Recurrent renal cell carcinoma after 45 years

Metastatic pulmonary nodule after a seventeen-year disease-free interval resected through thoracoscopic subsegmentectomy: A case report

The lung is the most common site of metastasis in patients with renal cell carcinoma (RCC). Metastatic RCCs, even those classified as stage I, can recur after >10 years. Therefore, it is critical to completely resect metastatic nodules. Here, we report the case of a 74‐year‐old man who underwent a nephrectomy for RCC and was diagnosed with lung metastasis 17 years later. The metastatic nodule was resected through complete thoracoscopic subsegmentectomy. He had previously undergone partial nephrectomy for clear cell renal carcinoma pT1bN0M0. During his annual follow‐up, a computed tomography scan revealed a pulmonary nodule. The intraoperative frozen section revealed a metastatic clear cell RCC. Thus, additional lobectomy was not performed. The postoperative course was uneventful with no complications. This case demonstrates that even early stage metastatic clear cell renal carcinoma can recur after over 17 years. Thoracoscopic segmentectomy is less invasive and can preserve pulmonary function.

Local and Regional Recurrences of Clinically Localized Renal Cell Carcinoma after Nephrectomy: A 15 Year Institutional Experience with Prognostic Features and Oncologic Outcomes

OBJECTIVE

To evaluate outcomes for patients with local recurrence (LR) of clinically localized renal cell carcinoma (RCC) without concurrent systemic metastasis from our institution, an event that occurs rarely (1%-3%) after surgery. LR may be a harbinger of poor outcomes, and the best management of these patients is unclear.

MATERIALS/METHODS

We retrospectively reviewed patients surgically treated for clinically localized RCC (cT1-2N0M0) with subsequent LR (in the partial or radical nephrectomy bed) and/or regional recurrence (RR; in the abdomen distant from the direct site of surgery) without concurrent metastasis from our institutional database (2004-2018). Comparative and survival analyses were performed.

RESULTS

Out of 3038 total patients, 1895 had clinically localized RCC, with 30 patients (1.6%) having isolated LR/RR. Median time to recurrence was 26.5 months (IQR:16-35). Of 26 patients treated with local therapy, 14 (53.8%) recurred over a median follow-up time of 29.5 months (IQR:12-45). The 1-year and 2-year secondary recurrence-free survival rates are 60.7% and 49.7%, respectively. Two or more sites of locoregional recurrence significantly predicted secondary recurrence/metastasis after local therapy for local recurrence (hazard ratio: 2.22, P= .04).

CONCLUSION

Our results suggest local therapy is appropriate for select patients with LR/RR, with almost 50% of patients undergoing a second local therapy remaining alive with "local cure" and no secondary recurrence. The number of sites of recurrence can be used to better select patients that will benefit from local therapy or systemic/combination therapy. This work provides a framework onto which further studies regarding local therapy and locoregional recurrence of RCC can be performed.

Solitary, Late Metastatic Recurrence of Renal Cell Carcinoma to the Pancreas: A Case Report

Renal cell carcinoma (RCC) accounts for 3% of all adult malignancies and is known for metastatic initial presentation, unpredictable metastatic pathway, and late recurrence post-curative resection. We report a case of solitary late metastatic renal cell carcinoma to the pancreas more than 10 years after radical nephrectomy. A high index of suspicion must be maintained to detect RCC late recurrence and metastasis to rare and atypical locations. A lifelong follow-up is recommended.

Asynchronous abdominal wall and sigmoid metastases in clear cell renal cell carcinoma: A case report and literature review

Sigmoid metastasis of renal cell carcinoma (RCC) is very rare. Herein we report a case of pathologically proven asynchronous abdominal wall and sigmoid metastases after a right nephrectomy. An 84-year-old man underwent right radical nephrectomy for clear cell renal cell carcinoma (ccRCC) 13 years ago. Solitary contralateral abdominal wall metastasis was found for left abdominal mass 9 years after nephrectomy. The man experienced melena underwent resection of sigmoid colon tumor in February, 2016. The postoperative pathological examinations revealed that the tumors were metastases of ccRCC. Recurrence more than 5 years after nephrectomy has been accepted as late recurrence by the majority of urologists now. Late recurrence is one of the specific biological behaviors of RCC. Asynchronous late recurrence of abdominal wall and sigmoid metastases in ccRCC has not been reported before. When patients have sigmoid mass after nephrectomy for RCC, doctors may consider the possibility of late recurrence.

