An Atypical Presentation of a Saddle Embolism in the Setting of Malignancy

A 52-year-old male presented to the emergency room with acute abdominal pain. Imaging determined acute appendicitis, with an incidental finding of a renal mass. The biopsy was positive for renal cell carcinoma, and the patient underwent simultaneous appendectomy and nephrectomy. Postoperatively, the patient developed hypoxia at night with exertion, requiring oxygen supplementation. The remainder of his vital signs were stable. Due to renal function, a ventilation/perfusion (V/Q) scan was conducted, which showed a high probability of pulmonary embolism (PE). Follow-up computed tomography angiography of the chest showed a massive saddle embolism. Interventional radiology performed an uncomplicated thrombectomy, oxygen saturations improved, and the patient was discharged on apixaban.

Cardiac Challenges in Immune Checkpoint Therapy: Complete Heart Block With Pembrolizumab

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, yet they come with a spectrum of immune-related adverse events, including cardiac complications. We present the case of a 72-year-old male with metastatic renal cell carcinoma who developed complete heart block and ventricular arrhythmias following pembrolizumab therapy. Despite no evidence of myocarditis, the patient's condition rapidly deteriorated, ultimately resulting in his demise. This case underscores the critical need for vigilance in recognizing and managing potential cardiotoxicity associated with ICIs. Additionally, it highlights the importance of multidisciplinary collaboration in optimizing diagnostic and therapeutic strategies for patients undergoing immune checkpoint inhibitor therapy.

Palliative Treatment of Leptomeningeal Carcinomatosis From Renal Cell Carcinoma With Local CyberKnife Radiotherapy and Systemic Pazopanib Therapy: A Case Report

Leptomeningeal carcinomatosis (LMC) from renal cell carcinoma (RCC) is rare. There is no established treatment strategy for LMC, and the prognosis is extremely poor. We describe a case of LMC from RCC treated with local CyberKnife radiotherapy (CKR) and systemic therapy with pazopanib. The patient was a 63-year-old man with brain metastases from right RCC. Surgery and CKR were performed for the brain metastases, and the lesions were subsequently controlled. The patient developed isolated lesions in the pituitary stalk, right internal auditory canal, left ventricular choroid plexus (CP), left facial nerve, and medulla oblongata after the surgery and CKR for brain metastases. We diagnosed LMC and treated the patient with systemic therapy with pazopanib. We performed local therapy with CKR for lesions of the pituitary stalk, right internal auditory canal, left facial nerve, and medulla oblongata. The CP lesion was not treated with CKR because the lesion tended to shrink after systemic therapy with pazopanib. There were no symptoms due to LMC until the end of life and no adverse events due to CKR. Ten years and five months after the nephrectomy for RCC, one year and four months after the initial CKR for brain metastases, and nine months after the diagnosis of LMC, the patient died due to pleural effusion from lung metastases. Our case suggests that CKR combined with pazopanib may be effective as a palliative treatment for LMC from RCC.

Exceptional and Sustained Response to Belzutifan in Von Hippel-Lindau Disease-Associated Central Nervous System Hemangioblastoma

Von Hippiel-Lindau (VHL) disease is a rare genetic disorder characterized by a variety of benign and malignant neoplastic growths arising in multiple different organ systems. About 60%-84% of patients develop hemangioblastomas, benign tumors comprised of newly formed blood vessels that often occur in the central nervous system (CNS) and retinas. Treatment options for this disease were limited before the Food and Drug Administration (FDA) approval of belzutifan, a HIF2α inhibitor. We present a case of a 25-year-old woman with VHL who underwent treatment with belzutifan over 18 months. It was noted that her CNS lesions decreased significantly in size over the course of her treatment, and she had minimal adverse effects. Her excellent and sustained therapeutic response to the treatment highlights the real-world clinical benefit of belzutifan and the possibility that this could play a crucial role in treating VHL by postponing or completely avoiding repeated surgical and radiotherapeutic intervention and their associated comorbidities.

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.

Unusual Cutaneous Lesions in a 53-Year-Old Female: A Potential Indicator of Underlying Renal Cell Carcinoma

Hereditary leiomyomatosis and renal cell cancer (HLRCC) is a rare autosomal dominant genetic disorder resulting from mutations in the fumarate hydratase (FH) gene. It is characterised by a predisposition to cutaneous and uterine leiomyomas (fibroids) and an aggressive form of renal cell carcinoma (RCC). We report the case of a 53-year-old female who presented with an unusual rash in the context of a personal and family history of uterine leiomyomas requiring hysterectomy. A skin biopsy confirmed cutaneous leiomyomas and subsequent genetic testing demonstrated a pathogenic heterozygous mutation on exon 7 of the FH gene, confirming a diagnosis of HLRCC. Due to the recognised association with renal cell carcinoma in this syndrome, abdominal imaging was performed, which excluded RCC, and the patient was commenced on lifelong surveillance with annual abdominal magnetic resonance imaging.

Recurrent Left Renal Fossa Clear Cell Renal Cell Carcinoma With Pancreatic Tail Invasion Presenting as Intestinal Obstruction

Distant renal cell carcinoma (RCC) metastatic disease is mostly seen in the lungs, bones, and lymph nodes. The incidence of local recurrences within the ipsilateral retroperitoneum (RFR) is very low. We report a case of a 79-year-old male with recurrent left renal fossa RCC with pancreatic tail invasion who presented with large bowel obstruction. To the best of our knowledge, no cases have been reported of recurrent left renal fossa RCC initially presenting as extrinsic large bowel obstruction.

Anesthetic Management of Renal Cell Carcinoma With Level 3 Inferior Vena Cava Extension in a Patient With Severe Coronary Artery Disease

A 49-year-old male with untreated type 2 diabetes and a family history of coronary artery disease (CAD) presented with right flank pain and profound progressive dyspnea on exertion to the emergency department of Ben Taub Hospital, a tertiary county hospital. Workup revealed right renal cell carcinoma with metastatic extension into the inferior vena cava (IVC). In addition, the patient had significant CAD with 95% occlusion of the proximal left anterior descending coronary artery amenable to percutaneous coronary intervention (PCI). After multidisciplinary discussions involving cardiovascular anesthesiology, cardiology, urology, and cardiothoracic surgery, it was estimated that the mortality benefit of immediate tumor resection outweighed the patient's need for PCI and further cardiac optimization. The patient underwent curative resection and thrombectomy under transesophageal echocardiography (TEE) guidance without complication, made an expedient recovery, and was discharged home on postoperative day seven.

