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Solitary Distant Metastases from Unsuspected Renal Carcinomas
THE JOURNAL OF UROLOGY
Vol. 80, No. 6, December 1958 Printed in U.S.A.
SOLITARY DISTANT METASTASES FROM UNSUSPECTED RENAL CARCINOMAS RICHARD CHUTE, ELWOOD F. IRELAND, JR. AND JOHN D. HOUGHTON From the Urological and Pathological Services of the Veterans Administration Hospital, Boston, Mass. At the outset let it be made clear that the renal carcinomas considered in this presentation are not those of the renal pelvis, nor Wilms tumors, but are those solid malignant tumors of the renal parenchyma classified in a general way as renal cell carcinoma or hypernephroma. The members of this group, regardless of their exact individual histological classification, generally speaking, behave alike as regards the generation of distant metastases. While these kidney malignancies may invade adjacent organs by direct local extension through the capsule, and also may spread by way of the lymphatics to the regional lymph nodes, there is general agreement that the solitary distant metastases which are considered in this paper are blood-borne and occur because these tumors also grow directly into the veins of the kidney. Thus tumor cells gain entrance into the bloodstream, and migrate by way of the renal vein and the inferior vena cava as malignant emboli to other regions of the body. McDonald and Priestley, in careful dissections of 509 hypernephromas, found invasion of the renal vein by tumor in more than 50 per cent. Statistically the chest, including lungs, pleura and chest wall, is definitely the commonest site of metastases, which occur there in more than 50 per cent of all cases. Bones are the next most commonly involved, followed by the liver, and then various other organs, including the brain in an appreciable number of cases. Metastases have been found at one time or another in different cases in almost every organ or tissue of the body, including such widely separated ones as the heart, tongue, intestines, sternum and clavicle, buttock, epididymis, thyroid gland, skin, and the other kidney. Very commonly metastases occur early, and it is not particularly rare to have distant metastases appear while the primaiy renal tumor is still small, and long before it has given any other sign or symptom of its existence. It is generally conceded that about one-third of the cases of renal Read at annual meeting of American Urological Association, Inc., New Orleans, La., April 28May 1, 1958. 420
malignancy already have demonstrable metastases by the time the primary tumor is discovered. Out of a recent series of 37 cases of renal cell carcinoma seen at this hospital, metastases were found in 25 or 67 per cent. Surprisingly the urinalysis not infrequently is absolutely normal. As a consequence of these two characteristics: that distant metastases may involve any tissue in the body, and that they may develop long before the primary renal tumor has given any other evidence of its existence, a wide variety of symptoms and signs may be produced whose source and significance may be extremely puzzling. Not only may these furnish no clue as to their real origin, but they may even simulate other conditions, diverting attention from the "silent" primary kidney tumor so that the true diagnosis is not made until late-sometimes only after the microscopic examination of tissue from a biopsied or excised metastasis, and sometimes not until autopsy. In fact, so often has a mistaken diagnosis of some other disease entity been made that Creevy states that these tumors " ... should be classed ... as among the great mimics encountered in clinical medicine. By direct pressure, by necrosis or hemorrhage, by extension or by metastasis they can reproduce the clinical appearances of an amazing variety of disorders." This propensity to mimic other disorders has not been stressed sufficiently, and as a consequence does not seem to be generally appreciated. In view of this the authors wish to call attention to this matter, which is illustrated in the first three of the cases which will be presented. Another most interesting phenomenon is that, while the majority of metastases are multiple, occasionally solitary metastases do occur. Figures on the frequency of solitary metastases are hard to find, but it seems that although they are not common they are also not rare. The literature contains a number of reports that the removal of such a single metastasis, accompanied by the extirpation of the primary renal tumor, has resulted in the cure of the patient. For instance, Barney and Churchill reported a case where surgical excision of the kidney tumor and of a
METASTASES FROM U)!SUSPECTED RE)!AL CARCINOMAS
421
Fw. 1. Pneumoencephalogram shows left lateral ventricle pushed down and forward by tumor (metastatic renal carcinoma).
