Manifestation Of Renal Cell Carcinoma Research Articles

An interdisciplinary consensus on the management of brain metastases in patients with renal cell carcinoma.

Brain metastases are a challenging manifestation of renal cell carcinoma. We have a limited understanding of brain metastasis tumor and immune biology, drivers of resistance to systemic treatment, and their overall poor prognosis. Current data support a multimodal treatment strategy with radiation treatment and/or surgery. Nonetheless, the optimal approach for the management of brain metastases from renal cell carcinoma remains unclear. To improve patient care, the authors sought to standardize practical management strategies. They performed an unstructured literature review and elaborated on the current management strategies through an international group of experts from different disciplines assembled via the network of the International Kidney Cancer Coalition. Experts from different disciplines were administered a survey to answer questions related to current challenges and unmet patient needs. On the basis of the integrated approach of literature review and survey study results, the authors built algorithms for the management of single and multiple brain metastases in patients with renal cell carcinoma. The literature review, consensus statements, and algorithms presented in this report can serve as a framework guiding treatment decisions for patients. CA Cancer J Clin. 2022;72:454-489.

MEDIASTINAL LYMPHADENOPATHY AS METASTATIC MANIFESTATION OF RENAL CELL CARCINOMA

SESSION TITLE: Fellows Lung Cancer Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Renal cell carcinoma (RCC) is one of the common malignancies diagnosed in United States.(1) Since early 1990s, its incidence has risen and thought to be attributed to the increased prevalence of risk factors such as smoking, obesity and hypertension.(2) With the advent and frequent utilization of imaging such as ultrasonography and computed tomography (CT), mortality related to RCC has declined.(1) Lung is a common site for metastatic dissemination due to invasiveness of RCC into nearby vascular structures. We present an unusual case of RCC with lymphatic metastasis to lungs, contrary to the known mechanism of vascular metastasis. CASE PRESENTATION: 57-year-old female, current smoker of 25 pack years, presents to the hospital with complaints of recurrent painful hematuria after failing outpatient management for presumed nephrolithiasis. CT abdomen showed a 9.7 cm mass in superior pole of left kidney with involvement of the adjacent adrenal gland. A subsequent chest CT showed a 1.1 cm right lower lobe sub-pleural nodule, 1.1 cm right paratracheal lymphadenopathy, and 1.47 cm subcarinal lymphadenopathy (Figure 1). Patient underwent endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy of station 11R with pathology consistent with renal cell carcinoma. Patient was referred for nephrectomy followed by oncologic evaluation for further management with chemotherapeutic and possible immunological therapy. DISCUSSION: The incidence of pulmonary metastasis in RCC is approximately 50-60%.(3) Although commonly presenting as solitary or multiple nodules, pleural, lymphatics, or embolic phenomenon have been reported.(3) Interestingly, RCC can present with hilar or mediastinal lymphadenopathy. In cases where extensive pulmonary metastasis is present, RCC can be discovered during EBUS-TBNA, as noted in our case. (5) In our case, patient had positive lymph node for malignancy associated with the sub-pleural based nodule. It is possible that the lymphadenopathy was an indirect seeding after metastasis to right lower lobe nodule, or direct seeding into mediastinal and hilar lymph nodes. The presence of the right lower lobe nodule makes direct lymph node seeding less likely. CONCLUSIONS: In patients who present with hematuria with incidental findings of lymphadenopathy, it is worth considering RCC as a plausible diagnosis due to various pulmonary manifestations related to RCC. Reference #1: Chow, W., Dong, L., and Devesa, S. (2010). Epidemiology and risk factors for kidney cancer. Nature Reviews Urology. 2010; 7(5): 245-257. Kabaria, T., Klaassen, Z., and Terris, M. (2016). Renal cell carcinoma: links and risks. Int J Nephrol Renovasc Dis. 2016; 9: 45-52. Reference #2: Motzer, R., Bander, N., and Nanus, D. (1996). Renal-cell carcinoma. N Engl J Med 1996. 335(12): 865-875. Agarwal, A., Sahni, S., Iftikhar, A., and Talwar, S. (2015). Pulmonary manifestations of renal cell carcinoma. Respiratory Medicine 109: 1505-1508. Reference #3: Val-Bernal, J., Martino, M., Romay, F., and Yllera, E. (2018). Endobrnchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal metastases of clear cell renal cell carcinoma. Pathology Research and Practice. 2018; vol 214 (7): 949-956. DISCLOSURES: No relevant relationships by Kushagra Gupta, source=Web Response No relevant relationships by Anthony Loschner, source=Web Response No relevant relationships by Elizabeth McCaskey, source=Web Response No relevant relationships by Toribiong Uchel, source=Web Response

