Metastatic processes and a potential indication of treatment for metastatic lesions of renal adenocarcinoma

Extremely Delayed Cerebral Metastasis from Renal Carcinoma Report of Four Cases and Critical Analysis of the Literature

Brain metastases from renal carcinoma may appear even a long time after surgical treatment of the primary tumor. The authors present 2 series of patients, one of which has already been published and the other new, for a total of 4 cases of brain metastasis from renal carcinoma with late onset, which occurred 13, 17, 26 and 12 years after primary surgical treatment. The other cases described in the literature were also critically reviewed.

Renal cell carcinoma: Atypical metastasis to inguinal lymph nodes

Renal cell carcinoma (RCC) is a common tumor of the urinary tract. It is known to have variable presentations due to the extremely vascular nature of the organ. RCC are known to metastasize to lungs, bone, and brain commonly but atypical metastasis to various sites are reported in literature but as very rare pathology. We report a case of a 60-year-old female who presented with multiple inguinal and axillary lymph node enlargements which on excision biopsy showed metastatic RCC. RCC can present with synchronous metastatic deposits in the various organs. RCC can metastasize to some atypical sites as well such as thyroid, orbit, and neck as mentioned earlier in literature. The patient presenting with extra-regional lymph nodes like inguinal and axillary is extremely rare, and so far only one clinical case could be found from India in 2008. A 61-year-old female presented in the emergency department with left flank pain and hematuria. Imaging showed left swollen kidney but multiple lymph nodes in retroperitoneum, left inguinal and axillary region. Excisional biopsy confirmed metastatic renal clear cell carcinoma. The case was referred to an oncologist after left radical nephrectomy for further treatment. Renal cancer is quite common aggressive disease. Due to its vascular nature, it may present quite atypically as evident from literature. Although treatment of metastatic carcinoma is still controversial surgery is the mainstay of treatment and guidelines consider metastasectomy and cytoreductive nephrectomy as valid option followed by targeted systemic therapies. RCC has quite a high potential to metastasize in the versatile pattern, in our case, it is evident that valid management is still surgery but needs support from the multidisciplinary team.

The Role of Adrenalectomy in Renal Cancer

CONTEXT

Since the 1960s, routine ipsilateral adrenalectomy (IA) has been considered an integral step in the removal of renal tumors as a part of a radical nephrectomy. However, recent data from the past decade have narrowed the indications for adrenalectomy and called into question the need for adrenalectomy at all in the treatment of renal cell carcinoma (RCC).

OBJECTIVE

We sought to identify the role of adrenalectomy in the treatment of RCC. Specifically, we wanted to answer the following questions: What is the incidence of ipsilateral adrenal involvement by cancer? How reliable is preoperative imaging? What is the rate of ipsilateral and contralateral metachronous recurrence? And finally, what are the potential noncancer sequelae from unnecessary removal of the adrenal gland?

EVIDENCE ACQUISITION

A systematic literature search of Embase, PubMed, Cochrane, and Ovid Medline was performed to identify studies evaluating the role of adrenalectomy during RCC surgery. Only articles published in English from the years 2000-2015 were included. Case reports, articles about primary adrenal tumors, letters to the editor, and surgical technique papers were excluded.

EVIDENCE SYNTHESIS

We found little evidence to suggest that routine IA is associated with a higher risk of short-term surgical or medical complications. We did not find evidence that IA is associated with improved cancer control. Tomographic preoperative imaging of the adrenal gland demonstrating no cancer involvement is rarely wrong (<1% of the time), and the few adrenal lesions missed on imaging can often be identified intraoperatively. Some evidence indicates that IA may be associated with worse long-term survival. Adrenalectomy rates have been decreasing in recent years, reflecting a changing practice pattern.

CONCLUSIONS

IA at the time of kidney surgery for a renal mass should be performed only if radiographic or intraoperative evidence indicates adrenal gland involvement.

PATIENT SUMMARY

We sought to define the role of adrenalectomy in patients with kidney cancer. Although there are not high-quality studies to answer this question definitively, we conclude that the adrenal gland should be spared unless there is clinical evidence of adrenal involvement.

