Bilateral renal cell carcinoma: influence of synchronous and asynchronous occurrence on patient survival

Bilateral renal cancers: oncological and functional outcomes

PURPOSE

The authors assessed the characteristics of bilateral renal cancers.

METHODS

From January 1995 to January 2015, 65 patients underwent surgery for bilateral renal cancers. Thirty-four of the patients had 36 synchronous tumors, while the remaining 29 had metachronous tumors. The mean age of the patients was 60 ± 11 years. There were 22 females and 43 males. In all cases, bilateral partial nephrectomies or unilateral nephrectomy and contralateral nephron-sparing surgery were performed.

RESULTS

The mean sizes of the synchronous tumors were 5.0 ± 2.7 and 4.7 ± 3.0 cm at the first and the second operations, respectively. The average diameters of the metachronous carcinomas were 6.6 ± 3.0 and 3.1 ± 1.6 cm at the initial and the second surgeries, respectively. Histologic concordance was 91.1 % in the synchronous and 96.5 % in the metachronous tumors. The mean postoperative creatinine levels increased by 116 %, while the GFR decreased by 44.8 % in synchronous tumors at the second operation. The mean postoperative creatinine levels increased by 42 %, while the GFR decreased by 30.4 % in metachronous carcinomas at the second operation. The mean follow-up time was 4.8 ± 3.7 years. During this period, distant metastases occurred in two patients with synchronous tumors and in six cases with metachronous tumors. Local recurrences were detected in one case of synchronous tumor and in four patients with metachronous carcinomas. The 5-year overall and tumor-specific survivals were 53 and 80 %, respectively.

CONCLUSIONS

In patients with bilateral renal carcinomas, the histologic concordance was 93.6 %. The bilateral partial nephrectomies or unilateral nephrectomy and contralateral resection provided acceptable oncological and functional outcomes.

Prognosis and characteristics of renal cell carcinoma in hemodialysis patients: bilateral occurrence does not influence cancer-specific survival

OBJECTIVES

To compare characteristics and prognosis unilateral and bilateral renal cell carcinoma (RCC) in hemodialysis (HD) patients.

METHODS

Overall 246 HD patients who had undergone a radical nephrectomy for RCC were enrolled in this study. Unilateral RCC occurred in 201 patients, synchronous bilateral RCC in 15 and metachronous bilateral RCC in 30. Cancer-specific survival (CSS) was accessed by the Kaplan-Meier method.

RESULTS

Five-year CSS was not significantly different between the two groups (unilateral, 90%; bilateral, 90%; P=0.9509). In total 17 of the 201 patients (8.5%) with unilateral occurrence and four of the 45 patients (8.9%) with bilateral occurrence died from kidney cancer during the follow-up period. The presence of acquired cystic disease of kidney (unilateral, 73%; bilateral 91%; P=0.00319) and the mean duration of HD before surgery (unilateral: 157±91 months, bilateral: 189±83.5, P = 0.0319) were significantly different between the two groups. There were more multifocal tumors in bilateral than in unilateral occurrence (bilateral: 74%, unilateral: 30%, P<0.0001). There were significant differences in CSS according to HD duration before surgery (5-year CSS >180 months 82%, ≤180 months 95%; P=0.0004), tumor grade (G1 100%, G2 90%, G3 38%; P<0.0001), and tumor size (>4 cm 75%, ≤4 cm 98%; P<0.0001).

CONCLUSIONS

The type of occurrence of RCC, unilateral or bilateral, in HD patients does not appear to influence CSS. Patients with a longer duration of HD have to be followed up rigorously because they tend to have poor cancer prognosis.

Long-term management of bilateral, multifocal, recurrent renal carcinoma

Patients with bilateral multifocal renal cell carcinoma are at increased risk of developing locally recurrent or de novo tumors after nephron-sparing procedures. When dealing with recurrent renal masses the options are limited to observation, total nephrectomy, ablation, or repeat surgical intervention. The main reason for recurrence after nephron-sparing surgery is likely to be the presence of multifocal disease, which is identified in 4.3-25.0% of radical nephrectomy specimen. Bilateral renal involvement is seen in almost 90% of cases of multifocal renal carcinoma, and conversely the majority of patients with bilateral disease will have multifocal tumors. Many patients who are treated for multifocal disease, therefore, require subsequent surgical interventions. The outcome data for repeat renal interventions demonstrate reasonable functional and oncologic outcomes despite higher rates of perioperative complications. Our own results support the use of reoperative renal surgery rather than total nephrectomy and renal replacement therapy.

The impact of temporal presentation on clinical and pathological outcomes for patients with sporadic bilateral renal masses

BACKGROUND

The origin of bilateral renal masses has not been definitively established to date. As limited studies on the genetics of bilateral tumors exist, defining the clinical behavior of these lesions remains important.

OBJECTIVE

To evaluate the impact of synchronous versus metachronous presentation on clinicopathological outcomes of patients with bilateral renal masses.

