Clinical cases Metastatic Renal Cell Carcinoma: Atypical - PDF document

nr. 4 / 2016 • vol 15 Clinical cases Metastatic Renal Cell Carcinoma: Atypical presentation and poor outcome M. Lazar 1 , L. Maxim 1 , C.Dochit 2 , I. Scarneciu 1 1 Department of Urology, Emergency Clinical County Hospital, Brasov, Romania 2 Department of Pathology, Emergency Clinical County Hospital, Brasov, Romania 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 Materials and Methods Renal Cell Carcinoma accounts for 3% of adult can- A 67-year-old male, with no prior medical history cers 1 . Metastatic Renal Cell Carcinoma (mRCC) is a se- whatsoever, presented to the Medical department for rious condition with poor prognosis and outcome, in weight loss, abdominal pain, intestinal transit disor- spite of recent advances in medical therapy. 30-40% of ders. Preliminary tests revealed two painless palpable patients with RCC present or will develop metastatic masses localized in the anterior abdominal wall and a disease 2 . Usual sites of dissemination are lung, lymph mass growing near the left kidney, showed by the ul- nodes, bone and brain, skeletal muscle metastasis be- trasound (US). The patient was referred to our Urology ing atypical with but few reported cases in literature 3,4 . 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 Correspondence to: Assist. Prof. Ioan Scarneciu, M.D., PhD. emergency Clinical County Hospital Brasov, Romania email: urologie_scarneciu@yahoo.com Romanian Journal of Urology 51

Romanian Journal of Urology nr. 4 / 2016 • vol 15 Clinical cases the inferior lower pole of the left kidney, which appar- A debulking left nephrectomy was performed, via lum- ently did not arise from the renal parenchyma and two bar posterior aproach. lesions contained in the anterior muscular wall, bilat- The bivalved resected specimen: apparently the tu- erally. All lesions showed good contrast enhancement mor does not arise from the kidney parenchyma, grow- and seemed to be well delimitated. ing in the Gerota fat tissue. 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- Image 2: Operative specimen well, in the way of loosing sensitivity in both his legs. 52

nr. 4 / 2016 • vol 15 Clinical cases typically elevated in digestive cancers (pancreatic, col- orectal, cholangiocarcinoma). Conclusions Confronted with such clinical evolution of a mRCC, one’s aim should be improvement of patients quality of life. Image 3: Histopathoilogical aspects References 1. Z. Kirkali, C.Cal. Renal Cell Carcinoma. Oncological Urology. The pathological report of kidney specimen (in- Springer-Verlag London Limited 2008. cluding IHC test) confjrmed a Renal Cell Carcinoma, 2. KN. Garg. IOSR Journal of Dental and Medical Science. Me- grade Fuhrman IV, with sarcomatoid focal component, tastasectomy in solitary abdominal wall metastases of RCC . with high propensity for muscular metastases. 3. CP. Karakousis, U. Rao, e Jennings. Renal Cell Carcinoma met- The patient status continued to deteriorate postop- astatic to skeletal muscle mass. Journal Of Surgical Oncology. 17.287-293/1981. eratively, showing signs of complete paralysis in both 4. CL. Herring, JM. Harrelson, SP. Schully. ClinOrthopRelat Res. his lower limbs. A spine MRI and a CT of abdomen and 1998 Oct; (355): 272-81. thorax where performed, with fjndings of thoracic ver- 5. S. Kumar, PK. Sharma, MK. Bera. Isolated abdominal wall me- tebrae metastasis and medullary compression and a tastasis from Renal Cell Carcinoma. Adv Biomed Res. 2015; mediastinal mass, all of which were not present at the 4:65. 6. BY. Lee, Je Choi, JM park, WH Jee, JY. Kim, KH. Lee, HS. Kim, one month earlier scan. In concert with the oncolo- KS. Song. Various image fjndings of skeletal muscle metasta- gists, it was decided that nothing more could be done seswith clinical correlation. Skeletal Radiol. 2008; 37:923-8. in the way of curing the patient, palliative care being 7. B. Pirimoglu, H. Ogul, A. Kisaloglu, L. Karaca, A. Okur, MM., in order. Patient died in the matter of weeks following Kantarci. Multiple muscle metastasesof RCC after radical ne- hospital discharge. phrectomy. Int. Surg. 2015 Apr; 100141: 761-764. 8. CD. elia, T. Cai, L. Luciani, M. Bonzanini, G. Malossini. Pelvic and muscular metastases of Renal Cell Carcinoma: A case re- port. Oncol Lett. 2013 Apr; 5(4): 1258-1260. 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 Romanian Journal of Urology 53