Metastatic Clear Cell Renal Cell Carcinoma Presenting as Acute Appendicitis

Renal cell carcinoma (RCC) is a malignant tumor arising from the epithelial cells of kidney tubules. It may metastasize to many sites; however, metastasis of RCC to the appendix is very rare. Renal cell carcinomas usually metastasize to the lungs, lymph nodes, bones, or liver. Metastasis usually occurs within three years after radical nephrectomy; however, there is evidence of RCC metastasis many years following nephrectomy.

Giant Renal Cell Carcinoma (RCC): A Case Report of Delayed Diagnosis and Management

Renal cell carcinoma (RCC) is the most common type of kidney cancer. It typically presents with macroscopic hematuria, weight loss, and or a palpable flank mass. Diagnosis of this disease involves imaging techniques such as abdominal ultrasound and CT scans. Care for RCC can consist of ablation, tumor removal, nephrectomy, and systemic treatment options. Herein, we present a case of a 50-year-old Hispanic male with complaints of rectal bleeding and hematuria. Prior to admission, the patient had been informed twice about high suspicion of renal malignancy. Due to low health literacy and barriers to communication, he failed to understand the magnitude of his diagnosis. Subsequently, he underwent a resection of a considerable 22 cm x 13 cm x 13 cm RCC of his left kidney. This case highlights the need for effective patient health education to prevent emotional distress in patients with low health literacy.

Renal Endometriosis in a Postmenopausal Female Mimics Renal Cell Carcinoma

A 61-year-old postmenopausal female with a past medical history of type 2 diabetes, nephrolithiasis, and recurrent urinary tract infections presented to an outpatient urology clinic with a chief complaint of urinary frequency, urgency, and burning after micturition. Associated symptoms included nausea, a low-grade fever with chills, and right flank pain. After treatment with antibiotics did not relieve all of her symptoms, imaging was obtained, showing a cystic mass with calcifications in the right kidney. Following laparoscopic partial right nephrectomy and total hysterectomy with bilateral salpingo-oophorectomy, pathological examination of the right kidney mass highlighted endometrial stromal cells consistent with endometriosis of the right kidney. The left ovary also contained endometrial stromal cells, confirming another diagnosis of endometriosis of the left ovary. This case highlights the importance of considering renal endometriosis in the differential diagnosis of renal masses in women, even if they are postmenopausal.

Metastatic Renal Cell Carcinoma Masquerading as a Laryngeal Tumor: A Case Report

Renal cell carcinoma (RCC) commonly metastasizes to various organs such as the lungs, liver, bones, and brain. However, isolated metastases to the head and neck region, especially the larynx, are very rare. This report presents a case of laryngeal growth that was eventually confirmed to be a metastatic deposit from an undiagnosed RCC. We report a case of a 66-year-old male who presented to the clinic with painless neck swelling and a change in voice. The scan showed a soft tissue mass in the thyroid cartilage. Histopathology of the resected laryngeal tumor confirmed metastatic clear cell carcinoma. A metastatic workup revealed a renal mass, and the patient underwent laparoscopic adrenal-sparing left cytoreductive nephrectomy. The histopathological examination established the diagnosis of clear cell RCC. Subsequently, the patient was treated with pembrolizumab and lenvatinib. Follow-up imaging showed no residual or recurrent lesions. This case highlights the rarity of laryngeal metastasis from RCC and the importance of an accurate diagnosis through advanced imaging and histopathological examination.

Paraneoplastic Hypereosinophilia in Locally Advanced Clear Cell Renal Carcinoma

Renal cell carcinoma (RCC) can cause various paraneoplastic syndromes, including metabolic and hematologic disturbances. Paraneoplastic hypereosinophilia has been reported in a variety of hematologic and solid tumors. Hypereosinophilia due to RCC is very rare and is only available as case reports in the literature. A 66-year-old male patient's thoracoabdominal computed tomography (CT) performed showed an increase in size in the right kidney and a heterogeneous contrasting solid mass of approximately 12 cm × 9 cm, which formed lobulations in its contours. The patient was diagnosed with clear-cell renal carcinoma as a result of a kidney biopsy. In the patient with stage cT4NxM0, the leukocyte count was 40.000/µl and the eosinophil count was 20% in biochemical tests. With these results, the patient was evaluated as having severe paraneoplastic hypereosinophilia due to RCC. The patient was started on sunitinib 50 mg for two weeks on/one week off. No symptoms were observed due to hypereosinophilia. In the evaluation made two weeks after the start of the treatment, it was observed that eosinophil levels decreased to normal rates. Paraneoplastic hypereosinophilia due to renal cell carcinoma may indicate poor prognosis and rapid disease progression. Myelosuppressive therapy is required for symptomatic patients.

A Rare Case of Cutaneous Metastasis of Renal Cell Carcinoma to the Lateral Thigh

Renal cell carcinoma (RCC) is a common cancer type in the United States, and at the time of diagnosis, many patients already have metastatic disease. RCC typically metastasizes to the lungs, liver, and bones, with few cases manifesting cutaneous metastasis. Most incidences of RCC metastases reported in the literature have been on the face and scalp. We discuss a case of a 64-year-old male patient who presented with a history of RCC and a purpuric nodule on his lateral thigh. Histopathological examination revealed vacuolated cytoplasm with areas of cytoplasmic clearing; the cells stained positively for cytokeratin AE1/AE3, CAM5.2, and PAX8. Cutaneous metastatic RCC was subsequently diagnosed. Cutaneous manifestations of RCC, particularly to the thigh, remain a rare presentation of metastatic RCC.

