Papillary Renal Carcinoma Presenting as a Cancer of Unknown Primary (CUP) and Diagnosed through Gene Expression Profiling

Pathological Fracture of the Proximal Humerus Occurred on Metastases of Probable Kidney Origin in the Absence of Primary Lesions: A Case Report

Cancer of unknown primary (CUP) origin represents a diagnostic and therapeutic challenge. These tumours spread to different parts of the body even if the site of origin has not been identified. When renal metastases are observed without an obvious primary lesion, it is important to exclude the possibility of a primary kidney tumour that may be unknown or too small to be detected. The diagnosis of CUP is established after a careful clinical evaluation and diagnostic tests, including blood chemistry and laboratory tests, instrumental exams (CT, MRI, PET, bone scan), biopsy, and molecular and cytogenetic analysis. Once the diagnosis of CUP with kidney metastases is confirmed, treatment depends on the location of the metastases, the patient's health status, and available treatment options. The latter includes surgery to remove metastases, radiation therapy, or systemic treatment such as chemotherapy or immunotherapy. It is important that patients with CUP are evaluated by a multidisciplinary team of specialists, who can contribute to planning the most appropriate treatment. In this article, we report the clinical case of a patient with a pathological fracture of the proximal humerus which occurred on metastases of probable renal origin in the absence of primary lesions.

Extra-renal renal cell carcinoma arising in the kidney proximity but without an identifiable renal primary - an intriguing dilemma: Report of three cases and review of the literature

We report three patients with extra-renal renal cell carcinomas (RCC) found in the renal proximity, but unattached to the kidney. None had a history of RCC or an identifiable primary renal neoplasm at the time of the diagnosis and on follow-up. The patients included two males and one female aged 57, 77 and 63 years, respectively. One carcinomas was found in the perirenal tissue adjacent to the adrenal, one involved the adrenal gland, and one was a retroperitoneal mass found within the lymph nodes. Two extra-renal RCCs represented clear cell RCCs and one was an unclassifiable RCC. No patient had evidence of metastases at presentation and disease progression during the follow-up. This report adds to the literature on this unusual clinical scenario and further supports the concept of extra-renal RCC, which is not a well-recognized clinical phenomenon. We also reviewed other similar reports documenting the absence of identifiable renal primaries in the setting of either disseminated metastatic disease or isolated distant metastases of presumed renal origin. Similarly, some carcinomas of apparent renal derivation have been also identified during a work-up of metastatic carcinomas of unknown primary. The aim of this study is to raise further awareness of this unusual and intriguing clinical scenario that currently lacks a definitive explanation and standardized therapy strategies. Establishing a correct diagnosis may allow treatment with specific targeted therapies in selected clinical cases.

Carcinoma of Unknown Primary Site (CUP) With Metastatic Renal-Cell Carcinoma (mRCC) Histologic and Immunohistochemical Characteristics (CUP-mRCC): Results From Consecutive Patients Treated With Targeted Therapy and Review of Literature

BACKGROUND

Carcinoma of unknown primary site (CUP) is a heterogenous group of metastatic cancer with no detectable primary tumor site. Diagnostic assessment occasionally presents CUP with metastatic renal-cell carcinoma (mRCC) histologic and immunohistochemical characteristics (CUP-mRCC). Efficacy and toxicity data for vascular endothelial growth factor inhibitor therapies in CUP-mRCC patients are few.

PATIENTS AND METHODS

We retrospectively reviewed consecutive patients with CUP-mRCC at a single institution between 2007 and 2018. Treatment outcomes were assessed from initiation of renal-cell carcinoma-specific therapy, including response rate, progression-free survival, and overall survival.