1945 Isolated Gastric Varices as the Sole Manifestation of Renal Cell Carcinoma

INTRODUCTION: Isolated gastric (fundal) varices (IGV) are a consequence of left (sinistral) portal hypertension commonly caused by splenic vein thrombosis (SVT). It occurs when SVT results in a backflow into the collateral short gastric and gastroepiploic vessels. Common causes of SVT include pancreatic and splenic pathologies. Renal cell carcinoma (RCC) is an extremely rare cause, and by itself, RCC is lethal because of the vagueness of its presenting symptoms. CASE DESCRIPTION/METHODS: A 76 year-old male with a past medical history of chronic anemia is presenting with two day history of hematochezia. He denies any personal or family history of colon cancer. He is not on anticoagulation or NSAID regimen. On evaluation, patient was noted to have non-remarkable vital signs. Physical exam was fairly unremarkable. Initial CBC was remarkable for severe anemia with hemoglobin of 6.1. MCV was normal. After routine transfusion, he was evaluated by gastroenterology and underwent an EGD, colonoscopy and capsule endoscopy. EGD was remarkable for 2 cm diameter non bleeding fundic gastric lesion. Colonoscopy and capsule endoscopy were unremarkable except for findings of dark blood in the distal ileum and throughout the colon. Tagged RBC scan was negative. Endoscopic ultrasound was obtained that showed multiple tubal, anechoic structures in the cardia of the stomach consistent with varices. CT abdomen and pelvis then confirmed a giant mass filling the left renal fossa presumably primary renal cell neoplasm with displacement of the pancreas and splenomegaly. CT chest was obtained and confirmed pulmonary nodules likely suggesting metastatic lesions. He then underwent splenectomy and nephrectomy with adjuvant chemotherapy for the metastatic disease. DISCUSSION: Sinistral (left) portal hypertension (SPH) was first outlined by Greenwald and Wasch in 1939. It is a clinical syndrome in which a patient with a patent portal vein and normal hepatic (liver) function tests develops isolated gastric variceal bleeding secondary to splenic vein thrombosis. Interestingly, only two cases have documented renal cell carcinoma as a cause of SPH in the last 30 years. Patients with this condition need to be considered for a prophylactic splenectomy and removal of associated arteries and veins, as well as a total nephrectomy. In this case, with metastatic lesions to his lungs, involving hematology/oncology and general surgery and gastroenterology in the multidisciplinary decision making process would be in his best interest.

Wünderlich sindrom kao prva manifestacija karcinoma bubrega – prikaz slučaja

Aim: To present a case with spontaneous, non-traumatic, perirenal haemorrhage (Wunderlich syndrome) as a first manifestation of renal cell carcinoma. Case report: A 37-year-old female was admitted to the emergency unit with sudden and severe pain in the left lumbar area of abdomen. She has normal voiding, without macrohaematuria or trauma in her medical history. Because of her generally instable state she was referred to emergency multi-slice computed tomography (MSCT) exam of the abdomen and pelvis which reveals inhomogeneous mass in the upper pole of the left kidney. Radiology report indicated perirenal haemorrhage most likely caused by an angiomyolipoma. The patient was operated on by urologist who performed a partial nephrectomy of the left kidney and evacuation of haematoma. Samples were taken for histopathology and cromophobe renal cell carcinoma which caused the perirenal haemorrhage was diagnosed. Our patient is controlled on regular basis, without signs of tumour recurrence. Conclusion: Wunderlich syndrome as the first manifestation of renal cell carcinoma is a very rare but life-threatening manifestation of renal cancer that warrants urgent surgery. MSCT of the abdomen and pelvis is a method of choice in haemodynamically unstable patients with acute abdominal/lumbar pain.

Cutaneous Metastases and Right Hemiplegia as First Manifestations of Renal Cell Carcinoma

Cutaneous Metastases and Right Hemiplegia as First Manifestations of Renal Cell Carcinoma

A Stauffer's syndrome variant associated with renal cell carcinoma and thrombocytopenia

Stauffer's syndrome is a rare paraneoplastic manifestation of renal cell carcinoma which is characterized by elevated alkaline phosphatase, erythrocyte sedimentation rate, α-2-globulin, γ-glutamyl transferase, thrombocytosis, prolongation of prothrombin time and hepatosplenomegaly, in the absence of hepatic metastasis and jaundice. In this case report, we report a patient who was admitted with fever, fatigue, abdominal pain, weight loss and pruritus in whom renal cell carcinoma was incidentally found in the right kidney during an initial workup.

