Surgical management of large renal tumors

Surgical challenges in the treatment of a giant renal cell carcinoma with atypical presentation: A case report

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Description of the largest renal cell carcinoma ever resected.

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Unusual presentation led to a delay in diagnosis.

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Tumor size necessitated careful intraoperative maneuvers.

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Major resections are possible in community hospital with multidisciplinary team.

Introduction

For the management of localized renal cell carcinoma (RCC), surgical resection is the standard of care. Considerations are given to achieve good outcomes with conservative measures. When the tumor is exceedingly large the safest alternative is total nephrectomy.

Presentation of case

The patient is a 75 year old man with a 5 year history of increasing abdominal distension. There was no recent hematuria or any other genitourinary complaints. CT revealed a giant complex mass that occupied the majority of the abdomen likely arising from the retroperitoneum. Early in diagnosis, the mass was suspected to arise from the left kidney. The decision was made to proceed with surgery for both treatment and diagnosis. Resection of the tumor revealed a 28.0 × 25.0 × 15.0 cm encapsulated neoplasm. Histopathology determined this to be a papillary RCC. Resection of the mass resulted in en bloc partial nephrectomy immediately followed by a completion of the nephrectomy, lymphadenectomy, and abdominal wall repair. Postoperative course was excellent.

Discussion

The aim of this report is to determine the surgical challenges posed by a tumor of this magnitude and the multidisciplinary approach necessary to treat it. In the often indolent course seen with RCC, surgeons are faced with the task of handling advanced disease, requiring more radical procedures for good outcomes.

Conclusion

The size of the tumor in this case presented several challenges in the operative setting. The sheer mass of the tumor gave no other choice than to perform exploratory laparotomy and complete nephrectomy upon resection.