solitary lung metastasis resulted in a cure, as the patient was living and in good health when examined as long as 20 years later. Other authors have reported probable cures following resection of the primary kidney tumor and a single metastasis, including a number of cases of solitary metastases to the lunii;, the brain and the bones Out of the present series of 37 patients with renal cell carcinoma seen at this hospital, six were originally thought to have solitary metastases, and in all but one of these six patients, who refased amputation at the shoulder for a metastasis to the humerus, an attempt at the complete surgical extirpation of the primary renal tumor and also of the solitary metastasis was carried out. In two of these five operated patients, whose supposed single metastasis was removed, further metastases later developed. This leaves three patients, plus the one who refused operation, who are now thought to have very possibly had solitary metastases. In one of these three patients it was found impossible to completely remove a metastasis to the brain, but in the other two, with apparently solitary metastases to the lung, and to the chest wall and axilla respectively, it is possible that a cure has been obtained. However, the followup period in this group is shmt, and the final results await the test of time. ·when dealing with this group of tumors, the prognosis in regard to curability by surgery is guarded, as the statistical probability is that
metastases will occur early and will not be solitary. However, their erratic and completely unpredictable behavior as to whether they will occur nmmally, or phenomenally early, or abnormally late-sometimes years after nephrectomy-and also as to whether or not a given metastasis may be truly solitary, occasionally provides an unexpectedly good turn of events. With this point of view, the following cases are presented, culled from 37 recent cases of renal cell carcinoma treated at the Veterans Administration Hospital in Boston. CASE REPORTS
E. R. (B.V.A.H. 18731) was a 54-year-old man who entered the hospital with rather rapidly progressing neurological signs suggesting a brain tumor. This was confirmed by x-ray studies (fig. 1). Craniotomy was performed and a plumsized tumor removed from the left parietal region. JVIicroscopic examination of this indicated metastasis from renal cell carcinoma. Accordingly, pyelography was then done revealing a large left renal tumor. Urinalysis was normal. En bloc removal of the left kidney, adrenal, spleen and tail of the pancreas was then performed. Pathological examination revealed renal cell carcinoma with direct invasion of the adrenal, The patient made a satisfactory convalescence but died 11 months after nephrectomy from local
422
R. CHUTE, E. F. IRELAND, JR. AND J. D. HOUGHTON
the metastasis to the orbit, and died 8 months after nephrectomy. Autopsy showed the expected recurrence in the brain, and also one large metastatic lymph node in the region of the pedicle of the remaining kidney. Comment: This was another case of a very early metastasis, diagnosed clinically as a primary tumor of a different type, which appeared more than a year before the symptomless primary renal carcinoma was detectcd~and then only on account of the microscopic appearance of the metastasis.
Frn. 2. Photograph of patient with pulsatile bulging tumor of right supraorbital region (metastatic renal carcinoma). recurrence of the cerebral metastasis. Postmortem examination showed no tumor tissue elsewhere. Comment: This case · illustrates a solitary metastasis masquerading as a primary brain tumor. Since the primary renal tumor gave no signs or symptoms, it was not even considered until the microscopic examination of the tissue removed from the brain. F. D. (B.V.A.H. 15720) was a 64-ycar-old man who entered the hospital with a pulsatile bulging tumor of the right orbit and forehead of 8 months' duration (fig. 2). In order to remove this tumor, the entire right orbital contents and surrounding bone were excised. JVIicroscopic examination showed what was at first thought to be a nonchromaffin paraganglioma or chei;,10dectoma. However, further sections were cut and examination of these gave rise to a suspicion of metastatic renal cell carcinoma and, although urinalysis was normal, the patient was recalled for pyelography. This revealed a tumor of the right kidney which had given no signs or symptoms. Thereupon a large renal cell carcinoma was removed by nephrectomy six months after the metastasis to the orbit had been excised. The patient did very wen for five months, but then began to manifest signs and symptoms of intracerebral recurrence of
J. M. C. (B.V.A.H. 9459) was only 42 years old when a tumor that developed in the right lateral chest wall (fig. 3) was removed by block resection in July 1947. This revealed metastatic adenocarcinoma, but a most exhaustive search for the primary lesion, including pyelography, was --unst1ccessfuL He was followed closely and 2;,;;i' years later a hard gland developed in the right axilla for which a right radical mastectomy with axillary node dissection was performed. Although the node showed adenocarcinoma, the breast contained no primary tumor. Despite the fact that he felt well, the patient was kept under observation, and five years after mastectomy he had a daily afternoon elevation of temperature to 101F. Investigation revealed a large mass in the right upper quadrant which pyelography showed to be a renal tumor. Urinalysis was normal. Right nephrectomy was then performed for a large papillary adenocarcinoma of the kidney which had grown into the renal vein. The histological appearance of the chest wall lesion, the axillary node and the kidney was identical. At the present time, 3 years 3 months after nephrectomy, the patient is well and apparently free of disease, with negative physical examination and x-rays. Comment: A most unusual and baffling case where "the buggy preceded the horse" and a solitary metastasis appeared 8 years before the "silent" primary renal carcinoma was discovered. C. K. (B.V.A.H. 11246) a 27-year-old man, after having noticed hematuria intermittently for 8 months, underwent a left nephrectomy in February 1952 for a papillary cystadenocarcinoma of the kidney. Two years later on routine checkup examination two discrete nodules were discovered close together in the lung (fig. 4) and a left upper lobectomy was performed. :Microscopic examination showed metastatic
METASTASES FROM UXSUSPECTED RENAL CARCINOMAS
423
Fm. 3. X-rays show destructive lesion of eighth right rib (metastatic renal carcinoma).
