and prognostic factors were determined by Kaplan-Meier analysis and log rank test.

RESULTS

Thirty-three patients were identified who underwent resection (n = 29) or local ablation (n = 4) of RCCLM in the Netherlands between 1990 and 2008. These patients comprise 0.5% to 1% of the total population of patients diagnosed with RCCLM in that period. There was no operative mortality. The overall survival at 1, 3, and 5 years was 79, 47, and 43%, respectively. Metachronous metastases (n = 23, P = 0.03) and radical resection (n = 19, P < 0.001) were statistically significant prognosticators of overall survival. Size < 50 mm (n = 18, P = 0,54), solitary metastases (n = 19, P = 0.93), and presence of extrahepatic metastases (n = 11, P = 0.28) did not have a statistically significant impact on survival.

CONCLUSIONS

The favorable 5-year survival rate of 43% without operative mortality as found in this nationwide study indicates that selected patients with RCCLM can benefit from surgical treatment.

Bone metastases from renal cell carcinoma: patient survival after surgical treatment

Background

Surgery is the primary treatment of skeletal metastases from renal cell carcinoma, because radiation and chemotherapy frequently are not effecting the survival. We therefore explored factors potentially affecting the survival of patients after surgical treatment.

Methods

We retrospectively reviewed 101 patients operatively treated for skeletal metastases of renal cell carcinoma between 1980 and 2005. Overall survival was calculated using the Kaplan-Meier method. The effects of different variables were evaluated using a log-rank test.

Results

27 patients had a solitary bone metastasis, 20 patients multiple bone metastases and 54 patients had concomitant visceral metastases. The overall survival was 58% at 1 year, 37% at 2 years and 12% at 5 years. Patients with solitary bone metastases had a better survival (p < 0.001) compared to patients with multiple metastases. Age younger than 65 years (p = 0.036), absence of pathologic fractures (p < 0.001) and tumor-free resection margins (p = 0.028) predicted higher survival. Gender, location of metastases, time between diagnosis of renal cell carcinoma and treatment of metastatic disease, incidence of local recurrence, radiation and chemotherapy did not influence survival.

Conclusions

The data suggest that patients with a solitary metastasis or a limited number of resectable metastases are candidates for wide resections. As radiation and chemotherapy are ineffective in most patients, surgery is a better option to achieve local tumor control and increase the survival.

Systematic review of pancreatic surgery for metastatic renal cell carcinoma

BACKGROUND

This study examined the clinical outcome of patients with pancreatic metastases from renal cell carcinoma (RCC).

METHODS

A systematic literature search produced individual data for 311 surgically and 73 non-surgically treated patients with pancreatic RCC metastases. A further ten patients underwent resection at the authors' institution.

RESULTS

In the resected group, pancreatic metastases were solitary in 65.3 per cent, symptomatic in 57.4 per cent, and were preceded and/or accompanied by extrapancreatic disease in 22.3 per cent. Respective values in the unresected group were 59, 60 and 58 per cent. Disease-free survival rates were 76.0 and 57.0 per cent respectively at 2 and 5 years after resection, and overall survival rates were 80.6 and 72.6 per cent. The only significant risk factor for disease-free survival after pancreatic resection was extrapancreatic disease (P = 0.001), and that for overall survival was symptomatic RCC metastasis (P = 0.031). Two- and 5-year overall survival rates were 41 and 14 per cent respectively in unresected patients.

CONCLUSION

The actuarial 5-year overall survival rate following pancreatic surgery for RCC metastases was 72.6 per cent, as determined by pooled analysis from published series. Extrapancreatic disease was an independent risk factor for recurrence, but had no significant impact on overall survival.

Combined nephrectomy and major hepatectomy: indications, outcomes, and recommendations

BACKGROUND

Simultaneous nephrectomy with major hepatectomy (NMH) is uncommon. We reviewed our experience with NMH.

STUDY DESIGN

Records of patients who underwent NMH at Emory Hospital between January 1995 and May 2008 were examined. Patients undergoing resection of three or more liver segments at the same setting as a total nephrectomy were included. Indications and outcomes were assessed.