22-year survival following radical nephrectomy and several metastasectomies in a case of renal cell carcinoma

Renal cell carcinoma (RCC) is a common malignancy. Metastases can be seen both synchronously, at the time of diagnosis, and metachronously during follow-up. At the time of diagnosis, 23% of the patients have metastatic disease. and 25% of patients will develop metastasis during follow-up period after nephrectomy. Nearly 80% of them develop within the first 5 years. However late metastasis of RCC have been also reported within the postoperative 10 years in the literature. For metastatic lesions, if surgically feasible, metastasectomy, and targeted pharmaceutical agents have been recommended. However any randomized controlled study which aimed to determine treatment protocol in patients who develop multiple metastases has not been cited in the literature. Herein, we are presenting a case with renal cell carcinoma in whom within 22 years of follow-up after 10 years of survival multiple metastases in different organs were detected which were managed with surgical, and medical treatments. As far as we know, this case is the first patient with the longest survival whose non-pulmonary metastases had been treated with more than one surgical interventions.

Surgical Management of Local Recurrences of Renal Cell Carcinoma

Surgical resection either in the form of radical nephrectomy or in the form of partial nephrectomy represents the mainstay options in the treatment of kidney cancer. In most instances, resecting the tumor bearing kidney or the tumor itself provides durable cancer specific survival rates. However, recurrences may rarely develop in the renal fossa or remnant kidney. Despite its rarity, locally recurrent RCC is a challenging condition in terms of the possible management options and relatively poor prognosis. If technically feasible, wide surgical excision and ensuring negative surgical margins are the most effective treatment options. Repeat surgeries (completion nephrectomy, excision of locally recurrent tumor, or repeat partial nephrectomy) may often be complicated, and perioperative morbidity is a major concern. Open approach has been extensively applied in this context and 5-year cancer specific survival rates have been reported to be around 50%. The roles of minimally invasive surgical options (laparoscopic and robotic approach) and nonsurgical alternatives (cryoablation, radiofrequency ablation) have yet to be described. In selected patients, surgical resection may have to be complemented with (neo)adjuvant radiotherapy or medical treatment.

Cancer Metastases: Early Dissemination and Late Recurrences

BACKGROUND

Metastatic cells from a primary tumor can occur before the primary cancer is detected. Metastatic cells can also remain in the patient for many years after removal of the primary tumor without proliferating. These dormant malignant cells can awaken and cause recurrent disease decades after the primary treatment. The purpose of this article is to review the clinical evidence for early dissemination and late recurrences in human malignant tumors. We used the following definitions: dormancy of cells may be defined as a nonproliferating state or an arrest in the cell cycle that results in a prolonged G0 phase. If one accepts the term "late metastases" to indicate a period exceeding 10 years from the removal of the primary tumor, then the two malignancies in which this occurs most frequently are cutaneous malignant melanoma (CMM) and renal cell carcinoma (RCC).

METHODS

PubMed, Web of Science, and Scopus were searched with the keywords "metastases," "early dissemination," "late recurrences," "inadvertently transmitted cancer," "tumor growth rate," "dormancy," "circulating tumor cells," and "transplantation of cancer."

RESULTS

Several case reports of early dissemination and late recurrences of various types of malignancies were found. Analyses of the growth rates of several malignant tumors in the original host indicated that the majority of cancers had metastasized years before they were detected. CMM, RCC, and malignant glioblastoma were the three most common malignancies resulting from an organ transplantation. CMM and RCC were also the two most common malignancies that showed dormancy. In several cases of transplanted CMM and RCC, the donor did not have any known malignancy or had had the malignancy removed so long ago that the donor was regarded as cured.