papillary renal cystadenocarcinoma. 17\Then seen recently, four years after lobectomy, he appeared to be free of disease, with negative physical examination and x-rays. Another case had a left lower lobectomy for a pulmonary metastasis, presumed to be solitary, 4 years following a nephrectomy for renal cell carcinoma. Unfortunately this did not effect a cure. Generalized metastases developed and the patient died two years later. From the foregoing case reports, it is obvious that many patients from whom the primary renal lesion and the presumed sole metastasis are removed will not be cured because other metastases will develop. HoweveT, reports in the literature indicate-that s0n1e of these patierrts will be cured, and two of the cases presented are encouraging in this regard, although the followup time of 3 years and 4 years, respectively is much too short to be significant. This gives a ray of hope to an otherwise absolutely hopeless prognosis, and makes it mandatory, before deciding that a patient with a renal tumor and a metastasis is incurable, to carefully consider the possibility of the metastasis being a solitary one and, if so, the further possibility of extirpating both the primary lesion and the metastasis. In addition, patients who have had renal carcinomas removed must be followed carefully so that any belated solitary metastasis which occurs may be detected early 0
Fm. 4. X-rays show nodules in lung (metastatic renal carcinoma).
and eradicated with surgical vigor and some degree of optimism. In the case of any patient with signs and symptoms which arc puzzling and not entirely characteristic of any particular disease entity, or in the case of any patient ,vith obscure abdominal distress, or an unexplained fever, or with an unusual tumor, or with metastatic disease, whose source is unknown, metastasis from "silent" renal carcinoma must always be considered. The possibility of this is even greater in the case of lytic lesions of bone, especially if they are hot and
424
R. CHUTE, E. F. IRELAND, JR. AND J. D. HOUGHTON
pulsatile, and in the case of pulmonary tumors and brain tumors. SUMMARY
Distant blood-borne metastases from malignant tumors of the renal parenchyma of the carcinoma-hypernephroma group may occur in any tissue of the body and may also develop very early, long before the "silent" primary tumor in the kidney is suspected. As a consequence of these two characteristics, these metastases may produce a wide variety of symptoms and signs whose source and significance may be extremely puzzling. In fact, they may simulate other conditions so closely that a mistaken diagnosis of some other disease is made. This propensity to mimic other disorders has not been stressed sufficiently and as a consequence is not generally realized. It is well illustrated in three of the cases presented. 1Vhile most metastases are multiple, solitary metastases may occur. A number of case reports in the literature indicate cures following the removal of the primary renal tumor and the solitary metastasis. While it is realized that many patients in whom this procedure is accomplished will not be cured because other metastases will develop, in some the disease will be eradicated completely, and two of the cases presented are encouraging in this regard. Therefore, it is felt that, when a renal metastasis is apparently solitary, a surgical attempt should be made to extirpate it and its primary kidney tumor with some degree of optimism. In the case of any patient with puzzling abdominai<.Symptoms whose source is obscure, or with an '~nexplaincd fever, or with an unusual tumor, or with metastases whose source is unknown, mefastasis from "silent" renal carcinoma must be considered. This is especially true in the case of lytic lesions of bone, particularly if they are pulsatile and hot, and in the case of pulmonary tumors and brain tumors. Thirty-seven cases of kidney tumor of the renal carcinoma-hypernephroma type at the Veterans Administration Hospital in Boston have been reviewed ..:\fore than 67 per cent had metastases, but it is thought possible that the metastases may have been solitary in 11 per cent (4 patients). Several case reports have been presented that exemplify the varied and puzzling symptoms
produced by metastases, and also illustrate both unsuccessful and apparently successful surgical attempts to eradicate renal tumors and presumed solitary metastases.