RESULTS

Twenty patients underwent NMH. Mean (+/- SD) age was 59.9+/-12.8 years, 6 (30%) were women, and 15 (75%) presented with comorbidities. Most kidney neoplasms were renal cell carcinomas of the right kidney (n=16, 80%) with a mean diameter of 10.0+/-6.1 cm. Eight patients (40%) also underwent thrombectomy for inferior vena cava tumor thrombus. The most common indications for hepatectomy were direct liver invasion in eight patients (40%) and distant hepatic metastases in nine (45%); liver tumors were 4.2+/-3.3 cm (mean +/- SD) in diameter. Mean (+/- SD) operative time was 8.3+/-2.6 hours. Liver resections included 15 (75%) right hepatectomies and 5 (25%) left hepatectomies. In all cases, tumor negative hepatic margins were achieved. Median operative blood loss was 1,700 mL (range 200 to 8,000 mL). Ten patients (50%) suffered complications in the postoperative period; three of these suffered major complications, resulting in one perioperative death (5%). Mean hospital stay was 12+/-8.8 days. Overall survival was 25 months (range 0 to 34 months).

CONCLUSIONS

In this large series of nephrectomy with simultaneous major hepatectomy, morbidity and mortality were acceptable. In specialized centers NMH may be considered in properly selected patients for combined resection for synchronous neoplasms of the kidney and liver.

Liver resection for metastases from renal cell carcinoma

BACKGROUND

This study was conducted to evaluate the safety and efficacy of liver resection in patients with hepatic metastases from renal cell carcinoma and to identify selection criteria for patients suitable for resection.

METHODS

Between January 1988 and March 2006, 31 patients underwent liver resection for metastases from renal cell carcinoma. Patients were identified from a prospective database and retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on long-term survival.

RESULTS

The overall 1-, 3- and 5-year survival rates were 82.2%, 54.3%, and 38.9%, respectively. One patient was deceased and 4 developed complications during the postoperative course. In the univariate analysis, site of the primary tumor (P = 0.013), disease-free interval (P = 0.012), and resection margins (P = 0.008) showed significant influence on long-term survival. In the multivariate analysis, only the resection margins were identified as an independent prognostic factor after liver resection.

CONCLUSIONS

Liver resection is effective and safe in the treatment of patients with hepatic metastases from renal cell carcinoma and offers the chance of long-term survival and cure. Achieving a margin-negative resection is the most important criterion in the selection of suitable patients for liver resection. However, the number of patients in the present study was small, and investigations of larger series may provide further prognostic parameters in these patients.

Nonmetastatic renal-cell carcinoma: is it really possible to define rational guidelines for post-treatment follow-up?

Defining rational follow-up guidelines in patients treated for cancer is important, from both a medical and an economical perspective. Renal-cell carcinoma is reputed to be unpredictable in its course and only a few, and often contradictory, follow-up guidelines exist for patients treated for nonmetastatic renal-cell carcinoma. Recent advances in tumor biology have contributed to a better understanding of this cancer and have indicated that personalized follow-up regimens, based on tumor and host molecular characteristics, might be possible in the near future.

The Role of Imaging in the Surveillance of Urologic Malignancies

Urologic malignancies are common, accounting for approximately 25% of all new cancer cases in the United States. Patients with urologic malignancies require long-term surveillance to detect progression or recurrence as early as possible. The urologist is faced with the task of balancing patient safety and cost-effectiveness, while finding the most practical follow-up regimen. For each urologic malignancy, this article reviews the commonly used radiologic techniques for surveillance and offers recommended follow-up schedules.

Endoprosthetic elbow replacement in patients with solitary metastasis resulting from renal cell carcinoma

Renal cell carcinoma is one of the most common cancers, and solitary metastasis to bone occurs in 2.5% of these patients. Localization of solitary metastasis to the elbow joint is rarer still, and data about these patients are limited. Because, in these cases, metastasis presents with osteolytic bone destruction, radical removal of solitary lesions should be considered. The aim of this treatment is to control the tumor locally, to reduce pain, and to restore function. We describe 4 patients with a solitary metastasis to the elbow from renal cell carcinoma who had the tumor resected and were then fitted with a custom-made elbow prosthesis. After surgical reconstruction, all patients reported markedly reduced pain and had a good functional outcome. The literature and our experience indicate that the prognosis for patients with just a solitary metastasis is sufficiently encouraging to warrant the use of all surgical and oncologic treatment options, especially if the interval between the diagnosis of the primary tumor and the development of the metastasis is lengthy.