Do we continue to unnecessarily perform ipsilateral adrenalectomy at the time of radical nephrectomy? A population based study

PURPOSE

Since the mid 1990s evidence has supported ipsilateral adrenal gland sparing radical nephrectomy unless the gland appears involved on imaging or the primary tumor is large and located in the upper pole. However, it is unclear whether this shift in surgical practice has been adopted at the population level.

MATERIALS AND METHODS

Using the Ontario Cancer Registry we identified 5,135 patients in the province of Ontario who underwent radical nephrectomy between 1995 and 2004. Ipsilateral adrenalectomy and tumor involvement of the adrenal gland were ascertained from pathology reports. Further variables analyzed included age, gender, pathology, surgeon year of graduation, academic status of hospital/surgeon, hospital and surgeon volume, and year of surgery. We used multivariable logistic regression to assess outcomes.

RESULTS

The overall rate of adrenal gland involvement with cancer was 1.4%. The adrenal was involved in 3.2% of tumors larger than 7 cm vs only 0.89% of tumors 4 to 7 cm and 0.63% of tumors smaller than 4 cm. Factors predictive of adrenal involvement on multivariable analysis were tumor size greater than 7 cm and fat invasion. The overall adrenalectomy rate was 40.1%, which decreased slightly over time (40.6% in 1995 vs 34.8% in 2004). Variables predictive of adrenal removal on multivariable analysis included tumor size greater than 7 cm, presence of venous thrombus, upper pole location, higher hospital volume, and academic status of hospital or surgeon.

CONCLUSIONS

Despite evidence to support preservation of the ipsilateral adrenal gland during radical nephrectomy, the rate of adrenalectomy decreased only slightly in 10 years. Adrenalectomy remains overused in populations that are unlikely to benefit from the procedure.

Routine adrenalectomy in patients with locally advanced renal cell cancer does not offer oncologic benefit and places a significant portion of patients at risk for an asynchronous metastasis in a solitary adrenal gland

BACKGROUND

The indications for the removal of the ipsilateral adrenal gland in patients with renal cell carcinoma (RCC) and the long-term outcomes have not been well studied.

OBJECTIVE

We evaluated the risk of synchronous and asynchronous adrenal involvement in patients with RCC and the effect of adrenalectomy on recurrence and survival in a large, single-institution cohort.

DESIGN, SETTING, AND PARTICIPANTS

From 1970 to 2006, 4018 consecutive patients with RCC treated by surgical extirpation (radical nephrectomy [RN]: 3107; partial nephrectomy [PN]: 911) from Mayo Clinic were studied for adrenal involvement. Risk of asynchronous adrenal metastasis and cancer-specific survival (CSS) were also compared between those who underwent concomitant ipsilateral adrenalectomy (n = 1541) and those who did not (n = 2477) using multivariate Cox models.

INTERVENTION

Surgical removal of the adrenal gland at the time of kidney tumor resection.

MEASUREMENTS

Primary outcome is cancer specific survival; secondary outcomes are incidence of synchronous and asynchronous adrenal metastases.

RESULTS AND LIMITATIONS

Median postoperative follow-up among those still alive was 8.2 yr (interquartile range [IQR]: 5.3-13.6). Synchronous ipsilateral adrenal involvement was rare (n = 88; 2.2%). Ipsilateral adrenalectomy at the time of nephrectomy did not lower the risk of subsequent adrenal metastasis (hazard ratio [HR]: 0.96; 95% confidence interval [CI], 0.64-1.42) or improve CSS (HR: 1.08; 95% CI, 0.95-1.22). The development of asynchronous adrenal metastasis occurred in 147 patients (3.7%) at a median of 3.7 yr (IQR: 1.2-7.7) after initial surgery. The risk of developing an ipsilateral versus a contralateral asynchronous adrenal metastasis was equivalent at 10 yr in those who did not undergo adrenalectomy at initial surgery. This study is limited by its single-institution, nonrandomized nature.

CONCLUSIONS

Routine ipsilateral adrenalectomy in patients with high-risk features does not appear to offer any oncologic benefit while placing a significant portion of patients at risk for metastasis in a solitary adrenal gland. Therefore, adrenalectomy should only be performed with radiographic or intraoperative evidence of adrenal involvement.