DESIGN, SETTING, AND PARTICIPANTS

We identified 310 patients who were treated at the Mayo Clinic for sporadic bilateral renal masses between 1970-2003, including 148 (47.7%) with synchronous tumors and 162 (52.3%) with metachronous lesions.

INTERVENTION

Patients underwent surgical resection of bilateral renal tumors.

MEASUREMENTS

Clinicopathological features of synchronous and metachronous tumors were compared. Survival rates for patients with synchronous (n=92) and metachronous (n=100) renal cell carcinoma (RCC) were estimated using the Kaplan-Meier method and compared with the log rank test.

RESULTS AND LIMITATIONS

Metachronous tumors had a greater degree of pathological concordance than synchronous lesions, with 87.7% of metachronous tumors representing bilateral RCC, compared to 69.2% of synchronous masses (p=0.002). Patients with synchronous RCC tended to have an increased incidence of papillary RCC compared to patients with metachronous RCC, who were more likely to have bilateral clear-cell RCC (p=0.076). A longer interval between tumors was inversely associated with the risk of cancer death for patients with metachronous RCC (HR 0.90, 95% CI 0.81-0.99, p=0.039). Compared to patients with metachronous RCC, patients with synchronous bilateral RCC had similar 10-yr CSS (70.5% vs. 69.4%, p=0.51) and OS (47.5% vs. 51.2%, p=0.58). We nevertheless recognize that these findings may be limited by the study's retrospective, single-institution design.

CONCLUSIONS

Metachronous bilateral solid renal masses have a greater degree of pathological concordance and were more likely to represent malignancy. Surgical resection may provide durable cancer control for patients with bilateral RCC, with no difference in survival noted between synchronous and metachronous cancers.

Metachronous Bilateral Renal Cell Carcinoma: Risk Assessment, Prognosis and Relevance of the Primary-Free Interval

PURPOSE

We evaluated the prognosis, risk factors and relevance of the primary-free interval in a large cohort with metachronous bilateral renal cell carcinoma.

MATERIALS AND METHODS

We studied 120 patients with metachronous, bilateral renal cell carcinoma who were treated at 12 international academic centers. Logistic regression was performed to evaluate risk factors for contralateral metachronous renal cell carcinoma during followup. Disease specific survival was evaluated with univariate and multivariate analysis.

RESULTS

Median age at diagnosis of the first and second renal cell carcinomas was 54 and 62 years, respectively. The most common histological subtype was bilateral clear cell renal cell carcinoma (89% of cases). Familial renal cell carcinoma was found in 14% of patients, von Hippel-Lindau disease was found in 4% and nonfamilial renal cell carcinoma was found in 81%. The 15-year disease specific survival rates for the first and second renal cell carcinomas were 66% and 44%, respectively. Logistic regression revealed von Hippel-Lindau disease, a family history of renal cell carcinoma, multifocal first renal cell carcinoma and young patient age as independent risk factors for contralateral renal cell carcinoma after surgery for unilateral renal cell carcinoma. A longer primary-free interval was associated with a better prognosis. When calculating disease specific survival from the diagnosis of the first renal cell carcinoma, the primary-free interval was an independent prognostic factor.

CONCLUSIONS

Long-term survival rates of metachronous, bilateral renal cell carcinoma are moderate. von Hippel-Lindau disease, a family history of renal cell carcinoma, multifocal first renal cell carcinoma and young patient age are independent risk factors for contralateral renal cell carcinoma. These risk factors support close and extended abdominal surveillance following nephrectomy for unilateral renal cell carcinoma. Patients with a longer primary-free interval have a more favorable prognosis.

Clinicopathological features and prognosis of synchronous bilateral renal cell carcinoma: an international multicentre experience

OBJECTIVE

To present a multicentre experience and the largest cohort to date of nonmetastatic (N0M0) synchronous bilateral renal cell carcinoma (RCC), as because it is rare the single-institutional experience is limited.

PATIENTS AND METHODS

We retrospectively studied 10 337 patients from 12 urological centres to identify patients with N0M0 synchronous bilateral RCC; the clinicopathological features and cancer-specific survival were compared to a cohort treated for N0M0 unilateral RCC.

RESULTS

In all, 153 patients had synchronous bilateral solid renal tumours, of whom 135 (88%) had synchronous bilateral RCC, 118 with nonmetastatic disease; 91% had nonfamilial bilateral RCC. Bilateral clear cell RCC was the major histological subtype (76%), and papillary RCC was the next most frequent (19%). Multifocality was found in 54% of bilateral RCCs. Compared with unilateral RCC, patients did not differ in Eastern Cooperative Oncology Group performance status (ECOG PS) and T classification, but bilateral RCCs were more frequently multifocal (54% vs 16%, P < 0.001) and of the papillary subtype (19% vs 12%), and less frequently clear cell RCC (76% vs 83%, P = 0.005). For the outcome, patients with nonmetastatic synchronous bilateral RCC and unilateral RCC had a similar prognosis (P = 0.63); multifocality did not affect survival (P = 0.60). Multivariate analysis identified ECOG PS, T classification, and Fuhrman grade, but not laterality, as independent prognostic factors for cancer-specific survival.