Metastatic renal cell carcinoma presenting as epistaxis

Metastatic tumors in the nasal and paranasal sinuses are very rare. The origin of metastatic tumors in the nasal or paranasal sinuses is often renal cancer. Renal cell carcinomas are known for their tendency to early metastasis, and symptoms due to the metastatic lesion may be the only initial manifestation. In this paper we deal with the case of a 73-year-old patient who presented with recurrent epistaxis. The presence of a primary renal cell carcinoma was recognized only after surgical removal of the metastatic tumor. The presentation, difficulties in diagnosis and treatment of this tumor are discussed, with a review of the literature.

Hepatic resection for metastatic renal tumors: is it worthwhile?

BACKGROUND

Liver metastases of malignant renal tumors are regarded as having an ominous prognosis because they are infrequently amenable to radical surgery and respond poorly to chemotherapy. Little is known of the outcome of isolated metastases to the liver for which resection is potentially curative.

METHODS

Data on 14 patients with liver metastases from renal tumors who underwent a liver resection in a single center between 1982 and 2001 were analyzed retrospectively.

RESULTS

There was no operative or postoperative mortality. The median survival was 26 months, with a survival rate of 69% at 1 year and 26% at 3 years. The curative pattern of hepatectomy (2-year survival, 69% vs. 0%; P =.001), an interval between the nephrectomy and the diagnosis of liver metastases in excess of 24 months (2-year survival, 71% vs. 25%; P =.05), tumor size <50 mm (2-year survival, 83% vs. 17%; P =.006), and the possibility of achieving a repeat hepatectomy in the case of recurrence (2-year survival, 100% vs. 21%; P =.02) were associated with a better outcome after the liver resection. Four patients were alive without evidence of disease at 6, 12, 26, and 96 months after the first hepatic resection, and one was alive with hepatic recurrence 18 months after resection.

CONCLUSIONS

In patients with liver metastases of malignant renal tumors, an aggressive policy for achieving tumor eradication seems to offer a chance for long-term survival, especially after a long disease-free interval from the nephrectomy. However, despite an aggressive policy for achieving tumor eradication, recurrence frequently occurs after liver resection.

Treatment of osseous metastases in patients with renal cell carcinoma

The records of 99 patients treated at one institution for osseous metastases secondary to renal cell carcinoma were reviewed. Patients were followed up for at least 24 months or until death. Survival was analyzed with respect to age, gender, disease-free interval, location of osseous metastases, number of osseous metastatic sites, resection of osseous metastases, and primary tumor resection. The mean age of the 72 men and 27 women was 60 years (range, 34-82 years) and the mean followup was 20 months (range, 2-81 months). Twenty-six patients (26%) had a solitary osseous metastasis, 47 patients (48%) had multiple osseous metastases, and 26 patients (26%) had additional visceral involvement such as the lung and brain at the time of diagnosis. In 49 patients (49%), the renal cell carcinoma was diagnosed concurrently with detection of the osseous metastasis. The presence of one osseous renal carcinoma metastasis, wide resection of the lesion, and a history of nephrectomy were identified as independent predictors of survival in patients with renal cell carcinoma. The eight patients who had wide resection of a solitary osseous metastasis in combination with a nephrectomy had a disease-specific survival rate of 100% (mean followup, 69 months; range, 24-76 months). Patients who present with these characteristics are candidates for aggressive surgical treatment with curative intent.

Long-term results after pulmonary resection of renal cell carcinoma metastases

BACKGROUND

Until now no conclusive data exist regarding the factors influencing long-term survival after pulmonary resection of renal cell carcinoma metastases. The aim of the present study, therefore, was to discover definitive prognostic factors for survival using a large and homogeneous single center patient cohort.