Resolution of paraneoplastic immune thrombocytopenia following everolimus treatment for metastatic renal cell carcinoma

Autoimmune thrombocytopenia is an uncommon but reported paraneoplastic manifestation of renal cell carcinoma (RCC). Treatment usually involves management of the underlying malignancy; however, steroids have shown a benefit in published case reports. Here, we describe a patient with profound thrombocytopenia secondary to metastatic RCC. It was refractory to steroid and intravenous immunoglobulin, but the platelet count improved markedly following initiation of everolimus. The possible explanation includes immunomodulation, tumour lysis or a combination of both effects. This is the first reported case of everolimus used in paraneoplastic thrombocytopenia from RCC. More studies are needed for further investigation of its potential use in secondary immune thrombocytopenia from RCC and perhaps other malignancies.

Diffuse Alopecia Areata Associated with a Solid-Organ Malignancy: Case Report and Literature Review

  Alopecia areata (AA) is an autoimmune disease, manifesting as non-scarring hair loss. Here we report a 57-year-old woman, who presented with sudden diffuse non-scarring hair loss on the scalp. Histology confirmed the diagnosis of AA. Imaging studies revealed the presence of an irregular mass in the left kidney, and histology demonstrated spindle cell-type renal cell carcinoma. There was spontaneous regrowth of hair after surgical and chemotherapy treatments. Reports of AA as first manifestation of malignancy are uncommon, and to our knowledge, this is the first report of AA as a paraneoplastic manifestation of renal cell carcinoma. This report also suggests that screening for malignancy should be considered in older patients, who present with sudden and diffuse AA.

Giant cervical adenopathy as first manifestation of renal cell carcinoma

Giant cervical adenopathy as first manifestation of renal cell carcinoma

Bleeding Gastric Polyp: A Rare Manifestation of Renal Cell Carcinoma 7 years after Nephrectomy

Purpose: Renal cell carcinoma can notoriously recur in unusual locations many years after initial cure and presentation as upper GI bleeding from a gastric polyp is rare. Case: An 83 year old diabetic woman was evaluated for one week of exertional dyspnea, fatigue and melena. She had history of clear cell type renal cell carcinoma of left kidney and underwent left nephrectomy seven years ago. Six months before presentation, she was evaluated for worsening iron deficiency anemia. An EGD showed three non-bleeding gastric ulcers and colonoscopy was normal. Patient was started on twice daily proton pump inhibitor. On current presentation, physical examination was within normal limits except melena in rectum. Laboratory examination showed: hemoglobin 8.6 g/dL (range= 12-15) and GFR 40 ml/min/1.73 m2 (normal= >59). She required multiple transfusions with packed red cells. An EGD was performed which revealed 3 ulcerated semi-pedunculated bleeding polyps in fundus and melanic patches in the antral region. All polyps were removed without complications. Histopathology revealed metastatic clear cell carcinoma. Melanic patches were not biopsied and there was no cutaneous or oral pigmentation. CT chest revealed multiple bilateral lung nodules biopsy of which confirmed late recurrence of renal cell carcinoma. Conclusion: High index of suspicion should be maintained for GI metastasis of renal cell carcinoma in patients presenting with GI bleeding and history of this malignancy.Figure: GD showing bleeding gastric polyp and antral melanosis.

Staufferʼs Syndrome: Another Protean Manifestation of the “Internistʼs Tumor”