Renal cell cancer without a renal primary

Renal cell carcinoma has been increasing in incidence over the past two decades. Men are affected more than women and metastatic disease at presentation occurs in up to one third of patients. Metastasis can occur to virtually any organ, and involvement of multiple organs is not uncommon. To date, no reports have been found of metastatic disease without a renal primary. We present a case of renal cell cancer initially presenting as a subcutaneous mass with subsequent pancreatic and parotid gland metastases in absence of a primary renal source.

[Current role of lymphadenectomy and adrenalectomy in radical surgery for renal cancer]

Radical nephrectomy is the only curative treatment for renal cell cancer. Standard treatment includes ipsilateral adrenalectomy and lymph node dissection. In recent years, development of nephron-sparing surgery and early detection of small renal tumors has led to question this approach. The role of lymphadenectomy and adrenalectomy in surgical treatment of renal cancer is reviewed.

Renal adenocarcinoma presenting as a groin swelling: a case report

Renal cell carcinoma (RCC) is known to have myriad presentations due to the extremely vascular nature of the organ. RCC are known to metastasize extensively to various organs of the body. We report a case of a 70-years-old male who presented with multiple inguinal lymph node enlargements which on excision biopsy showed metastatic adenocarcinomatous deposit. Search for the primary revealed a RCC arising from the left kidney. Inguinal lymph nodal metastasis, an uncommon site of distant metastasis in renal neoplasm, as a fi rst clinical sign leading to the diagnosis is not yet reported in literature.

Adrenal sparing surgery in the treatment of renal cell carcinoma: when is it possible?

Despite the fairly low incidence of adrenal involvement, adrenalectomy continues to be performed routinely as part of radical nephrectomy. With the recent development of modern imaging techniques and their widespread use, the frequency of small, low stage renal cell carcinomas (RCC) has grown considerably, giving rise to more conservative surgical approaches. We conducted a retrospective study in order to evaluate the incidence and characteristics of adrenal metastasis in RCC, trying to clarify the accuracy of computerized tomography (CT) in the diagnosis and the real need for adrenalectomy during surgery for RCC. The medical records of 192 patients undergoing radical nephrectomy and ipsilateral adrenalectomy for localized or advanced RCC, from 1996 to 2001, were analyzed retrospectively. We considered two subgroups of patients, 73 with stage T1-2 disease (group 1) and 119 with T3-4N0-1M0-1 disease (group 2) according to the 1997 TNM classification. In all cases, a blinded review of the preoperative abdominal CT was performed and an adrenal gland was considered to be abnormal if there was any aberration. Histopathology records of the surgical specimens were examined to determine the accuracy of the CT in identifying adrenal involvement by RCC. Descriptive statistics were used to evaluate the collected data. The overall incidence of adrenal metastasis was 4.1%. Mean renal tumor size in patients with adrenal involvement was 7.8 cm. The tumor stage correlated with the probability of adrenal spread ( P<0.05), with T1-2 tumors accounting for 1.3% of cases only. An adrenal gland was diagnosed as abnormal on preoperative CT in 20 patients (10.4%). CT scans had 87.5% sensitivity, 92.9% specificity, 99.4% negative predictive value and 35% positive predictive value for adrenal involvement by RCC. Adrenal involvement is not likely in patients with localized early stage RCC, and adrenalectomy is unnecessary in such cases, particularly when the CT is negative. However, radical nephrectomy, including removal of the ipsilateral adrenal gland, should be performed in patients with large, high risk tumors.

Endoscopic assisted posterior decompression for spinal neoplasms

The authors describe a technique for anterior thoracic decompression via a posterolateral approach for spinal metastatic disease followed by anterior and posterior column stabilization. We discuss the benefits of decompression via a posterolateral approach including minimization of cord retraction, avoidance of thoracotomy, early mobilization and shorter hospital stay. Technical details are reviewed and difficulties of the approach discussed.

Spinal cord decompression: an endoscopically assisted approach for metastatic tumors

STUDY DESIGN

The paper describes a technique for complete vertebrectomy and spinal cord decompression, followed by a formal anterior column reconstruction, using endoscopic instruments. This procedure is indicated for patients with radioresistant metastasis of the thoracic spine, particularly those involving the upper thoracic segments where a thoracotomy is difficult and carries a high morbidity, and for patients with pulmonary disease who cannot tolerate a standard thoracotomy. Results in nine consecutive cases are reported.

