Clinical cases Metastatic Renal Cell Carcinoma: Atypical - - PDF document

• nr. 4 / 2016 • vol 15

Romanian Journal of Urology 51

Clinical cases

Metastatic Renal Cell Carcinoma: Atypical presentation and poor outcome

• M. Lazar1, L. Maxim1, C.Dochit2, I. Scarneciu1

1 Department of Urology, Emergency Clinical County Hospital, Brasov, Romania 2 Department of Pathology, Emergency Clinical County Hospital, Brasov, Romania

Correspondence to: Assist. Prof. Ioan Scarneciu, M.D., PhD. emergency Clinical County Hospital Brasov, Romania email: urologie_scarneciu@yahoo.com

Abstract 67-year-old caucasian male presented for non-specifjc symptomatology, consisting in upper abdominal pain, in- testinal transit disorder, weight loss, in which clinical examination revealed 2 palpable small masses, contained in the musculature of the anterior abdominal wall, bilaterally. Investigations showed a metastatic left RCC (mRCC), with unusual sites of cancer spreading. Keywords: abdominal wall metastasis, metastasis, mRCC, RCC, skeletal muscle. Introduction Renal Cell Carcinoma accounts for 3% of adult can- cers 1. Metastatic Renal Cell Carcinoma (mRCC) is a se- rious condition with poor prognosis and outcome, in spite of recent advances in medical therapy. 30-40% of patients with RCC present or will develop metastatic disease 2. Usual sites of dissemination are lung, lymph nodes, bone and brain, skeletal muscle metastasis be- ing atypical with but few reported cases in literature 3,4. Materials and Methods A 67-year-old male, with no prior medical history whatsoever, presented to the Medical department for weight loss, abdominal pain, intestinal transit disor-

• ders. Preliminary tests revealed two painless palpable

masses localized in the anterior abdominal wall and a mass growing near the left kidney, showed by the ul- trasound (US). The patient was referred to our Urology

• Department. CT scan of thorax and abdomen was per-

formed to confjrm the presence of tumors and for stag- ing purpose. CT showed a 40/60 mm mass adjacent to

Romanian Journal of Urology

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Clinical cases

the inferior lower pole of the left kidney, which appar- ently did not arise from the renal parenchyma and two lesions contained in the anterior muscular wall, bilat-

• erally. All lesions showed good contrast enhancement

and seemed to be well delimitated.

Image 1: Abdominal CT scans

Giving the multiple localisation of tumors, a prima- ry yet undetected cancer could not be ruled out, so a gastroenterologic consult was required. Inferior and superior digestiv tract endoscopy was performed, with no fjndings. An elevated CA 19-9 (250 U/ml) was found. Results We performed a resection of both abdominal wall masses (small well delimitated tumors) in diagnostic

• purpose. The pathology report describing metastatic

lesions of a poorly diferentiated RCC, grade Fuhrman IV. In the mean while, the patient started to feel un- well, in the way of loosing sensitivity in both his legs. A debulking left nephrectomy was performed, via lum- bar posterior aproach. The bivalved resected specimen: apparently the tu- mor does not arise from the kidney parenchyma, grow- ing in the Gerota fat tissue.

Image 2: Operative specimen

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Clinical cases

The pathological report of kidney specimen (in- cluding IHC test) confjrmed a Renal Cell Carcinoma, grade Fuhrman IV, with sarcomatoid focal component, with high propensity for muscular metastases. The patient status continued to deteriorate postop- eratively, showing signs of complete paralysis in both his lower limbs. A spine MRI and a CT of abdomen and thorax where performed, with fjndings of thoracic ver- tebrae metastasis and medullary compression and a mediastinal mass, all of which were not present at the

• ne month earlier scan. In concert with the oncolo-

gists, it was decided that nothing more could be done in the way of curing the patient, palliative care being in order. Patient died in the matter of weeks following hospital discharge. Discussions 30-40 % of RCC patients have metastatic disease at presentation, and 25 % will develop metastases after nephrectomy 5,6,8. However, skeletal muscle metastases are very un-

• common. There have been few reported cases 2,3,4,5,6,7.

They occur in late-stage disease, but as in the present- ed case, they can be the fjrst fjnding of the underlying

• cancer. Reasons for the rare localization of metastases

in skeletal muscles are multiple: irregular blood-fmow due to muscular contraction, lactic acid activity, prote- ase inhibitors and killer-lymphocytes activity 2,8. In our case, although surgical resection of primary tumor and muscular metastases was done, the patient developed rapidly metastases in other sites (spinal bones and mediastinum), which were unresectable and considered incurable by means of postoperative adjuvant therapies. The clinical course was not infmu- enced by the surgical resection. What we also consider peculiar in this patient was the raised CA 19-9, which is

Image 3: Histopathoilogical aspects

typically elevated in digestive cancers (pancreatic, col-

• rectal, cholangiocarcinoma).

Conclusions Confronted with such clinical evolution of a mRCC,

• ne’s aim should be improvement of patients quality
• f life.

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