Malignant Pleural Effusion As the Initial Presentation of Renal Cell Carcinoma: A Case Report and Literature Review

Renal cell carcinoma is the most common renal neoplasm. Its presentation is often very occult, and it may be discovered incidentally. It may present with the classic symptoms of back pain, flank pain, hematuria, or hypertension. Renal cell carcinoma may also present with malignant pleural effusion at diagnosis; however, it is very rare. In this case report and literature review, we describe a 77-year-old male who was diagnosed with renal cell carcinoma after presenting with a malignant pleural effusion - an extremely rare phenomenon. An analysis of the literature yielded 13 case reports, including ours, where the diagnostic presentation of renal cell carcinoma was a malignant pleural effusion. Our patient presented with left-sided chest pain. Imaging was suggestive of pleural effusion. CT and MRI imaging demonstrated masses in the upper and lower poles of the right kidney suggestive of renal cell carcinoma. CT imaging also showed lung nodules that were suggestive of pulmonary metastases. Biopsy and immunostaining of pleural tissue were positive for clear cell renal cell carcinoma. Therapeutic thoracentesis was performed. Despite this, the patient developed recurrent large-volume pleural effusions requiring drainage and placement of a pleural catheter. Our patient's extremely rare presentation of malignant pleural effusion as the diagnostic presentation of renal cell carcinoma along with recurrent, large-volume effusions requiring drainage has only been reported in the form of case reports in the literature.

Cardiac Metastasis From Renal Cell Carcinoma

While metastasis is common, it is unusual for renal cell carcinoma (RCC) to spread to the heart and even more so without involving the inferior vena cava (IVC). In fact, only a few cases have been reported where RCC has metastasized to the heart without IVC invasion. There have been only a few cases published that show RCC metastasis to the heart without invasion through the IVC. Here, we present an interesting case of a patient that was found to have RCC metastasis to the lungs that had a direct invasion to the left atrium.

Asymptomatic Giant Right Renal Oncocytoma: A Case Report

Renal oncocytoma is usually detected incidentally. It can be considered as a renal cell carcinoma (RCC) on preoperative imaging. They usually present as small masses and usually look like benign tumors. Giant oncocytomas are rare. A 72-year-old male patient was seen in the outpatient department for left scrotal swelling. Ultrasound (US) showed a giant mass compatible with RCC in the right kidney which was incidentally detected. Abdominal computed tomography (CT) revealed a mass with an axial diameter of 167×146 mm, compatible with RCC, a heterogeneous mass of soft tissue density with central necrosis. There was no evidence of tumor thrombus in the right renal vein or inferior vena cava. Open radical nephrectomy was performed through an anterior subcostal incision. Pathological examination revealed a 17×15 cm renal oncocytoma. The patient was discharged on the sixth day postoperatively. Clinically or radiologically, renal oncocytoma and renal cell carcinoma usually cannot be distinguished, although oncocytoma may be suspected if a central scar with fibrous extensions is seen, the so-called "spoke-wheel appearance". The treatment decision should be made according to the clinical aspects. Radical/partial nephrectomy or thermal ablation can be considered as treatment options. In this article, we review the literature on the radiological and pathological features of renal oncocytoma.

Recurrent Metastatic Renal Cell Carcinoma Diagnosed With Endoscopic Ultrasound-Guided Fine Needle Aspiration 18 Years After Initial Surgery

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an alternative approach to sample kidney lesions that is less commonly used compared to percutaneous CT or ultrasound guidance. In this case, we present a 70-year-old female who was diagnosed with metastatic renal cell carcinoma (RCC) 18 years post-nephrectomy with EUS-FNA in conjunction with immunohistochemistry. This case report supports the use of EUS-FNA in conjunction with immunohistochemistry as a robust technique that can safely and effectively diagnose recurrent renal cell carcinoma.

Cryoablation for Renal Cell Carcinoma Prior to Liver Transplantation: A Case Report

Extrahepatic malignancies are a relatively rare incidental finding during liver transplant work-up that provides a significant barrier to continued transplant evaluation and requires treatment to limit the risk of recurrence. There have only been 11 previously reported cases of pre-liver transplant renal cell carcinoma (RCC), of which all underwent partial or radical nephrectomy. Percutaneous cryoablation therapy has been gaining acceptance as a curative treatment alternative for RCC and is a new therapeutic standard for patients who are poor candidates for surgical resection. Recent studies have demonstrated the safety and efficacy of cryoablation for RCC in native kidneys and in solid masses in kidney allografts, but there is no data on the efficacy or recurrence of RCC when cryoablation is used for the treatment of RCC in a native kidney prior to solid organ transplantation. The patient underwent percutaneous cryoablation therapy of a T1a RCC of the native kidney 10 months prior to orthotopic liver transplant (OLT) without subsequent partial or radical nephrectomy. At seven years post-ablation therapy, the patient has no evidence of tumor recurrence despite immunosuppressive therapy post-transplantation. Cryoablation is potentially a safe and highly effective means of treating RCC in patients who are not candidates for nephrectomy secondary to complications associated with end-stage liver disease. In our case, the patient was treated with cryoablation and received standard post-transplant immunosuppression without recurrence of RCC at seven years. More studies are needed to determine inclusion and exclusion criteria for cryoablation and to confirm long-term efficacy as well as a strategy for duration and frequency of surveillance in these patients.

Metastatic Jejunal Renal Cell Carcinoma Intussusception Presenting as Melena

Renal cell carcinoma (RCC) most commonly metastasizes to the lungs, and it is uncommon for RCC to metastasize to the small bowel. Small bowel metastasis commonly presents with gastrointestinal (GI) bleeding. In rare cases, a metastatic small bowel mass can serve as a lead point for intussusception. In this report, we present the case of a male patient whose chief complaint was melena. The patient denied any abdominal pain or nausea. Investigation with push enteroscopy revealed a jejunal mass, and further evaluation with CT showed small bowel intussusception. The patient subsequently underwent small bowel resection and anastomosis. Histopathology confirmed that the jejunal mass was metastatic RCC. We present this case in order to showcase the utility of push enteroscopy in the diagnosis of small bowel metastasis in RCC.