OBJECTIVES

To demonstrate the feasibility and benefits of endoscopically assisted decompression and stabilization through a single, extrapleural, posterolateral approach.

SETTING

The Cleveland Clinic, Cleveland, Ohio, USA.

METHODS

Posterolateral decompression of the thoracic spinal cord offers potential advantages over traditional combined procedures (anterior thoracotomy and posterior instrumentation), including reduced operative time, decreased morbidity, and reduced hospital stay. Previous studies have not demonstrated the same neurological benefit for posterolateral decompression as for anterior vertebrectomy and decompression, however, Surgical indications, rationale and technique for an improved posterolateral approach, augmented by endoscopic methods, are provided, and initial clinical results are described.

RESULTS

Drawbacks to the traditional posterolateral decompressions have included poor visualization of the spinal cord and anterior tumor, poor access to tumor on the side contralateral to the approach, and the need to manipulate the spinal cord to completely remove both adjacent tumor and tumor adherent to the dura. Transpedicular decompression using endoscopy is described in nine patients. The mean operative time for the combined procedure was 6.0 h, with a mean blood loss of 1677 cc. Neurological recovery and maintenance were excellent. Inpatient days averaged 6.5, and ICU days averaged 1.4. Two patients died of disease eight and 14 months post-op, and seven were living, with disease, 3-36 months after surgery.

CONCLUSIONS

Endoscopically assisted decompression can reduce morbidity, hospitalization, and treatment costs while matching the efficacy of traditional combined procedures. Endoscopy provides a readily available and easily applied tool that dramatically improves the surgeon's vision, providing light, magnification, and a direct view of remote structures.

Endoscopically assisted decompression for metastatic thoracic neoplasms

STUDY DESIGN

The author describes a technique for complete vertebrectomy and anterior decompression followed by a formal anterior column reconstruction, using readily available endoscopic instruments. This procedure is indicated in patients with radioresistant metastasis of the thoracic spine, particularly those involving the upper thoracic segments where a thoracotomy is difficult and causes a high rate of morbidity. This is also a suitable technique for patients with pulmonary disease who cannot tolerate a standard thoracotomy.

OBJECTIVES

To demonstrate the feasibility and potential benefits of endoscopically controlled decompression through an extrapleural, posterolateral approach.

SUMMARY OF BACKGROUND DATA

Posterolateral decompression of the thoracic spine offers potential advantages in comparison with traditional anterior-posterior procedures combining thoracotomy and posterior instrumentation, including decreased operative time, decreased morbidity, and reduced hospital stay. Results of previous studies have not demonstrated the same benefit for posterolateral decompression as for anterior vertebrectomy and decompression. Drawbacks to the traditional posterolateral decompressions have included poor visualization of the spinal cord and anterior tumor, poor access to tumor on the side contralateral to the approach, and the need to manipulate the spinal cord to completely remove adjacent tumor and tumor adherent to the dura.

METHODS

Surgical indications, rationale, and technique are provided, and initial clinical results are described.

RESULTS

Transpedicular decompression using endoscopy is described in five patients. The mean operative time for the combined procedure was 7.25 hours, with a mean blood loss of 1800 mL. Neurologic recovery and maintenance were excellent. Inpatient days averaged 7.5, and intensive care days averaged 2. One patient died of disease 8 months after surgery, and four were living, with disease, 3-24 months after surgery.

CONCLUSIONS

Endoscopically assisted decompression can reduce morbidity, hospital stay, and treatment costs while matching the efficacy of traditional combined procedures. Endoscopy provides a readily available and easily applied tool that dramatically improves the surgeon's vision, providing light, magnification, and a direct view of remote structures.

Renal cell carcinoma metastases. Review of unusual clinical metastases, metastatic modes and patterns and comparison between clinical and autopsy metastatic series

We reviewed all cases of unusual clinical metastases of renal cell carcinoma found in the English literature. The percentages of usual and unusual clinical metastases are compared with data of some large autopsy series. The involvement of various organs is considered and some metastatic modes and patterns are reported. The analysis shows that clinical metastases are obviously underdiagnosed. Correct staging based on careful clinical investigations is paramount for optimal management of metastatic renal cancer.