78 Upland Road, Brookline 46, Mass. (R. C.) REFERENCES ALEXANDER, J. AND HAIGHT, 0. : Pulmonary resec tion for solitary metastatic sarcomas and carcinomas. Surg., Gynec. & Obst., 85: 129146, 1947. BARNEY, J. D. AND CHURCHILL, E. D.: Adenocarcinoma of the kidney with metastasis to lung. J. Urol., 42: 269-276, 1939. 0RILE, GEORGE, JR.: Pulsating tumors of the sternum. Ann. Surg., 103: 199-209, 1936. 0REEVY, 0. D.: Confusing clinical manifestations of malignant renal neoplasms. Arch. Int. Med., 55: 895-916, 1935. DEMING, 0. L.: The prognosis and problems in renal tumors. J. Urol., 55: 571-582, 1946. DEMING, 0. L.: Renal neoplasms: An enigma and a challenge. J. Urol., 69: 1-9, 1953. FooT, N. 0., HUMPHREYS, G. A. AND WHITMORE, W. · F.: Renal tumors: Pathology and prognosis in 295 cases. J. Urol., 66: 190-197, 1951. HAGER, B. H. AND ScHIFFBAUER, H. E.: Silent adenocarcinoma of the kidney with single metastasis to the chest. Tr. Amer. Assoc. G.U. Surg., 34: 1-7, 1941. HALE, N. G. AND BURKLAND, 0. E.: Unrecognized renal tumors: A study of 54 cases in 6577 autopsies and personal cases. J. Urol., 49: 426-431, 1943. HARVEY, N. A.: Kidney tumors: A clinical and pathological study, with special reference to the "hypernephroid" tumor. J. Urol., 57: 669-692, 1947. HooD, R. T., JR., McBuRNEY, R. P. AND CLAGETT, 0. T.: Metastatic malignant lesions of the lungs treated by pulmonary resection. J. Thoracic Surg., 30: 81-89, 1955. McDONALD, J. R. AND PRIESTLEY, J. T.: Malignant tumors of the kidney: Surgical and prognostic significance of tumor thrombosis of the renal vein. Surg., Gynec. & Obst., 77: 295-306, 1943. MELicow, M. M.: Classification of renal neoplasms: A clinical and pathological study based on 199 cases. J. Urol., 51: 333-385, 1944. NALLE, B. 0., JR.: Distant metastases of 58 renal neoplasms. J. Urol., 57: 662-668, 1947. OSTRUM, H. W. AND FELTER, J. S.: Silent nephroma. J. Urol., 43: 39-51, 1940. RowLANDS, B. 0.: Pyrexia as the sole presenting symptom of a hypernephroma. Brit. J. Urol., 23: 267-270, 1951. RuscHE, 0.: Silent adenocarcinoma of the kidney with solitary metastases occurring in brothers. J. Urol., 70: 146-151, 1953. STi.iRTEBECKER, T. P.: Metastatic hypernephroma of the brain from a neurosurgical point of view. A report of 19 cases. J. Neurosurg., 8: 185-197, 1951. STRIEDER, J. W.: Surgical management of neoplastic pulmonary metastases. New Eng. J. Med., 254: 1059-1062, 1956. THROCKMORTON, M. A.: Prognosis of hypernephroma: Review of the literature and report of 42 cases. J. Urol., 73: 773-776, 1955.
Vol. 80, No. 6, December 1958 Printed in U.S.A.