Cryoablation for the Treatment of Kidney Cancer: Comparison With Other Treatment Modalities and Review of Current Treatment

With cancer among the leading causes of death worldwide and kidney cancer among the more common cancers in the United States, it has become increasingly important to ensure that first-line treatments remain validated and supported in recent literature. Surgical intervention has long remained the gold standard for intervention but with newer techniques and technology on the horizon, there must be a constant review of other options that may provide improved outcomes and reduction of associated risks. Ablative techniques have gained traction and are becoming a valuable intervention for multiple different types of cancers, kidney cancer included. Cryoablation, a newer ablative technique taking advantage of extreme cold to freeze and destroy abnormal tissue, provides a promising option for treatment. Currently, no review article, to our knowledge, compares all the different treatment options for kidney cancer. Additionally, while some literature has addressed cryoablation in comparison to other methods of management, there has not been an extensive review to combine our current understanding of these comparisons. In this review article, we provide an overview of each of the commonly used treatments for kidney cancer and summarize the current literature regarding the advantages and disadvantages of each intervention. Finally, we seek to compare cryoablation, a newer option for treatment, to each of the approaches with the goal of evaluating the best methods for management and determining cryoablation's role alongside these current interventions.

Birt-Hogg-Dubé Syndrome: Two Patients With Different Initial Presentations

Birt-Hogg-Dubé syndrome (BHD) is a rare genetic disorder caused by germline mutations in the tumor suppressor folliculin gene (FLCN). This condition is characterized by benign skin hamartomas, pulmonary cysts, spontaneous pneumothorax, and an increased risk for developing kidney tumors which range from benign oncocytomas to malignant renal cell carcinomas including chromophobe, clear cell, or papillary subtypes. We describe two cases of BHD with different initial presentations. Patients underwent genetic testing and an FLCN mutation was identified, confirming the diagnosis. Through this case series, we aim to highlight the importance of recognizing key manifestations of BHD whether alone or in combination, followed by genetic testing and counseling and the need for regular follow-ups with surveillance imaging tests to detect renal cancer early on.

Early Detection of Immune-Mediated Hypophysitis With Use of Checkpoint Inhibitor Immunotherapy

Hypophysitis is the inflammation of the pituitary gland with varying effects on hormone function that may be present secondary to the use of certain medications, infections, systemic inflammatory disorders, and other etiologies. Immunotherapy-related hypophysitis is a rare phenomenon. However, it represents an indication of treatment interruption. We report a 60-year-old female with renal clear cell carcinoma on Nivolumab and Ipilimumab (NIVO/IPI) intravenously (IV). After the second cycle of therapy, the patient reported a fall, with associated lightheadedness, dizziness, nausea, vomiting, and hot flashes. The patient's symptoms and history were concerning for hypophysitis, so early treatment and cessation of the checkpoint inhibitors led to the patient's clinical improvement.

Efficacy and safety of HDACIs in the treatment of metastatic or unresectable renal cell carcinoma with a clear cell phenotype: A systematic review and meta-analysis

BACKGROUND

In this study, we evaluated the efficacy and safety of histone deacetylase inhibitors (HDACIs) in the treatment of renal cell carcinoma (RCC).

METHODS

PubMed, EMBASE, the Cochrane Library, CNKI, and the Wanfang database were searched to retrieve studies describing the use of HDACIs for the treatment of RCC published between January 1, 2009, and January 1, 2021. Relevant studies were selected, and data were extracted. Then, a meta-analysis was performed using R 3.5.2 software.

RESULTS

The results showed that the objective response rate (ORR) of HDACIs used to treat RCC was 26% [95% confidence interval (95% CI): 0.19∼0.34] and that the 1-year progression-free survival (PFS) rate was 29% (95% CI: 0.14∼0.59). The ORR and PFS rate of the combination group were better than those of the monotherapy group, and the ORR and PFS rate of the selective HDACI group were better than those of the pan-HDACI group. The incidences of neutropenia and thrombocytopenia were higher and the incidence of fatigue was lower in the selective HDACI group than in the pan-HDACI group.

CONCLUSION

This study initially confirmed the efficacy and safety of HDACIs for the treatment of RCC. Due to the limitations of the included studies, more high-quality studies are needed to validate the conclusions.

Page Kidney From a Subcapsular Urinoma Following Contralateral Radical Nephrectomy

Page kidney is a rare cause of hypertension and kidney injury; it results from extrinsic compression of the kidney due to fluid accumulation in the subcapsular space. Hypertensive crisis may be the only presenting clinical sign in patients with Page kidney. Urinomas are a very rare cause of Page kidney with very few cases reported in the literature. Urinoma should be suspected in patients presenting in hypertensive crisis who have a history of recent abdominal trauma, genitourinary malignancy, and renal instrumentation. Patients diagnosed with Page kidney from a urinoma should be managed with the least invasive means possible.

Endobronchial Tumor With Ball Valve Mechanism: A Real Airway Emergency

Central airway obstruction due to the tumor can present as near-complete tracheal obstruction. The results can be life-threatening requiring emergent intervention. Rigid bronchoscopy has been preferred for the management of central airway obstruction. However, there are relatively few studies comparing rigid bronchoscopy and flexible bronchoscopy in treating these cases. We describe a 61-year-old woman with a lower trachea tumor with ball valve occlusion of the left mainstem bronchus and complete occlusion of the right mainstem bronchus successfully managed with flexible bronchoscopy and iCAST^® stent. We herein highlight the role of therapeutic flexible bronchoscopy with airway stenting as an efficacious treatment modality for the management of malignant central airway obstruction. 

Metachronous Renal Cell Carcinoma: A Rare Presentation of Adrenal Crisis

Responsible for 2% of global cancer diagnoses, renal cell carcinoma (RCC) can metastasize to almost every organ system; however, metastasis to the contralateral adrenal gland is extremely rare. We report the case of a 59-year-old male who presented with atypical chest pain and altered mental status. The patient developed hypotension, with hyponatremia raising concern for adrenal insufficiency (AI). We confirmed a diagnosis of AI secondary to adrenal metastasis in the setting of radical nephrectomy with ipsilateral adrenalectomy, and the patient's symptoms resolved with adequate treatment. This report emphasizes the importance of complications caused by metastatic disease to the remaining adrenal gland in patients with RCC who have undergone ipsilateral radical nephrectomy.