METHODS

Between 1980 and 2000, 105 patients, after curative resection of lung metastases from renal cell carcinoma, were followed in this long-term study. These patients underwent a total of 150 surgical procedures. Survival analysis was done using the Kaplan-Meier method and the log-rank test. Multivariate analysis of prognostic factors was performed using the Cox multivariate proportional hazard model.

RESULTS

Median survival after curative resection reached 43 months (range, 1 to 218 months). Survival at 3, 5, and 10 years was 54%, 40%, and 33%, respectively. Univariate analysis revealed that a complete resection, a less than 4-cm diameter of the metastases and tumor-free lymph nodes at the time of primary operation, were highly significant dependent prognostic factors (p < 0.001). These factors were also shown to be independent prognostic factors as suggested by multivariate analysis (p < 0.05).

CONCLUSIONS

The size of the metastatic nodule, the completeness of pulmonary resection, and the lymph node status at the time of nephrectomy are the most important prognostic factors that influence survival after resection of pulmonary metastases. Recurrence of resectable pulmonary metastases does not impair survival, thus favoring repeated resection in patients with recurrent disease.

A Rare Case of Renal Cell Carcinoma Metastatic to the Sinonasal Area

We report a rare case of a hypernephroma that had metastasized to the sinonasal area as a solitary mass. Despite much difficulty, a confirmatory biopsy of the nasal mass was obtained. After radiotherapy had failed to arrest the tumor's growth, the mass was removed via a craniofacial resection. This case illustrates the importance of(1)a high index of suspicion in differentiating this rare tumor from other benign or malignant diseases, (2) awareness of the risk of hemorrhage and the role of preoperative embolization, (3) the need for paraffin histology rather than fine-needle aspiration or frozen section diagnosis, (4) individualizing therapy after due consideration of the characteristics of both the patient and the tumor, and (5) keeping abreast of the most current therapeutic modalities so that patient management can be individualized and optimized. Surgical excision offers the best hope for long-term survival, and it reduces the degree of pain, epistaxis, and disfigurement from the expanding tumor. When such tumors are not resectable, management with radiotherapy, hormonal therapy, immunotherapy, or chemotherapy can be considered.

Metastatic renal cell carcinoma to the nose and paranasal sinuses

BACKGROUND

Renal cell carcinoma represents 3% of all malignant tumors. Metastatic deposits of renal cell carcinoma to the head and neck region are infrequent. The objective of this work is to analyze the clinical presentation, radiologic features, surgical and radiotherapy treatment, and outcome of metastatic renal cell carcinoma to the nose and sinuses.

METHODS

Retrospective review of 6 patients diagnosed with renal cell carcinoma who had nasal metastasis develop and were seen at the Christie Hospital in Manchester over the past 8 years.

RESULTS

Six patients with renal cell carcinoma were seen with recurrent epistaxis, nasal obstruction, and unpleasant nasal crusting. Three patients had orbital involvement. Examination under general anaesthesia and biopsy was performed in all 6 cases. Histologic studies confirmed metastases of renal cell carcinoma in all 6 patients. All patients underwent local external beam radiotherapy. The most common dose used was 35 Gy in 8 daily fractions. All patients had symptomatic control of local nasal disease with a minimum follow-up of 2 years in 4 patients. Two patients died within 6 months of the radiotherapy treatment as a result of their primary tumor.

CONCLUSIONS

Metastatic renal cell carcinoma to the nose and paranasal sinuses is rare but has unpleasant symptoms. Local symptomatic control with radiotherapy is excellent.

Renal cell carcinoma with solitary synchronous pancreaticoduodenal and metachronous periprostatic metastases: report of a case

We report herein the case of a patient who underwent successful resection of a solitary metachronous periprostatic metastasis 12 months after undergoing a right radical nephrectomy with pylorus-preserving pancreaticoduodenectomy for renal cell carcinoma (RCC) with a synchronous pancreaticoduodenal metastasis. At present the patient is free of any signs of recurrence 12 months after removal of the metachronous mass in the periprostate. This case report supports the opinion that an aggressive surgical approach is appropriate for RCC metastasis.