Solitary brain metastasis 13 years after removal of renal adenocarcinoma

We report a case of a patient who developed a single brain metastasis to the cerebellum 13 years after removal of a renal adenocarcinoma. The cerebellar metastasis was removed twice due to local recurrence one year after the first operation. The patient is alive and doing well 18 months after the second neurosurgical procedure. The metastasis was not associated with any other evidence of disease. Brain metastasis may present many years after removal of kidney adenocarcinoma and when not associated with other evidence of disease their operative treatment may carry a good prognosis.

Possible metastatic routes via portacaval shunts in renal adenocarcinoma with liver metastasis

Renal adenocarcinoma findings from autopsies on patients with and without liver metastasis (635 and 936 patients, respectively) were investigated concerning the mode of metastasis. The patients with liver metastasis showed a significantly higher frequency of metastases to the lungs, lymph nodes, contralateral kidney, adrenals, pancreas, spleen, peritoneum, and intestines; in the female patients, those with liver metastasis had a higher frequency of metastasis to the ovary and uterus than patients without liver metastasis. Some of the metastases to those organs are explainable by venous spread via portacaval shunts as well as ordinary hematogenous or lymphogenous spread, especially, those to the contralateral kidney, adrenals, spleen, intestines, or ovary.

Results of surgical treatment of kidney cancer with solitary metastasis to contralateral adrenal

A large series of patients were reviewed in two major teaching institutions, and patients with a carcinoma of the kidney with a solitary metastatic deposit in the contralateral adrenal were identified. Their survival was analyzed and compared with the survival of those patients having a solitary metastatic deposit in other organs.

Two different lymph node metastatic patterns of a prostatic cancer

Among 753 autopsy prostatic cancer cases with a metastasis, 476 (63%) had a lymph node metastasis, whereas 277 (37%) did not. Two different lymph node metastatic patterns were observed: Type 1, combined metastasis involving the pelvic and paraaortic lymph nodes; and Type 2, metastasis to the paraaortic lymph nodes, but not to the pelvic lymph nodes. Type 1 metastasis cases showed a significantly more frequent metastasis to the bladder and rectum, and a less frequent metastasis to the lungs and liver. Hydronephrosis occurred more frequently (P less than 0.01) in the Type 1. Furthermore, in the Type 1 cases the lymph node metastasis appeared to be continuously invasive, but in the Type 2 cases, metastasis appeared to be the skip type or some metastases may have spread via the vertebral vein bypass route and may have been associated with a hematogenous metastasis.

Venous bypass for surgical resection of renal carcinoma invading the vena cava: a new approach

A new technique is described which facilitates the surgical removal of renal carcinoma from the inferior vena cava. The use of cardiopulmonary bypass with or without cardiac arrest has been advocated but with this procedure only the inferior vena cava is bypassed, using femoral and right atrial cannulation, assisted by a closed system electromagnetic centrifugal pump. In appropriate cases this less complex technique allows prolonged access to the inferior vena cava whilst providing equal protection from pulmonary embolisation and tumour dissemination; it also reduces morbidity, operating time, difficulty and cost when compared with cardiopulmonary bypass.

Brain metastasis in hypernephroma

Of 926 patients with hypernephroma, 36 (3.9%) had metastasis to the brain. The median age at presentation was 61 years (range, 34 to 82). Nineteen patients had a single lesion metastatic to the brain, and 16 of these lesions were supratentorial. In 28% of the patients, computed tomography showed hyperdense lesions before contrast material was injected. All patients, except 2 with incomplete records, had evidence of widespread disease involving bone, liver, or lung. The median time interval between the initial diagnosis and the discovery of brain metastasis was 65.5 weeks (range, 0 to 462), with only 2 patients initially presenting with brain metastasis. Twenty-five of the patients who received only radiation therapy had a median survival of 13 weeks (range, 4 to 146), while 7 selected patients who underwent surgical resection and postoperative radiation had a median survival of 66 weeks (range, 18 to 260). In 5 of the 7 patients, scans demonstrated recurrent tumor from 6 to 23 weeks postoperatively. One patient had a pronounced reduction in the size of the tumor after radiation therapy only. This study shows that brain metastasis is usually a late complication of hypernephroma and is associated with a poor prognosis.