Pembrolizumab-Associated Seronegative Myasthenia Gravis in a Patient With Metastatic Renal Cell Carcinoma

Seronegative myasthenia gravis is a rare, but potential adverse effect of immune checkpoint inhibition. There have been few but increasing number of cases reported in recent years, and early recognition is important for prompt diagnosis and management. Here, we describe the case of a 65-year-old male with metastatic renal cell carcinoma on pembrolizumab diagnosed with new-onset seronegative myasthenia gravis and review literature on its management.

Von Hippel-Lindau Disease: A Rare Radiological Case Report of a Symptomatic Patient and His Asymptomatic Genetic Counterpart

Von Hippel-Lindau (VHL) disease is an inherited syndrome manifested as a benign and malignant tumor. It is an autosomal dominant syndrome diagnosed approximately in 1 in 36,000 people.

We report a case where male siblings presented with the involvement of bilateral kidneys and the multi-cystic lesion on the pancreas in both. Reverse transcription polymerase chain reaction (RT-PCR) was conducted to detect the VHL gene, which turned out to be a significant finding in our study. The rare involvement of both pancreas and kidneys was noted in the siblings with VHL in the present study.

In patients with VHL-associated tumour presentations, the most frequent detection of pathogenic variants in the VHL gene is the result of directed genetic testing or inherited cancer gene panels. The presence of renal and pancreatic involvement is rare but a significant finding present within the family member who needs to be screened.

Comprehensive analysis of mutations of renal cell carcinoma in an autosomal dominant polycystic kidney disease patient

Renal cell carcinoma (RCC) is known to be more prevalent in autosomal dominant polycystic kidney disease (ADPKD) patients than in the general population. However, little is known about genetic alterations or changes in signaling pathways in RCC in patients with ADPKD.In the current report, whole-exome and transcriptome sequencing was performed for paired samples of tumor tissue, cyst tissue, and peripheral blood (triple set) from a patient diagnosed with ADPKD and RCC.A 68-year-old man with ADPKD underwent left partial nephrectomy and was diagnosed with RCC. DNA and RNA were extracted from the triple set of the patient. A nonsense mutation in PKD2 (p.Arg742X), which is well known as a pathogenic variant in ADPKD, was identified in the paired triple set. In the tumor sample, a somatic missense mutation of VHL (p.S65L) was found, which is known as a pathogenic mutation in Von Hippel-Lindau syndrome and RCC. Furthermore, loss of chromosome 3p, where VHL is located, was detected. Upregulated VEGFA was found in the analysis of RCC mRNA, which might be caused by the loss of VHL and accelerate angiogenesis in RCC.Proliferation was also expected to be activated by the MAPK signaling pathway, including NRAS and MAPK1 expression.

The tumor microenvironment in renal cell cancer

PURPOSE OF REVIEW

In addition to the provision of nutrients and growth factors that facilitate tumor cell proliferation and metastasis, the tumor microenvironment (MEV) restricts immune surveillance of tumor-associated antigens and limits the efficacy of immune checkpoint inhibitors, tumor vaccines, and other immune therapies. This review will focus on the immunosuppressive mechanisms operative within the tumor MVE of renal cell carcinoma.

RECENT FINDINGS

Several of the immunosuppressive mechanisms within the tumor MEV have been identified and are potentially druggable. Clinical trials with agents that target several of these inhibitory pathways are currently underway.

SUMMARY

Although renal cell carcinoma is one of several tumor types responsive to immune checkpoint inhibitors, the effectiveness of these agents is likely to be limited by the various tumor-infiltrating bone marrow-derived myeloid cells that comprise the MEV. Several strategies to combat the recruitment of these cells into tumor tissue or to neutralize their immunosuppressive function have shown encouraging results in animal tumor models and clinical trials.

AB026. Loss of KCNJ15 expression promotes malignant phenotypes and correlates with poor prognosis in renal carcinoma

Potassium inwardly rectifying channel, subfamily J, member 15 (KCNJ15) belongs to the inwardly rectifying potassium channel (KIR) family. Although members of the KIR family have been proven to play important roles in a variety of developmental processes, the expression, biological functions and molecular mechanisms of KCNJ15 in cancers remain unclear. Here, we first found that KCNJ15 was significantly downregulated in renal cell carcinoma (RCC), and this low expression was an independent prognostic factor for clear cell RCC. Moreover, KCNJ15 was associated with advanced TNM stage (n=150, P=0.014) and histologic grade (n=150, P=0.045). Furthermore, KCNJ15 overexpression significantly inhibited RCC cell proliferation, migration, and colony formation, arrested the cell cycle and induced apoptosis of RCC cells in vitro. The inhibitory effect of KCNJ15 overexpression may be regulated by its effects on the epithelial mesenchymal transition process and matrix metalloproteinase (MMP)-7 and p21 expression. These findings indicate that KCNJ15 may be a tumour suppressor in RCC and a possible target for RCC therapy.

Knockdown of TACC3 Inhibits the Proliferation and Invasion of Human Renal Cell Carcinoma Cells

Transforming acidic coiled-coil protein 3 (TACC3) is a member of the TACC family and plays an important role in regulating cell mitosis, transcription, and tumorigenesis. However, the expression pattern and roles of TACC3 in renal cell carcinoma (RCC) remain unclear. The aim of this study was to investigate the role of TACC3 in RCC. We demonstrated overexpression of TACC3 in human RCC cell lines at both RNA and protein levels. Moreover, knockdown of TACC3 repressed RCC cell proliferation, migration, and invasion in vitro. In addition, knockdown of TACC3 inactivated PI3K/Akt signaling in RCC cells. Furthermore, knockdown of TACC3 significantly reduced tumor growth in xenograft tumor-bearing mice. Taken together, our findings showed that TACC3 was increased in human RCC cell lines, and knockdown of TACC3 inhibited the ability of cell proliferation, migration, invasion, and tumorigenesis in vivo. Therefore, TACC3 may act as a therapeutic target for the treatment of human RCC.