CONCLUSIONS

Patients with N0M0 synchronous bilateral RCC and N0M0 unilateral RCC have a similar prognosis. The frequency of a familial history for RCC (von Hippel-Lindau disease or familial RCC) was significantly greater in bilateral synchronous than in unilateral RCC. The significant pathological findings in synchronous bilateral RCC are papillary subtype and multifocality.

Unusual renal cell carcinomas: a pictorial essay

Renal cell carcinoma (RCC) is the most common solid renal neoplasm. Clear cell (conventional) carcinoma is the most common pathologic subtype of RCC. Usually RCC is a hypervascular, solid, solitary mass with contour bulging. However, RCC can manifest different features according to the pathologic tumor subtypes. Preoperative diagnosis of cyst-associated RCC is very difficult, especially in cases of RCC originating in a cyst. Multiple or bilateral presentation of RCC occurs in fewer than 5% of cases. In addition, RCCs may demonstrate unusual findings such as infiltrative growth mimicking transitional cell carcinoma, fatty component mimicking angiomyolipoma, severe perinephric infiltration, and extensive calcifications mimicking inflammation or other tumor. RCCs can be associated with hereditary diseases such as von Hippel-Lindau disease. Familiarity with these radiologic features of unusual RCCs can help ensure correct diagnosis and proper management.

The effect of bilaterality, pathological features and surgical outcome in nonhereditary renal cell carcinoma

PURPOSE

We evaluated the differences in cancer specific, distant metastasis-free and local recurrence-free survival in patients with sporadic subtype concordant bilateral synchronous renal cell carcinoma and those with unilateral renal cell carcinoma, controlling for the covariates of subtype, stage, tumor size, grade and necrosis. We also analyzed early surgical complications and long-term renal function in patients who underwent staged surgery and those who underwent a single operation for bilateral synchronous renal cell carcinoma.

MATERIALS AND METHODS

We retrospectively evaluated 44 patients with sporadic subtype concordant bilateral synchronous renal cell carcinoma treated at our institution between 1970 and 1998. There were 32 patients with bilateral synchronous clear cell renal cell carcinoma and 12 with bilateral synchronous papillary renal cell carcinoma. These patients were compared with 1,714 with sporadic unilateral clear cell renal cell carcinoma and 322 with sporadic unilateral papillary renal cell carcinoma treated with partial or radical nephrectomy during that period. Outcomes were estimated using the Kaplan-Meier method and Cox proportional hazard models were used to test associations with outcome.

RESULTS

Clinicopathological features were similar for patients with bilateral synchronous and unilateral renal cell carcinoma except for the incidence of multifocality, which was 28% and 33% for bilateral synchronous clear cell and papillary renal cell carcinoma compared with 2% and 7% for unilateral clear cell and papillary renal cell carcinoma, respectively. Cancer specific survival and distant metastasis-free survival in patients with bilateral synchronous disease was similar to that in those with unilateral disease when controlling for subtype, stage, tumor size, grade and tumor necrosis. However, patients with bilateral synchronous clear cell renal cell carcinoma were more likely to experience local recurrence even after controlling for these covariates. The majority of patients (84%) with bilateral synchronous disease underwent bilateral surgery at a single operation. The incidence of early surgical complications was low, in that only 2 patients had urinary extravasation, 3 had acute renal failure and 1 was ultimately rendered anephric and required hemodialysis.

CONCLUSIONS

The incidence of multifocality was greater in patients with bilateral synchronous renal cell carcinoma than in those with unilateral renal cell carcinoma. There were no statistically significant differences in cancer specific and distant metastasis-free survival in patients with bilateral synchronous renal cell carcinoma and unilateral renal cell carcinoma of the same histological subtype. These results suggest that subtype concordant bilateral renal cell carcinoma is a result of multiple de novo primary events rather than primary renal cell carcinoma with contralateral renal metastasis. A surgical approach is appropriate for bilateral synchronous renal cell carcinoma and most cases can be approached at a single surgical procedure with acceptable morbidity.

Distinct patterns of chromosomal losses in clinically synchronous and asynchronous bilateral renal cell carcinoma

PURPOSE

Bilateral renal cell carcinoma has been reported to occur in 1% to 4% of patients with renal cancer. However, whether bilateral renal cell carcinoma involves metastatic lesions of the contralateral kidney or develops as simultaneous primary tumors remains unclear to date. Thus, we investigated chromosomal losses and von Hippel-Lindau (VHL) gene abnormalities in bilateral tumors from patients with nonfamilial bilateral renal cell carcinoma.