SOLITARY DISTANT METASTASES FROM UNSUSPECTED RENAL CARCINOMAS RICHARD CHUTE, ELWOOD F. IRELAND, JR. AND JOHN D. HOUGHTON From the Urological and Pathological Services of the Veterans Administration Hospital, Boston, Mass. At the outset let it be made clear that the renal carcinomas considered in this presentation are not those of the renal pelvis, nor Wilms tumors, but are those solid malignant tumors of the renal parenchyma classified in a general way as renal cell carcinoma or hypernephroma. The members of this group, regardless of their exact individual histological classification, generally speaking, behave alike as regards the generation of distant metastases. While these kidney malignancies may invade adjacent organs by direct local extension through the capsule, and also may spread by way of the lymphatics to the regional lymph nodes, there is general agreement that the solitary distant metastases which are considered in this paper are blood-borne and occur because these tumors also grow directly into the veins of the kidney. Thus tumor cells gain entrance into the bloodstream, and migrate by way of the renal vein and the inferior vena cava as malignant emboli to other regions of the body. McDonald and Priestley, in careful dissections of 509 hypernephromas, found invasion of the renal vein by tumor in more than 50 per cent. Statistically the chest, including lungs, pleura and chest wall, is definitely the commonest site of metastases, which occur there in more than 50 per cent of all cases. Bones are the next most commonly involved, followed by the liver, and then various other organs, including the brain in an appreciable number of cases. Metastases have been found at one time or another in different cases in almost every organ or tissue of the body, including such widely separated ones as the heart, tongue, intestines, sternum and clavicle, buttock, epididymis, thyroid gland, skin, and the other kidney. Very commonly metastases occur early, and it is not particularly rare to have distant metastases appear while the primaiy renal tumor is still small, and long before it has given any other sign or symptom of its existence. It is generally conceded that about one-third of the cases of renal Read at annual meeting of American Urological Association, Inc., New Orleans, La., April 28May 1, 1958. 420
malignancy already have demonstrable metastases by the time the primary tumor is discovered. Out of a recent series of 37 cases of renal cell carcinoma seen at this hospital, metastases were found in 25 or 67 per cent. Surprisingly the urinalysis not infrequently is absolutely normal. As a consequence of these two characteristics: that distant metastases may involve any tissue in the body, and that they may develop long before the primary renal tumor has given any other evidence of its existence, a wide variety of symptoms and signs may be produced whose source and significance may be extremely puzzling. Not only may these furnish no clue as to their real origin, but they may even simulate other conditions, diverting attention from the "silent" primary kidney tumor so that the true diagnosis is not made until late-sometimes only after the microscopic examination of tissue from a biopsied or excised metastasis, and sometimes not until autopsy. In fact, so often has a mistaken diagnosis of some other disease entity been made that Creevy states that these tumors " ... should be classed ... as among the great mimics encountered in clinical medicine. By direct pressure, by necrosis or hemorrhage, by extension or by metastasis they can reproduce the clinical appearances of an amazing variety of disorders." This propensity to mimic other disorders has not been stressed sufficiently, and as a consequence does not seem to be generally appreciated. In view of this the authors wish to call attention to this matter, which is illustrated in the first three of the cases which will be presented. Another most interesting phenomenon is that, while the majority of metastases are multiple, occasionally solitary metastases do occur. Figures on the frequency of solitary metastases are hard to find, but it seems that although they are not common they are also not rare. The literature contains a number of reports that the removal of such a single metastasis, accompanied by the extirpation of the primary renal tumor, has resulted in the cure of the patient. For instance, Barney and Churchill reported a case where surgical excision of the kidney tumor and of a
METASTASES FROM U)!SUSPECTED RE)!AL CARCINOMAS
421
Fw. 1. Pneumoencephalogram shows left lateral ventricle pushed down and forward by tumor (metastatic renal carcinoma).