AB204. Application of HPLC-MS metabolomics to the characterization and possible detection of renal cell carcinoma

Objective

Renal cell carcinoma (RCC) is a common malignant tumor of the urinary system. Early detection is the effective way to improve the prognosis of patients with renal cell carcinoma. In the development and progression of cancer accompanied by metabolic changes, so metabolomics has special advantages in diagnosis of RCC. The aim of this study is to find discriminating metabolites from RCC through a non-target metabolomics method.

Methods

We extracted the serum samples of RCC patients and controls for HPLC-MS detection, and used quantitative analysis of multivariate statistical methods were employed to analyze the data.

Results

In this study, we found that the metabolite in RCC significantly different from the controls, metabolic pathways including arachidonic acid and sphingolipid metabolism were found to be disturbed in RCC patients compared with controls.

Conclusions

Metabolite concentration in cells of the system change is most likely to switch to immune response and energy balance. This study indicates that metabolomics may be a valuable tool for the discovery of novel cancer biomarkers in the future.

AB065. Totally retroperitoneal laparoscopic radical nephrectomy with inferior vena cava thrombectomy (Mayo 0-3)

Background and Objective

Management of renal cell carcinoma (RCC) with tumor thrombus extending to the renal vein and inferior vena cava (IVC) is challenging. The aim of this study was to evaluate the benefit of totally retroperitoneal laparoscopic radical nephrectomy with inferior vena cava thrombectomy in such patients.

Patients and Methods

From July 2014 to May 2015, 12 patients underwent laparoscopic radical nephrectomy for renal cell cancer combined with tumor thrombus of the inferior vena cava. Thrombus extension classified by the Mayo Clinic and the 2009 TNM classifications, complications, postoperative management, and survival results were analyzed. The surgeries were performed by retroperitoneal approach totally. For substantial level I-III involvement, complete caval isolation, including laparoscopic control of infra-renal and supra-renal IVC, contra-lateral renal vein and lumbar veins was performed. Following thrombus extraction, the cavotomy was repaired with 4-0 prolene suture on RB-1 needle.

Results

Four patients had level 0, two patients had level I, five had level II, and one had level III thrombi according to the Mayo Clinic staging, and 11 were T3c and one was T4 according to the 2009 TNM classifications. Totally retroperitoneal laparoscopic approach was performed in patients with stage 0 to 3 thrombi. There was no intraoperative mortality and open conversion. The median follow-up interval was 8.6 months.

Conclusions

Renal cell cancer complicated with tumor thrombus without metastasis can be curable by performing a complete resection. The thrombus level determines the surgical approach and method. Our results confirm that Mayo level 0-3 caval vein tumor thrombus can be safely surgically treated by totally retroperitoneal laparotomy.

AB122. Changing from open to laparoscopic surgery and medium-term prognosis of renal cell carcinoma patients with venous tumor thrombus: a single center study of 276 cases

Objective

To review retrospectively the clinical information of patients with renal cell carcinoma (RCC) and venous tumor thrombus, and to evaluate the changing from open to laparoscopic surgery and medium-term prognosis of these patients.

Methods

From Jan 2000 to Dec 2014, 276 patients were treated with renal cell carcinoma and venous tumor thrombus at our institute. It was analyzed for their clinical and perioperative data and follow-up information.

Results

There were 133 and 143 patients with renal vein (RV) and inferior vena cava (IVC) tumor thrombus respectively, which include 84 with IVC level I, 38 with IVC level II and 21 with IVC level III. There were several steps for the changing from open to laparoscopic surgery for RCC patients with venous tumor thrombus. (I) Traditional open surgery: before 2012, open surgery was routinely done for such kind of patients. For those with large tumor and advanced tumor thrombus, the renal artery may be embolized preoperatively, which could ease the renal dissection and the artery control during surgery. There were 52 patients with advanced tumor thrombus above the hepatic vein in our study, who underwent cardiopulmonary bypass (CPB) assisted surgery without major complication. (II) Retroperitoneal laparoscopic surgery first and then transperitoneal open surgery: from 2012, we introduced laparoscopic techniques into the operation for these patients. For those with IVC tumor thrombus, we could effectively combine the advantages of the retroperitoneal laparoscopic procedure in rapid renal pedicle control and the open transperitoneal procedure in IVC tumor thrombectomy. Compared with the traditional open surgery group, the combined surgery group showed shorter operation time (225 vs. 300 min), less blood loss (150 vs. 625 mL) and shorter hospitalization time (7 vs. 11 days) (all P<0.05). (III) Combined retroperitoneal and transperitoneal pure laparoscopic procedure: from 2013, we had completed six cases of pure laparoscopic surgery with this combined pathway for RCC patients with early IVC tumor thrombus (level I and level II, below hepatic vein), which could take advantages of both laparoscopic pathways and minimize the injury to patients. The median follow-up time was 52 months for all patients (range, 6-138 months) with a follow-up rate of 81.2% (224/276). The median survival time was 58 months and the 5-yr overall survival rate was 48.7% for all patients. There was no significant difference between the prognosis of patients with RV and IVC tumor thrombus (P=0.117), while patients with early tumor thrombus (below hepatic vein) showed significantly improved survival than those with advanced tumor thrombus (above hepatic vein) (P=0.011).

Conclusions

Because of the complexity and difficulty of these surgical procedures, we routinely did traditional open surgery for patients with RCC and venous tumor thrombus before 2012. With the development of laparoscopic techniques in recent years, the operation for these patients turned to be minimally invasive-pure laparoscoic for tumor thrombus below hepatic vein, with good tumor control and promising middle-term prognosis.