MATERIALS AND METHODS

Genomic DNA was exacted from 2 tumors in 8 patients each with nonfamilial bilateral renal cell carcinoma, including clinically asynchronous and synchronous disease in 5 and 3, respectively. The DNA was then subjected to microsatellite analysis on 13 chromosomal loci. In addition, polymerase chain reaction-single nucleotide specific conformation polymorphism analysis and direct sequencing of 3 exons of the VHL gene were performed.

RESULTS

All 5 asynchronous cases showed loss of the same allele in bilateral tumors, indicating a common clonal origin. In contrast, 2 of the 3 synchronous cases showed different patterns of chromosomal loss in the right and left renal tumors, suggesting bilateral primary origins. The other synchronous case with loss of the same allele in each tumor involved right stage T3b and left stage T1a neoplasms. No VHL gene mutations were detected in any case.

CONCLUSIONS

Except for a small number of cases synchronous and asynchronous bilateral renal cell carcinoma may represent the simultaneous appearance of separate primary tumors and metastatic progression from the contralateral kidney, respectively.

Renal cell carcinoma in the solitary kidney: an analysis of complications and outcome after nephron sparing surgery

PURPOSE

We evaluated surgical techniques, pathological features and extended outcomes in patients with renal cell carcinoma in a solitary kidney treated with surgical excision.

MATERIALS AND METHODS

Between 1970 and 1998, 76 patients underwent nephron sparing surgery for sporadic renal cell carcinoma in a solitary kidney, including 63 with tissue specimens available for pathological review who comprised the cohort. Six (9.5%) patients had a congenitally absent kidney and 57 (90.5%) had previously undergone contralateral nephrectomy for renal cell carcinoma. The clinical and pathological features examined were patient age at nephron sparing surgery, sex, type of nephron sparing surgery (enucleation, partial nephrectomy or ex vivo resection), tumor size, nuclear grade, histological subtype and 1997 tumor stage. Overall cancer specific, local recurrence-free and metastasis-free survival as well as early (within 30 days of nephron sparing surgery) and late (30 days to 1 year after nephron sparing surgery) complications were assessed. Univariate and multivariate analyses were done to test for the associations of clinical and pathological features with outcome.

RESULTS

Most patients were treated with enucleation (36.5%), standard partial nephrectomy (38.1%) or the 2 procedures (11.1%) and in 8 (12.7%) ex vivo tumor resection was done. The renal cell carcinoma histological subtypes were clear cell in 82.5% of cases, papillary in 15.9% and chromophobe in 1.6%. Grade was 1 to 3 in 10 (15.9%), 42 (66.7%) and 10 (15.9%) tumors, respectively. At 5 and 10 years the overall survival rate was 74.7% and 45.8%, the cancer specific survival rate was 80.7% and 63.7%, the local recurrence-free survival rate was 89.2% and 80.3%, and the metastasis-free survival rate was 69% and 50.4%, respectively. Tumor stage and nuclear grade were significantly associated with death from any cause, death from renal cell carcinoma and distant metastases on multivariate analysis. Notably no patient with papillary or chromophobe renal cell carcinoma died of renal cell carcinoma, or had recurrence or metastasis. The type of nephron sparing surgery was not significantly associated with outcome, although there were too few patients with recurrence to assess the association of the type of nephron sparing surgery with local recurrence. The most common early complication was acute renal failure in 12.7% of cases, while the most common late complications were proteinuria in 15.9% and renal insufficiency in 12.7%.

CONCLUSIONS

The 1997 tumor stage and nuclear grade were significant predictors of death from any cause, death from renal cell carcinoma and distant metastases in patients treated with nephron sparing surgery for renal cell carcinoma involving a solitary kidney. Nephron sparing surgery in a solitary kidney can be performed safely and with minimal morbidity.

Risk and prognosis in renal neoplasms. A pathologist's prospective

The incidence of renal carcinoma has increased in the United States over the last two decades. An increased rate of detection of incidental tumors and a variety of exogenous risk factors may be responsible for this increase. Pathologic stage and nuclear grade remain the most important and practical prognostic features, however, the specific tumor type has emerged as important as the cytogenetic validation of recent renal carcinoma classification. Proliferation markers, DNA ploidy, and morphometry have powerful predictive value but are handicapped by cost and complexity. The search continues for molecules of diagnostic and prognostic utility that may also impact invasive and metastatic capability for this group of neoplasms whose course is principally determined by the completeness of the original resection.

The natural history of metachronous renal cell carcinoma

A case of metachronous renal cell carcinoma is reported in a 52-year-old male patient who had previously undergone radical nephrectomy for cancer in 1989. He was thereafter monitored with annual CT-scans. In January 1994, a small, solid, renal parenchymal mass was detected in the opposite kidney. Following that, three consecutive abdominal CT-scans were carried out over the year in order to evaluate any changes. Subsequently, elective right nephron-sparing resection was performed. This report discusses neoplasm detection, evolution and clinical approach in a patient with previous nephrectomy for cancer.