Purpose: A 46 yr man with no past medical history presented with fatigue, left flank pain and 60 lb weight loss for 8 months. He denied any recent alcohol, illicit drug or medication use. Physical examination revealed a palpable mass in the left flank. Most prominent laboratory abnormality were elevated alkaline phosphatase (Alk P) at 731(50- 120 U/l) and γ-glutamyltransferase (GGT) at 261 (3-60 U/l). Serum bilirubin and aminotransferases were normal. Total serum protein was 8.2 g/dl, albumin 2.2 g/dl and total cholesterol 163 mg/dL. Microcytic anemia, thrombocytosis and mildly deranged coagulation parameters were also present. Proteinuria and hematuria were noted on urinalysis. MRI abdomen showed a 17 cm heterogeneous left renal mass involving the left renal vein with para aortic lymphadenopathy suggestive of renal cell carcinoma. Mild hepatosplenomegaly with no focal lesions was noted. There was no intra or extrahepatic biliary dilatation or any evidence of cirrhosis. Immunologic investigations revealed the absence of rheumatoid factor and antineutrophil cytoplasmic, antimitochondrial and antismooth muscle antibodies. Hepatitis and HIV viral serologies were negative, serum free thyroxine was normal and polyclonal gammopathy was observed on protein electrophoresis. The cholestasis was diagnosed as a paraneoplastic phenomenon associated with renal cell cancer (Stauffer's syndrome) and a left radical nephrectomy was attempted. Intraoperatively, the mass was inoperable due to involvement of great vessels. Histopathological examination confirmed the diagnosis of poorly differentiated renal adenocarcinoma. The patient then elected for home hospice. Nonmetastatic nephrogenic hepatic dysfunction syndrome (Stauffer's syndrome) is a unique paraneoplastic manifestation of renal cell carcinoma that usually presents as anicteric cholestasis, though a variant presenting with jaundice has also been described. It is characterized by elevated Alk P, ESR, a-2-globulin, and GGT with thrombocytosis, prolongation of prothrombin time, and hepatosplenomegaly, in the absence of hepatic metastasis. The underlying pathophysiology of this paraneoplastic manifestation is assumed to be from interleukin-6 overexpression by the primary tumor. The cholestasis reverses spontaneously after resection of the tumor. This phenomenon has also been reported with leiomyosarcoma, angiosarcoma, malignant histiocytoma, prostate carcinoma, and bronchial adenocarcinoma. It may occasionally be the initial presentation of the underlying neoplasm and if suspected may be lead to an early diagnosis. We conclude that paraneoplastic syndromes especially from renal cell carcinoma should be kept in the differential in evaluating unexplained cholestasis.

Zosteriform Rash: Another Manifestation of “The Internist's Tumor”

Introduction Cutaneous metastases are a well-described manifestation of renal cell carcinoma, although papillary renal cell carcinoma appears to be less commonly associated with cutaneous metastasis than clear cell histology. Zosteriform rash has a papular or vesicular appearance in a dermatomal distribution, and it has been associated with primary cutaneous malignancies as well as metastases from hematologic and solid cancers. Zosteriform rash as a manifestation of cancer has been reviewed by other researchers; however, we are aware of no reports of renal cell carcioma that caused this unusual manifestation of malignancy, and we etail the clinical course of one of our patients in this report.

Stauffer's syndrome as a prominent manifestation of renal cancer: a case report

BackgroundRenal cell carcinoma is associated with a wide spectrum of para-neoplastic syndromes, which may be precursors of primary or recurrent disease. Non-metastatic hepatic dysfunction in patients suffering from renal cell carcinoma is known as Stauffer's syndrome. It is associated with the production of cytokines by the tumour, and several biochemical abnormalities, including elevated serum alkaline phosphatase.Case presentationWe describe a 36-year-old woman presenting with various non-specific, systemic disease manifestations, and elevated liver enzymes due to cholestasis as the main laboratory abnormality. Imaging studies showed a solid mass in the left kidney, which, after surgical excision, was identified as renal cell carcinoma. No metastasis was found.ConclusionStauffer syndrome may precede other manifestations of renal cell carcinoma. In case of unexplained abnormal liver function, particularly in presence of systemic symptoms, underlying renal cell carcinoma should be excluded by focused investigations.

Unusual manifestations of renal cell carcinoma

The imaging characteristics of renal cell carcinoma (RCC) vary widely, with masses ranging from cystic to solid, from homogeneous to heterogeneous and necrotic, from small to large, and from localized to extensive. Although the usual imaging features of RCC are well known to radiologists, various unusual imaging features can be particularly misleading; therefore, both usual and unusual imaging features should always be carefully assessed. In this pictorial review, we describe the following unusual imaging features: unusual subtypes, unusual tumor growth, unusual underlying disease, multiple and bilateral presentations, hemorrhage and arteriovenous fistula (AVF)-related presentations, and mimicking of benign tumors. Familiarity with the imaging features of both usual and unusual RCCs will facilitate prompt and accurate diagnosis and treatment.

Regresión espontánea tras nefrectomía de carcinoma renal metastásico: aportación de un caso con confirmación histológica y revisión de la literatura

The clinical manifestations of renal cell carcinoma are often late, so that approximately one third of the patients have metastatic disease at the time of diagnosis. In this case, the survival rate diminishes dramatically, with an average survival time of 12 months. However, some cases of spontaneous regression have been reported for this kind of tumor, either complete and permanent or partial and temporary. Spontaneous regression occurs in 0.4-4.0% of the patients with metastatic renal cell carcinoma. Many factors have been proposed as related with this rare but favorable event, but until now the origin remains unknown and no prediction can be made. We present a case of renal cell carcinoma with histologic confirmation of lung metastases and local relapse showing a spontaneous regression after nephrectomy.