Renal cell carcinoma

Renal cell carcinoma (RCC) is characterized by (a) lack of early warning signs, which results in a high proportion of patients with metastases at the time of diagnosis; (b) protean clinical manifestations; and (c) resistance to radiotherapy and chemotherapy. The estimates of new diagnoses and deaths from kidney cancer in the United States during 1996 are 30,600 and 12,000, respectively. RCC occurs nearly twice as often in men as in women. The age at diagnosis is generally older than 40 years; the median age is in the midsixties. The incidence of RCC has been rising steadily. Between 1974 and 1990, there was a 38% increase in the number of patients who had a diagnosis of RCC. This increase was accompanied by a significant improvement in 5-year survival. Both trends are likely the result of improved diagnostic capability. Newer radiographic techniques, including ultrasonography, computed tomography, and magnetic resonance imaging, are detecting kidney tumors more frequently and at a lower disease stage, when tumors can be resected for cure. Surgical treatment is the only curative therapy for localized RCC. Radical nephrectomy remains the mainstay of surgical management, but techniques are being modified. These modifications include partial nephrectomy and resection of vena caval thrombi. In highly selected cases, surgical resection of locally recurrent RCC or of disease at a solitary metastatic site is associated with long-term survival. Metastatic RCC is highly resistant to the many systemic therapies that have been extensively investigated. A minority of patients achieve complete or partial response to interferon, interleukin-2, or both. Response can be dramatic but is rarely durable. Because most patients do not achieve response, these agents are not considered effective treatments for RCC, but the response in some patients indicates the need for continued research on their use. Identification of new agents with better antitumor activity against metastases remains a high priority in clinical investigation of therapy for this refractory disease.

Renal cell carcinoma metastatic to the lung: potential benefit in the combination of biological therapy and surgery

PURPOSE

We evaluated outcomes in cases of renal cell carcinoma metastatic to the lung treated with surgery or biological therapy followed by surgery.

MATERIALS AND METHODS

We retrospectively evaluated 22 patients treated with surgical resection and 29 treated with biological therapy followed by surgery.

RESULTS

At the time of this study 31 patients (61%) were alive, including 15 with no residual disease and 16 with disease. Of the 22 patients treated with surgery without initial biological therapy 12 (55%) were alive at a median followup of 57 months (range 17 to 148) and 19 of the 29 (66%) treated with combination therapy were alive at a median followup of 48 months (range 19 to 78). A total of 19 patients (37%) died of progressive disease.

CONCLUSIONS

Our results suggest a role for an aggressive surgical approach in select patients with metastatic renal cell carcinoma, and demonstrate that patients who do not achieve a complete response to biological therapy may benefit from surgical resection of residual disease.

[Results of surgical treatment of metastases of renal carcinomas in 65 operated cases]

Several reports have assessed that the prognosis of metastatic renal cell carcinoma was better if patient's general condition was good, if primary tumor had been resected, if the time between nephrectomy and metastasis was long, if metastases are only pulmonary and bone marrow was not involved. The bone metastases of renal cell cancer have a bad reputation because of their haemorragic caracteristics and their resistance to radiotherapy.In the Orthopaedic and Traumatologic Department of the University hospital in Strasbourg, the authors had operated on 65 metastatic renal cell cancers. There were 55 patients (41 were men and 14 female), aged of 60 (range 41-84). Eight of them had 2 operations and 1 had 3 metastatic localisations.In 23% the metastases were present at the time of primary tumor diagnosis; in 17% the metastasis was even a signal metastasis. There were pathologic fractures in half of the cases (33 cases) and in the other half the metastasis had not fractured. The commonest site was the femur (40 of the 65 cases). The second site was the humerus (15 cases). There were also 7 vertebrae, 6 of them with neurologic deficit.The authors performed closed osteosynthesis in 27 cases (15 intramedullary nails, 7 Ender nails, 4 bipolar pinnings, 1 gamma nail), arthroplasty in 19 cases (6 standard prosthesis and 13 reconstruction prostheses) and an open osteosynthesis in 12 cases. They performed also 3 vertebrectomies by an anterior approach and 4 posterior decompressions and stabilisations.The average post operative survival was 15 months (range 0-109). Six patients died in the first post-operative month. Three non specific complications were observed: 2 prosthetic dislocations and one infected nail failure. 6 tumor extensions were observed on 2 prostheses, 3 intramedullary nails and 1 open osthesynthesis.The results were good for pain in 83% of the patients, the functional result good or fair in 78%.The efficacy of adjuvant medications was discussed, based on the literature data. Two groups of metastatic renal cell cancer were studied: the first with multiple metastases and a high speed progressive disease, the other with single metastasis and a low speed progressive disease. The surgical indications should be different in the two groups.