Case Report of a Patient with Bilateral Renal Cell Carcinoma Successfully Maintained on Continuous Ambulatory Peritoneal Dialysis after Bilateral Nephrectomy

We report on a patient who developed bilateral renal cell carcinoma during continuous ambulatory peritoneal dialysis for chronic renal failure. He was successfully maintained on this type of dialysis after bilateral abdominal nephrectomy.

Renal cell carcinoma metastases. Review of unusual clinical metastases, metastatic modes and patterns and comparison between clinical and autopsy metastatic series

We reviewed all cases of unusual clinical metastases of renal cell carcinoma found in the English literature. The percentages of usual and unusual clinical metastases are compared with data of some large autopsy series. The involvement of various organs is considered and some metastatic modes and patterns are reported. The analysis shows that clinical metastases are obviously underdiagnosed. Correct staging based on careful clinical investigations is paramount for optimal management of metastatic renal cancer.

A retrospective study of multicentric bovine renal cell tumors

Tissues from twenty mature cows with primary renal cell tumors were submitted over an 11-year period because of gross lesions detected during routine slaughter and inspection. Tumors visualized grossly were multiple and bilateral in seven cattle, multiple within one kidney in four cattle, and solitary in nine cattle. The tumors were primarily cortical, yellow-orange to tan, proliferative, well circumscribed, and extended above the capsular surface of the kidney. Tumors were microscopically multiple even when grossly described as solitary lesions, except in one cow. Twelve tumors (60%) were microscopically multiple in one kidney, seven tumors (35%) were multiple and bilateral, and only one cow (5%) exhibited extrarenal metastasis. Tumors from nineteen cows were composed of eosinophilic granular epithelial cells; tumors from one cow were clear cell type. Each tumor contained several histologic patterns. Corpora amylacea, proteinaceous secretions, and hemosiderin were characteristic findings in bovine renal cell carcinoma. All 20 cows with renal cell tumors exhibited positive immunoreactivity to uromodulin (Tamm-Horsfall protein).

Flow-cytometric DNA analysis of paraffin-embedded renal cell carcinoma tissue from patients treated by parenchymal-sparing surgery

OBJECTIVE

To determine the utility of deoxyribonucleic acid (DNA) ploidy pattern, detected by flow cytometry, in predicting the outcome of renal cell carcinoma (RCC).

PATIENTS AND METHODS

DNA content was retrospectively assessed by flow cytometry in 28 primary paraffin-embedded RCCs from 24 patients (16 men and eight women, mean age 61.9 years, range 40-89) who had undergone renal parenchymal-sparing surgery.

RESULTS

Tumour recurred locally in three patients, two with diploid tumours and one with aneuploid tumour. Two patients with diploid tumours had metastatic disease 11-58 months after surgery. Only one patient with aneuploid tumour developed metastatic disease. There was no difference in local recurrence or metastases with the type of renal parenchymal-sparing surgery used (enucleation or partial nephrectomy) nor any significant difference in overall survival (P = 0.11).

CONCLUSION

While DNA content might be of considerable predictive value for patients with RCC, these results showed that there was no difference in mortality rate, recurrence rate, or type of renal parenchymal-sparing surgery used between aneuploid and diploid tumours.

Ultrasound-guided microwave thermotherapy on a VX-2 carcinoma implanted in rabbit kidney

A temperature greater than 60 degrees C was maintained for 60 s within a 5-mm radius of a microwave electrode implanted in a rabbit kidney using 2450 MHz at 100 W for 30 s. Histological examination revealed complete coagulation necrosis in that area. VX-2 cells were inoculated into the kidneys of 10 rabbits. One week later, five rabbits received ultrasound-guided microwave thermotherapy, and the remaining five rabbits received no treatment. All rabbits with microwave thermotherapy had a complete response to treatment while all rabbits without therapy died of cancer within 6 weeks of the VX-2 implantation. These results indicate that ultrasound-guided microwave thermotherapy has the potential of being a nephron-salvaging treatment for small renal tumors.

Synchronous bilateral multilocular renal cell carcinoma. A rare case

A rare case of multilocular primary renal cell carcinoma (two sites in each kidney) in a 48-year-old woman is presented. The preoperative diagnosis was based on the computerized tomography findings. The patient underwent bilateral total nephrectomy and subsequently maintained renal dialysis.

The management of isolated renal recurrence of renal cell carcinoma following complete response to interleukin-2 based immunotherapy

The role of interleukin-2 based immunotherapy in advanced renal cell carcinoma is gradually expanding. Among patients who achieve significant responses to these regimens the subsequent development of isolated recurrences raises difficult management questions. We report 2 unusual cases of isolated recurrence in the remaining kidney following a sustained, complete response to interleukin-2 based adoptive immunotherapy. Both patients were treated with interleukin-2 based therapy following surgical resection of the primary renal tumor. The disease course of each patient is described and the literature is reviewed. Both patients were free of disease after relatively short-term followup. Surgery for patients with limited recurrence of renal cell carcinoma following an objective response to immunotherapy may, in select cases, be a reasonable treatment alternative.