CONCLUSION

(1) Metastases can frequently exist prior to the detection of the primary tumor. (2) Metastatic cells may reside in organs in the original host that are not usually the site of detectable secondary tumors, for example, the kidneys and heart. (3) Metastatic cells remain dormant for decades after the primary tumor has been removed. (4) Dormancy might be reversible and lead to late recurrences.

Extremely delayed brain metastasis from renal cell carcinoma

Brain metastasis occurs in 3.9-24% of patients with renal cell carcinoma (RCC), with an average interval from nephrectomy to brain metastasis of 1 to 3 years. A few cases have been reported where brain metastasis occurred after a delay of more than 10 years from the initial onset of renal cell carcinoma. This long interval for central nervous system metastasis from the primary cancer has been recognized as an indicator of better prognosis. Histopathological confirmation and aggressive treatment must be considered in these delayed brain metastases cases, since the patients usually show long survival and good prognosis. We present a case of a 76-year-old woman who developed extremely late multiple brain metastases 18 years after a nephrectomy for RCC.

Laparoscopic excision of local recurrence of renal cell carcinoma

Laparoscopic excision of local recurrent renal cell carcinoma appears to be a feasible technique in wellselected patients with low-volume mass not involving adjacent organs.

Background and Objective:

To report a single center's experience with laparoscopic excision of local recurrence of renal cell carcinoma.

Methods:

Between January and August 2011, 5 patients who underwent laparoscopic excision of local recurrence were identified from the institutional laparoscopic surgery database.

Results:

Four radical nephrectomies and 1 partial nephrectomy were performed for primary tumors. The mean ages of the patients were 57.4 y (range, 48 to 68) and 62.8 y (range, 53 to 71) at the time of primary surgery and laparoscopic recurrence excision, respectively. The average size of the primary tumor was 7.2cm (range, 4.5 to 11). The mean size of local recurrence was 3.46cm (range, 2.8 to 4.5). The original tumor T stages were T1b, T2b, and T4 in 3, 1, and 1 cases, respectively. The mean time to diagnosis of recurrence was 51.2 mo (range, 15 to 136). The pathology of one patient who had previously received targeted therapy with sunitinib, was necrosis, unlike the other 4 pathologies which revealed renal cell carcinoma. The mean operative time, estimated blood loss, and length of hospital stay were 86 min (range, 70 to 100), 100 mL (range, 20 to 300), and 4 d (range, 2 to 8), respectively. One pleural injury did not need open conversion and was repaired laparoscopically. At a mean follow-up of 8.4 mo, the cancer-specific and disease-free survival rates were 100% and 60%, respectively.

Conclusion:

Laparoscopic excision of local recurrence of RCC is a feasible technique in well-selected patients with low-volume mass not involving the adjacent organs.

Follow-up for Clinically Localized Renal Neoplasms: AUA Guideline

PURPOSE

The purpose of this guideline is to provide a clinical framework for follow-up of clinically localized renal neoplasms undergoing active surveillance, or following definitive therapy.

MATERIALS AND METHODS

A systematic literature review identified published articles in the English literature between January 1999 and 2011 relevant to key questions specified by the Panel related to kidney neoplasms and their follow-up (imaging, renal function, markers, biopsy, prognosis). Study designs consisting of clinical trials (randomized or not), observational studies (cohort, case-control, case series) and systematic reviews were included.

RESULTS

Guideline statements provided guidance for ongoing evaluation of renal function, usefulness of renal biopsy, timing/type of radiographic imaging and formulation of future research initiatives. A lack of studies precluded risk stratification beyond tumor staging; therefore, for the purposes of postoperative surveillance guidelines, patients with localized renal cancers were grouped into strata of low- and moderate- to high-risk for disease recurrence based on pathological tumor stage.