solitary lung metastasis resulted in a cure, as the patient was living and in good health when examined as long as 20 years later. Other authors have reported probable cures following resection of the primary kidney tumor and a single metastasis, including a number of cases of solitary metastases to the lunii;, the brain and the bones Out of the present series of 37 patients with renal cell carcinoma seen at this hospital, six were originally thought to have solitary metastases, and in all but one of these six patients, who refased amputation at the shoulder for a metastasis to the humerus, an attempt at the complete surgical extirpation of the primary renal tumor and also of the solitary metastasis was carried out. In two of these five operated patients, whose supposed single metastasis was removed, further metastases later developed. This leaves three patients, plus the one who refused operation, who are now thought to have very possibly had solitary metastases. In one of these three patients it was found impossible to completely remove a metastasis to the brain, but in the other two, with apparently solitary metastases to the lung, and to the chest wall and axilla respectively, it is possible that a cure has been obtained. However, the followup period in this group is shmt, and the final results await the test of time. ·when dealing with this group of tumors, the prognosis in regard to curability by surgery is guarded, as the statistical probability is that
metastases will occur early and will not be solitary. However, their erratic and completely unpredictable behavior as to whether they will occur nmmally, or phenomenally early, or abnormally late-sometimes years after nephrectomy-and also as to whether or not a given metastasis may be truly solitary, occasionally provides an unexpectedly good turn of events. With this point of view, the following cases are presented, culled from 37 recent cases of renal cell carcinoma treated at the Veterans Administration Hospital in Boston. CASE REPORTS
E. R. (B.V.A.H. 18731) was a 54-year-old man who entered the hospital with rather rapidly progressing neurological signs suggesting a brain tumor. This was confirmed by x-ray studies (fig. 1). Craniotomy was performed and a plumsized tumor removed from the left parietal region. JVIicroscopic examination of this indicated metastasis from renal cell carcinoma. Accordingly, pyelography was then done revealing a large left renal tumor. Urinalysis was normal. En bloc removal of the left kidney, adrenal, spleen and tail of the pancreas was then performed. Pathological examination revealed renal cell carcinoma with direct invasion of the adrenal, The patient made a satisfactory convalescence but died 11 months after nephrectomy from local
422
R. CHUTE, E. F. IRELAND, JR. AND J. D. HOUGHTON
the metastasis to the orbit, and died 8 months after nephrectomy. Autopsy showed the expected recurrence in the brain, and also one large metastatic lymph node in the region of the pedicle of the remaining kidney. Comment: This was another case of a very early metastasis, diagnosed clinically as a primary tumor of a different type, which appeared more than a year before the symptomless primary renal carcinoma was detectcd~and then only on account of the microscopic appearance of the metastasis.
Frn. 2. Photograph of patient with pulsatile bulging tumor of right supraorbital region (metastatic renal carcinoma). recurrence of the cerebral metastasis. Postmortem examination showed no tumor tissue elsewhere. Comment: This case · illustrates a solitary metastasis masquerading as a primary brain tumor. Since the primary renal tumor gave no signs or symptoms, it was not even considered until the microscopic examination of the tissue removed from the brain. F. D. (B.V.A.H. 15720) was a 64-ycar-old man who entered the hospital with a pulsatile bulging tumor of the right orbit and forehead of 8 months' duration (fig. 2). In order to remove this tumor, the entire right orbital contents and surrounding bone were excised. JVIicroscopic examination showed what was at first thought to be a nonchromaffin paraganglioma or chei;,10dectoma. However, further sections were cut and examination of these gave rise to a suspicion of metastatic renal cell carcinoma and, although urinalysis was normal, the patient was recalled for pyelography. This revealed a tumor of the right kidney which had given no signs or symptoms. Thereupon a large renal cell carcinoma was removed by nephrectomy six months after the metastasis to the orbit had been excised. The patient did very wen for five months, but then began to manifest signs and symptoms of intracerebral recurrence of
J. M. C. (B.V.A.H. 9459) was only 42 years old when a tumor that developed in the right lateral chest wall (fig. 3) was removed by block resection in July 1947. This revealed metastatic adenocarcinoma, but a most exhaustive search for the primary lesion, including pyelography, was --unst1ccessfuL He was followed closely and 2;,;;i' years later a hard gland developed in the right axilla for which a right radical mastectomy with axillary node dissection was performed. Although the node showed adenocarcinoma, the breast contained no primary tumor. Despite the fact that he felt well, the patient was kept under observation, and five years after mastectomy he had a daily afternoon elevation of temperature to 101F. Investigation revealed a large mass in the right upper quadrant which pyelography showed to be a renal tumor. Urinalysis was normal. Right nephrectomy was then performed for a large papillary adenocarcinoma of the kidney which had grown into the renal vein. The histological appearance of the chest wall lesion, the axillary node and the kidney was identical. At the present time, 3 years 3 months after nephrectomy, the patient is well and apparently free of disease, with negative physical examination and x-rays. Comment: A most unusual and baffling case where "the buggy preceded the horse" and a solitary metastasis appeared 8 years before the "silent" primary renal carcinoma was discovered. C. K. (B.V.A.H. 11246) a 27-year-old man, after having noticed hematuria intermittently for 8 months, underwent a left nephrectomy in February 1952 for a papillary cystadenocarcinoma of the kidney. Two years later on routine checkup examination two discrete nodules were discovered close together in the lung (fig. 4) and a left upper lobectomy was performed. :Microscopic examination showed metastatic
METASTASES FROM UXSUSPECTED RENAL CARCINOMAS
423
Fm. 3. X-rays show destructive lesion of eighth right rib (metastatic renal carcinoma).