AB186. The efficacy and safety of sorafenib in Chinese patients with metastatic renal cell carcinoma and prognostic factors related to its efficacy

Objective

Methods

Results

Conclusions

AB205. Deep sequencing reveals intensive interindividual and intraindividual heterogeneity in TCR-beta repertoire across multiple renal cell carcinoma subtypes

Objective

Methods

Results

Conclusions

AB180. The relationship between fructose-1, 6-bisphosphatase and hypoxia related genes expression in clear cell renal cell carcinoma

Objective

Fructose-1,6-bisphosphatase (FBP1) is often known as a rate-limiting enzyme in gluconeogenesis. Recently, its catalytic activity-independent function, repress hypoxia induced factor (HIF) in the nucleus, was identified. The aim of this study was to investigate the relationship between FBP1 and hypoxia related genes expression in clear cell renal cell carcinoma (ccRCC).

Methods

The expression levels of FBP1, HIF-1α, HIF-2α, erythropoietin (Epo) and carbonic anhydrase IX (CA9) were assessed by immunochemical staining in archival ccRCC paraffin blocks from 123 patients using the tissue microarray technique. The expression level of FBP1 was then correlated with clinicopathological factors and the expression levels of HIF-1α, HIF-2α, Epo and CA9.

Results

Clinicopathological factors including age, gender, TNM stage and Fuhrman grade were indifferent between the patients with low FBP1 expression and those with strong FBP1 expression in ccRCC. FBP1 expression level was positively correlated with the expression levels of HIF-1α (P=0.005) and Epo (P=0.010), but without correlation with the expression level of HIF-2α (P=0.123) and CA9 (P=0.513) in ccRCC tissues.

Conclusions

Our findings may be useful for recognizing the association between FBP1 and hypoxia related genes expression and understanding the mechanisms of ccRCC tumorigenesis.

AB130. ASC-J9 suppresses renal cell carcinoma progression by targeting an androgen receptor-dependent HIF2α/VEGF signaling pathway

Males have a higher incidence of renal cell carcinoma (RCC) than females, but the reason for this gender difference is unknown. Addressing this question, we report the discovery of an androgen receptor (AR)-induced HIF2α/VEGF signal that drives RCC progression. AR attenuation or augmentation in RCC cells altered their proliferation, migration, and invasion in multiple models in vitro and in vivo. Mechanistic investigations revealed that AR targeting inhibited RCC cell migration and invasion by modulating HIF2α/VEGF signals at the level of mRNA and protein expression. Interrupting HIF2α/VEGF signals with inhibitors of either HIF2α or VEGF was sufficient to suppress RCC progression. Similarly, the specific AR degradation enhancer ASC-J9 was sufficient to suppress AR-induced HIF2α/VEGF signaling and RCC progression in multiple models in vitro and in vivo. Taken together, our results revealed a novel role for AR in RCC initiation and progression with implications for novel therapeutic strategies.

AB88. Natural history of renal cell carcinoma: an immunohistochemical analysis of growth rate in patients with delayed treatment

Objectives

To investigate the natural history of renal cell carcinoma (RCC) with delayed treatment, and immunohistochemically analyzed the correlation between some biomarkers and the growth rate of RCC.

Patients and methods

We reviewed our institutional databases to identify renal tumors which were confirmed RCC by delayed surgical treatment after at least 12 months of active surveillance (AS). Growth rate was defined as average growth rate of the maximal diameter on CT or MRI. The clinicopathological characteristics, and immunohistochemical biomarkers (Ki-67, p53, bcl-2, and VEGF) were analyzed the correlation with the growth rate of RCC.

Results

We identified 45 RCCs from 45 patients. The mean patient age was 54 years (range, 26-78 years). The mean tumors size increased from 2.39 cm (range, 0.10-6.70 cm) at presentation to 4.54 cm (range, 1.40-11.80 cm) after a mean 45.4 months (range, 12-155 months) of AS. The mean growth rate was 0.71 cm/year (range, 0.07-4.44 cm/year), 36 (80.0%) tumors presented a growth rate ≤1.00 cm/year. Clear cell RCC (ccRCC) had a trend of growing faster than other histological subtypes. Pathological grade was significantly correlated with the growth rate of ccRCC (P=0.043). The Ki-67 labeling index (R=0.359, P=0.016) and p53 expression (P=0.019) were significantly correlated to the growth rate of RCC.

Conclusions

In general, RCCs under AS have a slow growing with a wide variation of growth rate, a portion of RCCs present rapid growth kinetics. Histological type, grade, Ki-67 and p53 are the potential predictors of growth rate of RCC during AS.

Unique angiogenic and vasculogenic properties of renal cell carcinoma in a xenograft model of bone metastasis are associated with high levels of vegf-a and decreased ang-1 expression

Management of various tumor metastases to bone has dramatically improved, but this is not so for renal cell carcinoma (RCC), which is a difficult surgical problem due to its great vascularity. Furthermore, the unique mechanisms that mediate RCC vasculogenesis in bone remain unknown. To understand this process we developed a xenograft model that recapitulates highly vascular RCC versus less vascular tumors that metastasize to bone. Human tumor cell lines of RCC (786-O), prostate cancer (PC3), lung cancer (A549), breast cancer (MDA-MB231), and melanoma (A375) were transduced with firefly luciferase (Luc), injected into the tibiae of nude mice, and differences in growth, osteolysis, and vascularity were assessed by longitudinal bioluminescent imaging, micro-CT for measurement of calcified tissues and vascularity and histology. The results showed that while RCC-Luc has reduced growth and osteolytic potential versus the other tumor lines, it displayed a significant increase in vascular volume (p < 0.05). This expansion was due to 3- and 5-fold increases in small and large vessel numbers respectively. In vitro gene expression profiling revealed that RCC-Luc expresses significantly (p < 0.05) more vegf-a (10-fold) and 20- to 30-fold less ang-1 versus the other lines. These data demonstrate the utility of this model to study the unique vasculogenic properties of RCC bone metastases.

pVHL-mediated transcriptional repression of c-Myc by recruitment of histone deacetylases

The biological functions of Myc are to regulate cell growth,apoptosis, cell differentiation and stem-cell self-renewal. Abnormal accumulation of c-Myc is able to induce excessive proliferation of normal cells. von Hippel-Lindau protein(pVHL) is a key regulator of hypoxia-inducible factor 1α(HIF1α), thus accumulation and hyperactivation of HIF1α is the most prominent feature of VHL-mutated renal cell carcinoma. Interestingly, the Myc pathway is reported to be activated in renal cell carcinoma even though the precise molecular mechanism still remains to be established. Here, we demonstrated that pVHL locates at the c-Myc promoter region through physical interaction with Myc. Furthermore, pVHL reinforces HDAC1/2 recruitment to the Myc promoter, which leads to the auto-suppression of Myc. Therefore, one possible mechanism of Myc auto-suppression by pVHL entails removing histone acetylation. Our study identifies a novel mechanism for pVHL-mediated negative regulation of c-Myc transcription.