Stauffer’s syndrome variant with cholestatic jaundice

Cholestasis is a common feature of several malignant diseases, including pancreatic, hepatic, gallbladder, and ampullary carcinomas. It is usually secondary to main bile duct obstruction or widespread hepatic metastasis, but it can also be a paraneoplastic syndrome of other underlying malignancies. Stauffer's syndrome is a rare paraneoplastic manifestation of renal cell carcinoma (RCC) that is characterized by elevated alkaline phosphatase, erythrocyte sedimentation rate, alpha-2-globulin, and gamma-glutamyl transferase, thrombocytosis, prolongation of prothrombin time, and hepatosplenomegaly, in the absence of hepatic metastasis and jaundice. A rare variant of this syndrome with jaundice has recently been described in 3 cases in the literature. We report a patient who presented with abdominal pain and cholestatic jaundice in whom RCC was incidentally found during initial workup. Jaundice and liver dysfunction resolved completely after surgical resection of the tumor. This case illustrates the protean manifestations of RCC, and the importance of considering Stauffer's syndrome and its variant in the differential diagnosis of anicteric and icteric cholestasis, which may allow early recognition and treatment of an underlying malignancy.

Hemorragia digestiva como forma de presentación de hipernefroma diseminado con metástasis gástricas

AbstractA 70-year-old woman was admitted to our hospital for evaluation of melena and anemia. Three months previously, esophagogastroduodenoscopy was performed for suspected anemia, and a small gastric polyp was removed. During the patient's hospital stay several investigations were performed. Abdominal ultrasonography and abdominal computed tomography revealed a large mass on the superior pole of right kidney compatible with renal cell carcinoma. A further upper gastrointestinal endoscopy revealed the presence of several small gastric polyps and pearly duodenal mucosa. Colonoscopy revealed non-specific sigmoiditis. Biopsy of the gastric mucosa and of the abdominal mass showed the presence of clear cells, as a manifestation of renal cell carcinoma. We discuss the rarity of gastric metastases from renal cell carcinoma and its clinical presentation with digestive bleeding.

Pulmonary embolism-the initial manifestation of renal cell carcinoma in a young woman.

We report a case of massive pulmonary embolus demonstrated on CT in a young woman presenting with dyspnea, with no known risk factors for embolism. Abdominal CT on further investigation showed a renal tumor invading the left renal vein and the inferior vena cava as the cause of the pulmonary embolus. In a patient presenting with pulmonary artery embolism without venous thrombosis, the differential diagnosis should include an occult tumor as the cause of the embolus.

Renal cell carcinoma: a paradigm of lanthanic disease.

Renal cell carcinoma is characterized by varied and sometimes obscure manifestations, which include unusual metastatic sites and paraneoplastic and vascular syndromes. In this review, uncommon metastatic sites and their clinical significance are discussed, particularly the thyroid, nasal structures, vagina, and gastrointestinal sites. Paraneoplastic syndromes appear to be related predominantly to cytokines or immunologic mechanisms. Vascular syndromes are related to the tendency of the tumor to spread by direct venous extension and to complications related to the vascularity of the tumor or its metastases. The recognition of unusual manifestations of renal cell carcinoma is important because these syndromes may lead to the diagnosis. Moreover, paraneoplastic syndromes and vascular findings may not indicate unresectability or incurability.

Renal cell carcinoma with involvement of iris and conjunctiva

Purpose: To report a case of metastatic renal cell carcinoma with involvement of the iris and bulbar conjunctiva. Methods: Case report. A 70-year-old man without known systemic disease developed an iris mass in his left eye. Iridocyclectomy was performed to remove the iris mass. Results: Histopathologically, the iris mass was consistent with metastatic renal cell carcinoma. Further evaluation disclosed a mass of the left kidney. The patient underwent a left nephrectomy and was found to have renal cell carcinoma, with focal penetration into the renal capsule. One month after the nephrectomy, he developed a highly vascular nodule of the left bulbar conjunctiva. An excisional biopsy was performed, and histopathology disclosed an additional focus of renal cell carcinoma. Conclusions: Iris and conjunctival involvement may be a clinical manifestation of renal cell carcinoma. Renal cell carcinoma should be considered in the differential diagnosis of a fleshy, vascular iris and a conjunctival nodule.