Surgical resection of brain metastases from renal cell carcinoma in 50 patients

OBJECTIVES

Metastases are frequently diagnosed among patients with renal cell carcinoma (RCC). Of 709 patients with brain metastases (BMET) who were operated on at our institution between 1974 and 1993, 50 (7%) were of renal origin.

METHODS

Medical records were reviewed retrospectively. Survival time was calculated by the Kaplan-Meier method and Cox proportional hazards model.

RESULTS

There were 38 men and 12 women. The median age was 60 years. The primary RCC was resected in 47 patients. Forty patients had a metachronous diagnosis of RCC and BMET. Median interval between the diagnosis of RCC and BMET was 17 months. In all 50 patients overall median survival (MS) from diagnosis of primary RCC was 31.4 months and from craniotomy was 12.6 months. Postoperative mortality was 10% (5 patients). In patients with primary RCC in the left kidney (n=25) versus right kidney (n=25) median survival from craniotomy was longer; 21.3 versus 7.4 months (P<0.014). Twenty-three patients (46%) had intratumoral hemorrhage. Eight patients had cerebellar metastasis (MS, 3.0 months) and 9 had multiple metastases resected (MS, 7.6 months). Thirty-eight patients had both brain and pulmonary metastases, and 16 of them had pulmonary resection (MS, 18.6 versus 8.0 months; P<0.03). Twenty-two patients received whole-brain radiation therapy (WBRT) after craniotomy and 18 did not receive WBRT (MS, 13.3 versus 14.5 months; P<0.62). The 1-year, 2-year, 3-year, and 5-year survival was 51%, 24%, 22%, and 8.5% respectively.

CONCLUSIONS

Only the resection of lung metastasis, supratentorial location of BMET, left-sided localization of primary RCC, and lack of neurologic deficit before craniotomy were statistically significant prognostic factors in Cox regression analysis. In the absence of effective systemic treatment, we suggest that patients with BMET from RCC be considered for operative resection for treatment and palliation.

Various features and surgical approach of solitary pancreatic metastasis from renal cell carcinoma

In this paper we report three cases of solitary pancreatic metastasis from renal cell carcinoma (RCC), treated surgically. Various features and the surgical approach of these metastases are discussed with references to the 33 previous published cases collected in the literature. Having eliminated widespread distant metastases, it is reasonable to restrict surgical resection of the pancreas to selected patients having a single synchronous or metachronous metastasis, or those having several unilateral metastatic foci. At any rate a careful long-term follow-up for patients with a past history of RCC is mandatory.

Renal cell carcinoma presenting as a solitary paranasal sinus metastasis

We present an unusual case of renal cell carcinoma presenting as a periorbital mass. The presenting symptom was a supraorbital swelling which proved to be a mucocoele which had arisen secondary to a solitary metastasis in the ethmoidal sinuses. We discuss the management strategy including the place of endoscopic biopsy, the choice of investigations and craniofacial resection.

Synchronous contralateral adrenal metastasis from renal cell carcinoma: a 7 year survival following resection

Solitary contralateral adrenal metastasis from a renal cell carcinoma is distinctly unusual but aggressive surgical resection alone can produce long-term survival.

Surgery of lung metastases in renal cell carcinoma

OBJECTIVE

To examine the impact on survival of pulmonary resection in the treatment of renal cell carcinoma that has metastasized to the lung.

PATIENTS AND METHODS

From June 1986 to July 1991, 19 patients were submitted to synchronous or asynchronous lung metastasectomy. Histological examination confirmed the presence of lung metastases from renal cell carcinoma in 16 cases (six synchronous and 10 asynchronous with a mean disease-free interval of 23 months). In the other three cases, histological examination revealed tuberculomas, chondroid hamartoma and foci of anthracosis.