Update on targeted therapies for clear cell renal cell carcinoma

PURPOSE OF REVIEW

The article reviews the evolution of targeted therapies for clear cell renal cell carcinoma (RCC) and recent developments in the field. The vast majority of work in kidney cancer deals with clear cell RCC, which is the most common variant of this malignancy. The identification of loss of function of the von Hippel-Lindau protein as the basis for clear cell RCC, in addition to the well designed clinical trials that have ensued, provide an outstanding model for the development of mechanism-based targeted therapy in cancer.

RECENT FINDINGS

The treatment of advanced and metastatic RCC continues to be a major challenge for uro-oncologists despite the approval of six targeted therapies over the past 5 years. This rapid growth in therapeutic options has brought much needed improvements in overall and progression-free survival, although durable complete responses are rare. However, the plurality of treatments also poses challenges in terms of selecting the best therapy for a given patient, designing trials with appropriate comparison arms and endpoints, identifying well tolerated and effective drug combinations or sequences, and determining the role of targeted therapies in the neoadjuvant and adjuvant settings.

SUMMARY

Vascular endothelial growth factor and mammalian target of rapamycin-targeted therapies continue to play a critical role in the management of advanced and metastatic RCC. Ongoing research to identify novel agents continues to build upon the work done during the elucidation of the von Hippel-Lindau/clear cell RCC pathway. It is hoped that ongoing and planned studies will enable development of therapeutic regimens that will incorporate agents with improved toxicity and better efficacy as well as defining a role for a multidisciplinary approach to the management of advanced RCC.

Laparoscopic radical nephrectomy for renal masses 7 centimeters or larger

OBJECTIVE

To report our operative experience and oncologic outcomes for the laparoscopic management of large renal tumors.

METHODS

All laparoscopic and hand-assisted laparoscopic radical nephrectomies performed at our institution were reviewed. Thirty patients with tumors >or=7cm and a pathologic diagnosis of renal cell carcinoma were included.

RESULTS

Mean operative time was 175.7+/-24.5 minutes, and mean estimated blood loss was 275.5+/-165.8 mL. No case required conversion to open radical nephrectomy. The mean hospital stay was 2.4+/-1.6 days. Four patients (13%) had minor complications. Of the 30 tumors, 18 were pathologic stage T2, 9 were stage T3a, 2 were stage T3b, and one was stage T4. At a mean follow-up of 30 months (range, 10 to 70), 22 patients (73%) were alive without evidence of recurrence, and 5 patients (17%) were alive with disease. One patient (3%) died of complications related to renal cell carcinoma, and 2 patients (7%) died from other causes. Overall survival was 90%, cancer-specific survival was 97%, and recurrence-free survival was 80%.

CONCLUSION

Laparoscopic radical nephrectomy for large tumors is a technically challenging operation. However, in experienced hands, it is a reasonable therapeutic option for the management of larger RCC neoplasms.

IPM chemotherapy in cytokine refractory renal cell cancer

Renal cell carcinoma (RCC) is notoriously chemoresistant. Current management of metastatic disease usually includes immunological agents of which the most clearly evaluated is alpha interferon. Following the failure of such agents no clear second-line therapy exists. The use of a novel combination of cisplatin, irinotecan and mitomycin may offer some palliative benefit in this situation. Thirty-three patients with cytokine refractory RCC and documented progression and documented active progressive disease with performance status 0-3 were enrolled. Therapy consisted of cisplatin 40 mg m(-2) on day 1 and day 15, irinotecan 100 mg m(-2) on day 1 and day 15, and mitomycin 6 mg m(-2) on day 1 of a 28-day cycle. The results showed that one patient (3%) had a partial response, eight (24%) had minor responses and nine (27%) had stable disease, overall 61% had symptomatic responses. Quality-of-life (QOL) assessment did not change significantly during therapy. Seventy-one percent of those who had primary refractory disease to cytokine therapy subsequently responded to IPM. The median progression-free interval was 4.8 months in this cohort on chemotherapy, compared to 3.9 months with their previous cytokine treatment. In conclusion, IPM produced symptomatic relief for a majority of patients with cytokine refractory RCC without any deterioration in QOL. Disease stabilisation on radiological assessment and symptomatic improvement were associated with prolonged survival. A degree of non-crossresistance to cytokine therapy was seen. IPM may be considered in patients with renal cancer following failure of cytokines.

Molecular cytogenetic analysis of 17 renal cancer cell lines: increased copy number at 5q31-33 in cell lines from nonpapillary carcinomas

Comparative genomic hybridization (CGH) was used to screen for genomic imbalances in cell lines derived from 13 nonpapillary renal-cell carcinomas (RCCs), two papillary RCCs, one renal squamous-cell carcinoma, and one transitional-cell carcinoma of the renal pelvis. Aberrations were found in all 17 lines. The most frequent changes in nonpapillary RCC cell lines were gains of 5q (85%), 7q (69%), 8q (69%) and 1q (54%) and losses of 3p (92%), 8p (77%), 4q (62%) and 14q (54%). High-level gains (HLGs) were detected at 4q12, 5p, 5q23-33, 7q22-qter, 8q23-24, 10q21-qter, 12p and 12q13-22. By means of fluorescence in situ hybridization (FISH) we narrowed the smallest common region involving 5q gains to the genomic segment between D5S642 and D5S673, and found that the HLG at 4q12 possibly involved amplifications of c-kit and PDGFRA. Two papillary RCC cell lines showed gains of entire chromosomes 7, 12 and 17. The CGH data reported here should help to facilitate the choice of individual renal-tumor cell lines for exploring target genes in regions of interest.