Renal cell carcinoma

Renal cell carcinoma accounts for 3% of all adult cancers and has many unusual features in its presentation, diagnosis, and management. It develops in a significant number of patients with acquired renal cystic disease, a disorder found almost exclusively in chronic hemodialysis patients. Abnormalities of chromosome 3 are frequently found in sporadic and familial forms. Radical nephrectomy remains the only potentially curative therapy for this tumor.

Gallbladder and pancreatic metastases from bilateral renal carcinoma presenting with hematobilia and anemia

A case of bilateral metachronous renal cell carcinoma with gallbladder and pancreatic metastases, presenting with hematobilia and anemia is presented. The presentation of metastatic renal cell carcinoma with hematobilia and anemia is previously unreported. This case illustrates (1) the occasionally very long interval between metachronous renal carcinoma; (2) this tumor's propensity to unusual metastases and unpredictable presentation; and (3) the significant palliation which may be achieved by appropriate surgical resection of these metastases.

Bilateral renal cell carcinoma with metastasis to thyroid

A case of bilateral synchronous renal cell carcinomas with metastases to the regional lymph nodes and later to the thyroid gland was treated with aggressive surgical extirpation and adjuvant gamma interferon. The patient continues to have an excellent performance status sixteen months after initial diagnosis despite a large tumor burden at presentation.

Renal carcinoma in a solitary kidney

We studied the clinical and pathological features of 26 patients with renal carcinoma of a solitary kidney, including 6 treated at this hospital. Four patients had a contracted kidney and 22 had previously undergone nephrectomy. Partial nephrectomy was performed in 16 patients, enucleation of the tumour in 5 and radical nephrectomy in 5 because of the size of the tumour. Ex vivo surgery was carried out in 4 patients. The duration of ischaemia ranged from 15 to 365 min but was longer in those who underwent ex vivo surgery (149 to 365 min). Of the 21 patients who underwent partial nephrectomy or enucleation, the serum creatinine level increased (greater than or equal to 2.0 mg/dl) post-operatively in 16 patients, of whom 9 required temporary haemodialysis. No recurrence has been noted in those who underwent partial nephrectomy, but 1 patient who underwent enucleation of the tumour developed a solitary pancreatic metastasis 2 years 6 months after surgery and was treated by a partial pancreatectomy. Kidney-preserving surgical procedures are considered to improve the quality of life, but careful follow-up is necessary.

Enucleation of tumor versus partial nephrectomy as conservative treatment of renal cell carcinoma

In patients with renal insufficiency, solitary kidney, or bilateral renal malignancies, conservative surgery for renal cell carcinoma has been suggested. The authors treated 17 such patients with either enucleation of tumor or partial nephrectomy. Overall survival from disease in this series was 58.8%. Seventy percent of patients undergoing enucleation and 42.9% undergoing partial nephrectomy survived with a mean follow-up period of 5 years. Survival or local recurrence rate after enucleative surgery is an effective treatment of renal carcinoma in selected patients, and despite concerns about tumor invasion of the pseudocapsule, the clinical data do not indicate any difference in survival. There was no significant difference between enucleation of tumor and partial nephrectomy regarding morbidity, mortality, or recurrence rate.

Conservative surgery for renal cell carcinoma: a single-center experience with 100 patients

From January 1956 to March 1987, 100 patients underwent a conservative (parenchyma-sparing) operation as curative treatment for renal cell carcinoma at our clinic. This series includes 56 patients with bilateral (28 synchronous and 28 asynchronous) and 44 with unilateral renal cell carcinoma; in the latter category the contralateral kidney was either absent or nonfunctioning (17 patients), functionally impaired (17), involved with a benign disease process (6) or normal (4). The pathological tumor stage was I in 75 patients, II in 9, III in 10 and IV in 6. A nephron-sparing operation was performed in situ in 86 patients and ex vivo in 14. Postoperatively, 93 patients experienced immediate function of the operated kidney, while 7 required dialysis (4 temporary and 3 permanent). The incidence of dialysis was greater after ex vivo than in situ surgery (p equals 0.0005). The mean postoperative serum creatinine level in 97 patients with renal function was 1.7 mg. per dl. (range 0.9 to 4.6 mg. per dl.). The over-all actuarial 5-year patient survival rate in this series is 67 per cent including death of any cause and 84 per cent including only deaths of renal cell carcinoma. Survival was improved in patients with stage I renal cell carcinoma (p less than 0.05). Survival also was improved in patients with unilateral renal cell carcinoma (p less than 0.05) and fewer patients in this category had recurrent disease postoperatively (p less than 0.0005). Nine patients (9 per cent) had local tumor recurrence postoperatively and 5 of these were rendered free of tumor by secondary surgical excision. Conservative surgery provides effective therapy for patients with localized renal cell carcinoma in whom preservation of renal function is a relevant clinical consideration.