CONCLUSIONS

Evaluation for patients on active surveillance and following definitive therapy for renal neoplasms should include physical examination, renal function, serum studies and imaging and should be tailored according to recurrence risk, comorbidities and monitoring for treatment sequelae. Expert opinion determined a judicious course of monitoring/surveillance that may change in intensity as surgical/ablative therapies evolve, renal biopsy accuracy improves and more long-term follow-up data are collected. The beneficial impact of careful follow-up will also need critical evaluation as further study is completed.

Renal cell carcinoma presenting as an ominous metachronous scalp metastasis

Renal cell carcinoma (RCC) accounts for 3% all of solid organ tumours and is slightly more common in men in the age range of 60 to 70 years. Skin metastases occur in 3% to 6% of RCCs. There are only approximately 30 cases of scalp metastases secondary to RCC in the literature. They usually occur late in metastatic disease and are a bad prognostic marker. A 67-year-old Caucasian male presented with a metastatic scalp lesion, 10 years post-radical treatment for RCC. His initial diagnosis was a T3bN0M0 RCC. He presented with a raised erythematous lesion on his parietal scalp, the histology of which demonstrated late metastatic recurrence. Shortly after this, he developed diffuse metastatic disease. Metastatic RCC can occur many years after initial diagnosis and present in many forms. Cutaneous metastatic lesions of RCC can mimic many other dermatologic conditions and carries an ominous prognosis. It is therefore important not only for the urologist, but also general practitioners and patients to be vigilant of any new skin lesion as a portent of impending metastatic disease.

Clinical characteristics and outcomes of patients with recurrence 5 years after nephrectomy for localized renal cell carcinoma

PURPOSE

We analyzed characteristics in patients with recurrent renal cell carcinoma 5 years or later after nephrectomy and determined predictors of survival after recurrence.

MATERIALS AND METHODS

From July 1989 to October 2008 at total of 2,368 nephrectomies were done for clinically localized, unilateral renal cell carcinoma at our institution. Of 256 patients with disease recurrence 44 had recurrence 5 years or more after nephrectomy. We compared clinicopathological characteristics in patients with disease recurrence before vs after 5 years. Survival from time of recurrence was assessed based on Memorial Sloan-Kettering Cancer Center risk score, symptoms at recurrence, metastasectomy, tumor diameter, and recurrence stage and site.

RESULTS

Patients with late recurrence tended to have fewer symptoms at presentation, smaller tumors (median 8.5 vs 7 cm) and less aggressive disease (pT1 in 18% vs 39%). Median overall survival was 6.1 years from time of recurrence. Five-year actuarial survival was 85% in 28 patients at favorable risk and 14% in 10 at intermediate risk (log rank p <0.001). The 5-year estimated overall survival rate was 72% in 31 patients with incidentally detected recurrence and 39% in 11 with symptoms at recurrence (log rank p = 0.01).

CONCLUSIONS

Data suggest that patients with cancer recurrence 5 years after nephrectomy are at favorable risk and have long-term median survival. A favorable Memorial Sloan-Kettering Cancer Center risk score and absent symptoms related to metastasis are associated with longer survival in these patients.

Solitary, late metastatic recurrence of renal cell carcinoma: two extraordinary cases

Late recurrence of renal cell carcinoma (RCC) has been well documented in the literature. We present two extraordinary cases of solitary, late metastatic recurrence of RCC. The first is a case of a solitary, adrenal metastasis excised 38 years after nephrectomy and the second is a case in which two solitary metastatic deposits were resected 14 and 26 years after excision of the primary tumor. In each of these patients the solitary metastases were initially believed to be primary tumors at other sites; however, on histological examination they were found to be metastatic RCC recurrences. In patients with a previous history of RCC presenting with apparently new solitary lesions, metastatic RCC must first be excluded.

Splenunculus mimicking late local recurrence of renal cell carcinoma

We report on a case of a splenunculus found in the renal fossa 14 years after left transperitoneal radical nephrectomy and splenectomy for renal cell carcinoma. The significance of splenunculi in differential diagnosis of space occupying lesions in the left renal bed is discussed.