RESULTS

To date, among the six patients with synchronous lung metastases, three have died, two are progressing and one has no evident disease after a mean survival of 24 months. Among the 10 patients who underwent surgical resection of metachronous lung metastases, one has died, three are progressing and six have no evident disease (mean survival time, 43 months).

CONCLUSION

While the presence of synchronous lung metastases is an unfavourable prognostic factor even after surgical removal (five out of six patients died or are in progression shortly after metastasectomy), the results after surgery of asynchronous lung metastases are encouraging, although the real efficacy of this treatment is still to be confirmed.

Surgeon's role in the management of solitary renal cell carcinoma metastases occurring subsequent to initial curative nephrectomy: an institutional review

BACKGROUND

Solitary metastases from a primary renal cell carcinoma (RCC) occur in < 10% of patients with metastatic RCC. To date, the benefit of surgically resecting such apparently solitary lesions has not been well documented.

MATERIALS AND METHODS

Forty-one patients (25 men, 16 women) with metastatic renal cell carcinoma treated by surgical excision of solitary metastases (1970-1990) were retrospectively reviewed. They comprised 9% of patients with metastatic hypernephroma seen during this period. All patients had undergone previous curative nephrectomy with a median disease-free interval of 27 months. Patients with skeletal, spinal cord, and lymph node metastases were excluded.

RESULTS

Metastases were intrathoracic (n = 20), intracranial (n = 7), and intraabdominal or in the extrapleural chest wall soft tissue (n = 10). Three patients had metastases to the thyroid gland and one had a solitary metastasis to an index finger. Median follow-up was 3.2 years. Complete resection was possible in 36 patients (88%) with a single lesion excised in 23 of these 36 patients (64%). There was no operative mortality. Predicted survival from the date of complete resection of metastases was 77%, 59%, and 31% at 1, 3, and 5 years, respectively, with a median survival of 3.4 years. One patient is alive without evidence of recurrent tumor 93 months from the first of 12 complete surgical resections. Varying adjuvant therapy was used in 50% of the patients. An increased histological tumor grade of the metastatic lesion relative to the original RCC was the only significant prognostic indicator identified. Disease-free interval and number of resected lesions were not significantly associated with patient survival.

CONCLUSION

A small fraction of renal cell carcinoma patients are candidates for potentially curative surgical resection of solitary metastatic lesions. Excision of such lesions may contribute to prolonged survival in selected instances.

Solitary late recurrence of renal cell carcinoma

Late recurrence of renal carcinoma is an unusual manifestation of this tumor but can occur in as many as 11 percent of patients surviving ten years. We describe a case of a solitary lesion occurring in the nephrectomy scar ten years following surgery. The literature is reviewed. Aggressive surgical management is warranted in the treatment of these solitary lesions. The use of advanced imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) can assist greatly in the management of patients.

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.

Chemoimmunotherapy of metastatic murine renal cell carcinoma using flavone acetic acid and interleukin 2

Metastatic renal cell carcinoma (RCC) remains largely incurable. We used a murine RCC (Renca) in BALB/c mice to investigate the treatment possibilities with chemoimmunotherapy using in vivo boosters of natural killer (NK) activity. Diffuse pulmonary metastases were induced by intravenous (i.v.) inoculation with 100,000 Renca cells. All untreated control animals died within one month from pulmonary metastases. Chemoimmunotherapy using the NK immunostimulator flavonic-8-acetic acid (FAA) at 200 mg./kg. i.v. was given on the third day post tumor inoculation, followed by four consecutive days of twice daily intraperitoneal (i.p.) administration of 10,000 units human recombinant interleukin-2 (rIL-2). This chemoimmunotherapy regimen consistently cured 70% of tumor-bearing animals. Mice cured by this chemoimmunotherapy regimen did not reject subsequent reinoculation with Renca, indicating absence of specific antitumor immunity as a result of the treatment. While FAA and rIL-2 have no demonstrable in vitro cytotoxicity for Renca, they are excellent boosters of in vivo NK activity. These data suggest a potential alternative treatment method for metastatic RCC, a tumor type for which no efficient cytostatic drugs are available.