Experience with extracorporeal surgery and autotransplantation for renal cell and transitional cell cancer of the kidney

Of 21 patients who underwent bench surgery for renal malignancies (renal cell carcinoma in 16 and transitional cell carcinoma in 5) 15 also had autotransplantation and 6 did not. In 5 patients the contralateral kidney was removed simultaneously for synchronous bilateral renal malignancy, and 16 had cancer in a solitary kidney. In the 3 patients who underwent nephrectomy for complications after autotransplantation no evidence of residual tumor was noted on histopathological examination. Of 9 patients 1 (11 per cent) had local recurrence after successful autotransplantation (renal cell carcinoma). Two patients with transitional cell carcinoma died of metastatic disease. Treatment failed in 31 per cent of the 16 patients with renal cell carcinoma (metastatic disease in 4 and metastatic disease with local recurrence in 1). Removal of solitary or synchronous bilateral renal cell cancer by bench surgery with subsequent autotransplantation is effective. For high grade transitional cell carcinoma of a solitary kidney its value is doubtful without adjuvant systemic treatment.

Renal cell carcinoma. Prognostic significance of morphologic parameters in 121 cases

Morphologic parameters were correlated with survival in 121 renal cortical neoplasms including 116 carcinomas and five oncocytomas. An increasing nuclear grade was generally correlated with a significant decrease in disease-free survival although no statistical difference was found between nuclear Grade 1 and 2 tumors. Similarly, a higher stage at diagnosis predicted a shorter disease-free survival. Renal vein invasion adversely affected prognosis only for high nuclear grade carcinomas. Papillary and spindled carcinomas, independent of nuclear grade, were associated with a significant decrease in disease-free survival compared to tumors with a solid pattern. Patients with large neoplasms (greater than 10 cm) had a significantly worse disease-free survival than patients with tumors 10 cm or less. The prognostic significance of tumor cell type is less clear. Patients with oncocytomas had the best disease-free survival compared with patients with tumors of other cell types. However, the difference in survival was not statistically significant for low-grade tumors, suggesting that nuclear grade rather than cell type may be the more important determinant.

Surgical treatment of localized renal cell carcinoma in von Hippel-Lindau's disease

From 1981 to 1986, 10 patients with von Hippel-Lindau's disease underwent an operation for bilateral nonmetastatic renal cell carcinoma. Of the patients 9 underwent unilateral partial nephrectomy and contralateral radical nephrectomy, and 1 underwent bilateral nephrectomy with subsequent hemodialysis and cadaver renal transplantation. Pathologically, the tumor was stage I in 9 patients and stage III in 1. Currently, 8 patients are alive after partial nephrectomy (5 to 56 months) with good renal function (mean serum creatinine 2.0 mg. per dl.) and no evidence of malignancy; 1 of these patients underwent excision of a cerebral metastasis 2 years after partial nephrectomy. One patient is alive on dialysis after removal of the renal remnant for local tumor recurrence. The patient who underwent transplantation is free of tumor with a well functioning allograft. The distinctive features of renal cell carcinoma in von Hippel-Lindau's disease that influence the management of these patients are reviewed.

Management of locally recurrent renal cell carcinoma after partial nephrectomy

While partial nephrectomy can provide effective treatment for selected patients with renal cell carcinoma, postoperative local tumor recurs in approximately 10 per cent of the cases. We describe 4 patients in whom tumor recurred in a solitary renal remnant after partial nephrectomy for renal cell carcinoma 1 to 6 years previously. The original tumor was pathological stage I in 2 patients and stage III in 2. Neither of the patients with stage I renal cell carcinoma had metastatic disease when locally recurrent carcinoma was noted. A second partial nephrectomy was done in these patients and they are alive 1 and 10 years later. Both patients with stage III renal cell carcinoma also had metastatic disease when locally recurrent carcinoma was noted. One patient died 1 year later and the other is alive 1 year later. Patients who undergo partial nephrectomy for renal cell carcinoma should be followed closely to allow for early detection of local tumor recurrence. When this occurs, secondary surgical treatment may be possible with complete tumor excision and the opportunity for extended survival.