papillary renal cystadenocarcinoma. 17\Then seen recently, four years after lobectomy, he appeared to be free of disease, with negative physical examination and x-rays. Another case had a left lower lobectomy for a pulmonary metastasis, presumed to be solitary, 4 years following a nephrectomy for renal cell carcinoma. Unfortunately this did not effect a cure. Generalized metastases developed and the patient died two years later. From the foregoing case reports, it is obvious that many patients from whom the primary renal lesion and the presumed sole metastasis are removed will not be cured because other metastases will develop. HoweveT, reports in the literature indicate-that s0n1e of these patierrts will be cured, and two of the cases presented are encouraging in this regard, although the followup time of 3 years and 4 years, respectively is much too short to be significant. This gives a ray of hope to an otherwise absolutely hopeless prognosis, and makes it mandatory, before deciding that a patient with a renal tumor and a metastasis is incurable, to carefully consider the possibility of the metastasis being a solitary one and, if so, the further possibility of extirpating both the primary lesion and the metastasis. In addition, patients who have had renal carcinomas removed must be followed carefully so that any belated solitary metastasis which occurs may be detected early 0
Fm. 4. X-rays show nodules in lung (metastatic renal carcinoma).
and eradicated with surgical vigor and some degree of optimism. In the case of any patient with signs and symptoms which arc puzzling and not entirely characteristic of any particular disease entity, or in the case of any patient ,vith obscure abdominal distress, or an unexplained fever, or with an unusual tumor, or with metastatic disease, whose source is unknown, metastasis from "silent" renal carcinoma must always be considered. The possibility of this is even greater in the case of lytic lesions of bone, especially if they are hot and
424
R. CHUTE, E. F. IRELAND, JR. AND J. D. HOUGHTON
pulsatile, and in the case of pulmonary tumors and brain tumors. SUMMARY
Distant blood-borne metastases from malignant tumors of the renal parenchyma of the carcinoma-hypernephroma group may occur in any tissue of the body and may also develop very early, long before the "silent" primary tumor in the kidney is suspected. As a consequence of these two characteristics, these metastases may produce a wide variety of symptoms and signs whose source and significance may be extremely puzzling. In fact, they may simulate other conditions so closely that a mistaken diagnosis of some other disease is made. This propensity to mimic other disorders has not been stressed sufficiently and as a consequence is not generally realized. It is well illustrated in three of the cases presented. 1Vhile most metastases are multiple, solitary metastases may occur. A number of case reports in the literature indicate cures following the removal of the primary renal tumor and the solitary metastasis. While it is realized that many patients in whom this procedure is accomplished will not be cured because other metastases will develop, in some the disease will be eradicated completely, and two of the cases presented are encouraging in this regard. Therefore, it is felt that, when a renal metastasis is apparently solitary, a surgical attempt should be made to extirpate it and its primary kidney tumor with some degree of optimism. In the case of any patient with puzzling abdominai<.Symptoms whose source is obscure, or with an '~nexplaincd fever, or with an unusual tumor, or with metastases whose source is unknown, mefastasis from "silent" renal carcinoma must be considered. This is especially true in the case of lytic lesions of bone, particularly if they are pulsatile and hot, and in the case of pulmonary tumors and brain tumors. Thirty-seven cases of kidney tumor of the renal carcinoma-hypernephroma type at the Veterans Administration Hospital in Boston have been reviewed ..:\fore than 67 per cent had metastases, but it is thought possible that the metastases may have been solitary in 11 per cent (4 patients). Several case reports have been presented that exemplify the varied and puzzling symptoms
produced by metastases, and also illustrate both unsuccessful and apparently successful surgical attempts to eradicate renal tumors and presumed solitary metastases.
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