Computerized tomography in the early postoperative management of renal cell carcinoma

Computerized tomography of the abdomen was used to detect local and intra-abdominal recurrence of renal cell carcinoma within 2 years in 22 patients with stage I, II or IIIA disease at the time of initial radical nephrectomy with regional lymphadenectomy. Six patients had recurrences initially limited to the abdomen and retroperitoneum. Therapeutic procedures, including surgical excision of recurrent tumor in 2 patients, did not alter the progression of the disease. Computerized tomography provides earlier detection of local recurrence of renal cell carcinoma but current therapy offers limited benefit when a recurrence is detected.

Renal cell carcinoma: survival and prognostic factors

Three hundred twenty-six patients treated at New York University from 1970 to 1982 were studied for survival in relationship to surgical stage, type of therapy, and pathologic characterization of the primary tumor. At the time of diagnosis 25.5 per cent of tumors were Stage I, 15 per cent Stage II, 28.5 per cent Stage III, and 31 per cent Stage IV. The retrospective study showed that patients with tumor confined within the capsule achieved the highest five- and ten-year survivals of 88 per cent and 66 per cent, respectively. Survivals decreased as tumor invaded perirenal fat (67% and 35%) or regional lymph nodes (17% and 5%). Tumor invasion into the renal vein alone did not significantly change five-year survival (84%) but lowered ten-year survival to 45 per cent. Patients with metastases at the time of nephrectomy did poorly regardless of site of metastases or kind of adjuvant therapy, except for those managed by surgical extirpation of the secondary lesion. Certain tumor characteristics were associated with a better prognosis, e.g., size below 5 cm in diameter, lack of invasion of collecting system, perirenal fat or regional lymph nodes, and predominance of clear or granular cells growing into a recognizable histologic pattern.

Metastatic patterns of prostatic cancer. Correlation between sites and number of organs involved

Prostatic cancer in 1885 autopsy cases was classified according to the number of organs involved in metastasis, and a comparison was made concerning the frequency of metastasis to the various organs. The frequencies of metastasis to the lungs and para-aortic lymph nodes were low in cases with single-organ involvement (4.6% and 2.3%, respectively), but increased rectilinearly in accordance with the number of organs involved and became high in cases with metastasis to three or more organs (49.1% and 21.8% in total, respectively). On the other hand, the frequencies of local extension to the bladder and invasion of the pelvic lymph nodes were high even in cases with single-organ involvement (34.5% and 9.2%, respectively) and were not significantly changed regardless of the number of organs involved. No significant correlation was seen between pelvic and para-aortic lymph node involvement. In cases with single-organ involvement, metastasis to the lumbar spine occurred frequently, but those to the ribs, sternum, and ilium occurred less frequently. There may be multiple metastases in cases with metastases to the para-aortic lymph nodes, sternum, and ilium. The number of metastatically involved organs is useful in analyzing the mode of metastasis.

The role and value of surgery in metastatic renal adenocarcinoma: a retrospective clinical study of 106 nephrectomized cases

The results of treatment of 106 consecutive nephrectomized cases with metastatic renal adenocarcinoma were analyzed. Over 50% of the patients were dead at 1 year and more than 80% at 2 years from the first metastases. The corresponding 5-year survival rate was 7.3%. Fourteen patients demonstrated a response to radiotherapy, hormonal therapy, cytotoxic drugs, or active specific immunotherapy. The 5-year survival rate of the responders was 14.3% from the first metastases. The 5-year survival rate for 22 patients presenting with only one metastasis was 32%. The corresponding figure for patients presenting with multiple metastases was 1%. Complete excision of metastases was possible in 12 patients, whose 5-year survival rate was 58.3%. All patients with solitary metachronous metastases completely excised lived 5 years or more. It seems that a small number of metastatic renal adenocarcinomas are slow-growing tumors that may simulate a favorable effect of a therapy, but at the same time such disease with nephrectomy, usually with minor tumor burden, in fact may also react better to the treatment, and this feature can cause difficulties in judging the value of any therapy in metastatic renal adenocarcinoma.