Selection of initial therapy for renal cell carcinoma

Complete surgical excision is the only effective method of treatment for renal cell carcinoma (RCC) and patients with extensive regional or distant metastases are incurable by any means. Accurate preoperative staging is therefore of critical importance, and computerized tomography and magnetic resonance imaging are the most accurate staging modalities. The traditional operative procedure for RCC has been the radical nephrectomy with excision of Gerota's fascia and its contents, resulting in a 60% to 70% 5-year survival of patients with localized tumors (T1-2 and N0 and M0). Extensive lymphadenectomy has not appreciably improved the cure rate. Indeed, less aggressive surgery has been recently proposed by some authors, based on the excellent results achieved after partial nephrectomy or for tumors in solitary kidneys, with survival after partial nephrectomy or enucleation similar to that after radical nephrectomy. Preoperative adjuvants such as angioinfarction or radiotherapy have not increased survival or local tumor control, and no regional or systemic postoperative adjuvant has proven to be of value. Until further data is accumulated, radical nephrectomy remains the treatment of choice for localized RCC.

Long-term effects of initial therapy

The long term effects of initial therapy are a combined consequence of the effects of treatment on the cancer and on the host. Local tumor control, whatever its impact on the occurrence of metastasis, is an achievable and worthwhile goal of therapy and the methods for attaining it may have significantly different effects on quality of life. These considerations are grossly illustrated for renal cell, bladder and prostatic cancers.

Renal cell carcinoma in von Hippel-Lindau syndrome

Thirty-seven cases of von Hippel-Lindau syndrome are reported. The urinary tract was studied in 23 patients; 15 of them had the renal lesions. Eight of these 15 patients had renal cell carcinoma, which was bilateral in six. Because 80 percent of these patients are seen initially by neurologists or ophthalmologists, the potential for the development of renal cell carcinoma in these patients, the familial nature of the disorder, and the need for early urologic investigations and subsequent close follow-up are emphasized.

Surgical enucleation for renal cell carcinoma

The results of an enucleative operation in 33 patients with renal carcinoma present bilaterally or in a solitary kidney are reviewed. All of the excised tumors were low grade and the majority of the patients had pathological stage I renal carcinoma. Postoperative followup ranged from 9 to 156 months (mean 45 months). The 3-year actuarial survival rate was 90 per cent. Tumor recurred locally in 2 patients (6 per cent). We conclude that enucleation is a safe technique that can yield excellent tumor control in selected patients with renal carcinoma.

Bilateral kidney tumors: oncocytoma and adenocarcinoma. A case report

An unusual case of bilateral kidney tumors with two histologically different tumors, one right-sided oncocytoma and one left-sided renal cell carcinoma is described. The morphological features of the two tumors are briefly delineated. The diagnostic dilemma between an oncocytoma and a renal cell carcinoma is discussed.

Treatment of renal cell carcinoma by in situ partial nephrectomy and extracorporeal operation with autotransplantation

During a 10-year period, 33 patients underwent in situ enucleation, in situ partial nephrectomy, or an extracorporeal operation for low-grade (1 or 2), low-stage (I or II), bilateral or solitary renal cell carcinoma. Only one patient (3%) (who had undergone in situ partial nephrectomy) had local recurrence; the projected 5-year rates of nonprogression of disease and survival from death due to cancer only were 76% and 87%, respectively. A group of patients who were closely matched for grade and stage of renal cell cancer underwent traditional transabdominal radical nephrectomy during the same time interval and had rates of nonprogression and survival similar to those of the conservative surgical group. Thus, in selected patients with low-grade, low-stage renal cell cancer, conservative surgical treatment (that is, renal parenchyma-saving procedures) can produce favorable results without the side effects (such as renal failure) associated with ablative renal operations.

Bilateral renal cell carcinoma and renal cell carcinoma in the solitary kidney

We report on 43 patients with renal cell carcinoma in a solitary kidney, 39 of whom underwent a potentially curative resection. Of 36 patients who had a nephron salvaging procedure only 4 required ex vivo surgical resection. The survival curves of patients with solitary or bilateral lesions are similar, and depend more on the adequacy of tumor resection and tumor stage than on the fate of the contralateral kidney. Crude survival in this series was 64 per cent for patients followed for more than 1 year.

Long-term results following partial nephrectomy for localized renal adenocarcinoma

From 1956 to 1980 partial nephrectomy was done on 23 patients with localized renal carcinoma occurring bilaterally or in a solitary functioning kidney. The mean postoperative followup was 5.4 years, and the 5-year patient survival rates considering death of renal cancer only or of any cause were 70.2 and 59.6 per cent, respectively. Survival was diminished in patients with bilateral asynchronous renal carcinoma. Renal carcinoma recurred postoperatively in 6 patients (26 per cent), including 3 (13 per cent) with local recurrence in the renal remnant. Currently, 12 patients (52 per cent) are alive with stable function and no evidence of malignancy. These long-term data support the efficacy of partial nephrectomy for selected patients with renal carcinoma.

Long-term survival of untreated bilateral renal cell carcinoma with supradiaphragmatic vena caval thrombus

We report a case of bilateral, synchronous and biopsy proved renal cell carcinoma with a vena caval thrombus and supradiaphragmatic extension. Although the patient was not treated she is asymptomatic 5 1/2 years after the diagnosis was established.