Analysis of imaging modalities, staging systems, and prognostic indicators for renal cell carcinoma

A retrospective analysis of 314 patients with renal cell carcinoma was done focusing mainly on imaging modalities and prognostic significance of tumor stage using both the Robson and TNM systems. Computerized tomography (CT) scan proved to be the most effective modality for staging. Overall staging accuracy was 62 and 68 percent for TNM and Robson staging, respectively, and understaging was more frequent than overstaging. The actuarial five-year survival using the Robson system was 73 percent for Stage A, 68 percent Stage B, 51 percent Stage C, and 20 percent Stage D. The main limitation of the Robson system is the heterogeneity of the Stage C group which includes patients with renal vein and those with nodal involvement with a significant difference in survival. The survival by the TNM system showed no difference in those with T1, T2, T3a and T3b disease but a significant difference in those with T3c or T4a. One hundred sixteen patients (37%) presented with metastatic disease with a median survival of seventeen months (range 2-204) for those with solitary metastasis and six months (range 1-132) for those with multiple metastases (the difference was not statistically significant). Except for anecdotal cases, nephrectomy with or without treatment of the metastases did not seem to affect survival significantly. The presence of spindle cell, alone or in association with clear or granular cell, affected the prognosis adversely. Thirty-one patients had their tumors identified incidentally. Their stage at diagnosis was earlier than the symptomatic group (Stage T1-T2: 77% vs 34%), and there was a significant difference in the disease-free survival at fifty-four months between the two groups (79% vs 57%, respectively).

Sternum resection and nephrectomy together in renal carcinoma with solitary sternal metastasis

The role of surgery and adjuvant therapy in renal tumors with metastasis is considered purely palliative. However, in cases of solitary metastasis, an aggressive surgical approach is justified by results reported in current literature, in terms of survival rate and quality of life. In bone metastasis there are additional functional problems related to the site of the lesion and to the extend of the excision. In the reported case, the tumor became evident with a serious compressive cervical-mediastinal simptomatology, due to a solitary sternal metastasis, that was resected along with the primary renal tumor.

Solitary metastases from renal cell carcinoma: a review

Nineteen patients with solitary metastatic lesions from renal cell carcinoma, 5 synchronous and 14 metachronous, were seen at the Tata Memorial Hospital over a 7 year period between 1981 and 1987. The mean metastatic interval for the metachronous lesions was 31.2 months. The commonest sites of metastases were bone, lung, and liver. The solitary nature of the metastasis was confirmed by appropriate investigations. All patients underwent nephrectomy for the primary kidney lesion. The metastatic lesions were treated with intent of cure. Only 1 patient with synchronous metastasis survived for 2 years and none survived 5 years while in the metachronous metastasis group, the estimated overall survival was 50% at 2 years and 25% at 5 years. The patients with a long metastasis-free interval were found to have a better survival. The patients with liver metastasis did poorly as compared to those with metastases at other sites. The stage of the disease also had a bearing on the survival.

The treatment of localized metastases in the proximal humerus from renal cell carcinoma

Four cases of a localized metastatic renal cell carcinoma within the proximal humerus are reviewed. In three of these cases radiation therapy resulted in relief of bone pain but did not control progression of the secondary tumor. In one case palliative radiation treatment combined with intramedullary nailing resulted in the total destruction of the whole humerus by secondary tumor during the 10-month period before the patient died. In the other three cases aggressive surgical treatment was performed. This treatment consisted of an en bloc resection of the proximal humerus, with reconstruction of the proximal humerus with a long-stem Neer humeral head replacement prosthesis. To obtain a good functional result, the soft tissues were reconstructed onto on intercalary allograft in one case; artificial rotator cuffs were used in two cases. After a mean follow-up period of 20 months, all three patients who underwent aggressive treatment hod painless shoulders, with fair function and no recurrence of carcinoma. En bloc resection with reconstruction of the proximal humerus is on effective method of avoiding limb oblation and contrailing painful solitary lesions from metastatic renal cell carcinoma.