RESULTS

Ten patients with CUP-mRCC were identified. Median age was 64 years. Histologies were clear-cell (30%), papillary type II (20%), and unclassified renal-cell (50%) carcinoma. International Metastatic Renal Cell Carcinoma Database Consortium risk group were favorable, intermediate, and poor in 0, 40%, and 60%, respectively. One patient received empiric first-line chemotherapy. Targeted treatments were pazopanib (n = 7), sunitinib (n = 2), and sorafenib (n = 1). Objective response rate was 40%, progression-free survival was 2.5 months (95% confidence interval, 1.2-3.8), and overall survival was 5.7 months (95% confidence interval, 0-24.0). Stratified for International Metastatic Renal Cell Carcinoma Database Consortium risk, overall survival in intermediate versus poor risk group were 18.6 months and 2.3 months, respectively. Second-line therapy did not result in disease control. No new or unexpected toxicities were observed.

CONCLUSION

CUP-mRCC treated with vascular endothelial growth factor-targeted therapy is valid, feasible, and safe even though these patients had several negative prognostic factors. CUP-mRCC patients should be identified among CUP patients for specific renal-cell carcinoma therapy.

Metastatic renal cell carcinoma with undetectable renal mass presenting as lymphadenopathy

Renal cell carcinoma has the ability to metastasize to any organ; about 16 % of affected patients present initially with metastasis. However, it is rare for this tumor to present with metastasis from an unidentified primary. The current use of immunohistochemistry and molecular genetics has enabled clinicians to reach a precise diagnosis. It has been hypothesized that the treatment protocol for metastatic renal cell carcinoma can be applied to cases with undetectable primary. In this paper, a novel case of metastatic renal cell carcinoma presenting with lymphadenopathy with no evidence of a primary renal lesion is reported from Kuwait cancer center.

Papillary Renal Cell Carcinoma Presented With Supraclavicular Lymph Node Metastasis Without Renal Primary Lesion

Renal cell carcinoma is a rare cancer in Thailand. Most of the patients present in advanced metastatic stage with identifiable renal mass. In this case report, we presents a case of male patient who manifested with supraclavicular lymph node enlargement and CT scan of chest and abdomen showed multiple sites lymph node metastasis but there was no primary mass detected anywhere. The pathology of supraclavicular lymph node was papillary cell adenocarcinoma. The differential diagnoses were papillary thyroid cancer, gastrointestinal tract carcinoma such as pancreato-biliary cancer, non small cell lung cancer, and renal cancer. Immunohistochemistry result were negative for TTF-1, Thyroglobulin, CD7 and CD20 which ruled out non-small cell lung adenocarcinoma, thyroid cancer and gastrointestinal tract cancer respectively. CD10, Vimentin and RCC were all positive and all are specific for renal cell carcinoma. The diagnosis was renal cell carcinoma, papillary cell type. Sunitinib, a tyrosine kinase inhibitor, is the treatment of choice for renal cell carcinoma since it improves objective response rate and shows longer progression free survival than IFNα.

Adenocarcinoma of unknown primary site

BACKGROUND

Metastatic cancer of unknown primary site occupies 0.5-10% of all diagnosed cancer patients and includes various tumors with diverse responses to systemic chemotherapy. Adenocarcinoma of unknown primary site (ACUPS), the most common subtype, has no standard treatment, rarely responds to conventional treatment and has a poor survival rate.

METHODS

The retrospective study was performed to investigate the clinical characteristics and the treatment outcomes of ACUPS.

RESULTS

Eighty-one patients with ACUPS diagnosed at Samsung Medical Center from May 1995 to July 1999 were included. The median age was 58 years (range, 29-77). The common sites of metastases were the lymph node, liver, lung and bone in order. In 49 of 81 patients (60.5%), the dominant tumor location was below the diaphragm. The majority of patients (76 of 81) were initially treated with systemic chemotherapy including cisplatin. Responses were evaluable in 70 of 76. Eighteen of 70 patients (25.7%) responded to chemotherapy and complete remission was observed in 6 patients. The overall median survival of 81 patients was 5.6 months. The median survival of the responding patients was 18.3 months but the median survival of the nonresponding patients was 4.6 months (p < 0.01). In univariate and multivariate analysis, age, performance status and response to initial chemotherapy were significant prognostic factors for overall survival.

CONCLUSION

We observed poor response to the treatment and survival rate in ACUPS, but complete remission and long-term survival were observed in a small number of patients.