Solitary late recurrence of renal cell carcinoma

CASE REPORT

SOLITARY LATE RECURRENCE OF RENAL CELL CARCINOMA JAY R . NEWMARK, M .D . GERALDINE M . NEWMARK, M .D . JONATHAN l . EPSTEIN, M . D . FRAY F MARSHALL, M .D . From the Departments of Urology, Pathology, and Radiology and the James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions . Baltimore, Maryland

ABSTRACT-Late recurrence of renal carcinoma is an unusual manifestation of this tumor but can occur in as many as 1 l percent of patients surviving ten years . We describe a case of a solitary lesion occurring in the nephrectomy scar ten years following surgery . The literature is reviewed . Aggressive surgical management is warranted in the treatment of these solitary lesions. The use of advanced imaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) can assist greatly in the manage ment of patients .

Approximately 25,000 new cases of renal cell carcinoma will he diagnosed in the United States this year.' Metastatic disease will be present in 25 percent of patients at the time of diagnosis . 2 Another 20-50 percent of patients who were thought to have localized disease will subsequently show metastases,' usually within a few years . Only a minority of patients will experience a late recurrence . Even more unusual is the solitary late occurrence of tumor in the nephrectomy scar . We report a case of this unusual presentation and discuss its significance .

nephrectomy was performed through a teuth-iuterspace flank incision . There was no gross tumor spillage at surgery (i .e ., the capsule was not entered and the specimen margins were free of tumor) . The specimen included a large necrotic, soft golden yellow tumor mass replacing approximately 90 percent of the kidney . The tumor was confined to the renal capsule and did not involve the adrenal gland, ureter, or the renal vein . 1listologically, the tumor showed tubular and papillary features with clear and granular cytoplasm (Fig . 2) . The nuclei were enlarged with prominent nucleoli (nuclear grade 3) . The cytology of the

CASE REPORT A twenty-two-year-old woman in her seventh month of pregnancy presented with intermittent gross hematuria . Initially, she was treated with antibiotics, which resulted in temporary resolution of her symptoms . When hematuria recurred, an ultrasound examination demonstrated a left renal mass . A limited computed tomographic (CT) exarnination confirmed a solid renal mass . Needle aspirate of the kidney revealed papillary fronds with markedly enlarged nuclei and prominent nucleoli, consistent with a renal cell carcinoma (Fig . 1) . Metastanc evaluation was negative . Left radical Submitted : October

14 . 1993 .

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FIGURE t . Needle aspiration shows papillary renal cell carcinoma (original magnification x 650) .

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FIGURE 4, Axial CT scan demonstrates possible rib involvement by the flank mass . Extension into the peritoneal cavity could not be excluded . FIGURE 2 . Radical nephrectomy specimen shows renal cell carcinoma (original magnification x 250) .

FIGURE 3 . Patient with flank tumor resected specimen was identical to that of the prior needle aspirate . Seven hilar lymph nodes were free of tumor. Postoperatively, the patient went into labor prematurely, necessitating cesarean section five days later. The patient recuperated uneventfully and the child recovered after a prolonged stay in the intensive care unit . Subsequently, the patient was evaluated annually for seven years with no evidence of recurrent disease . A second pregnancy six years later was uneventful . Pour years after that she presented with a large left subcutaneous flank mass, left flank pain, and nausea . The patient had noted the lesion three months previously but deferred examination until the size and discomfort worsened . Physical examination revealed a large mass beneath her flank scar arising from and fixed to the abdominal and chest walls (Fig . 3) . Laboratory findings included a white blood cell count of 8,300/cc', hematocrit 33 percent, urea nitrogen 10 mg/dL, creatinine 1 .1 mg/dL, and alkaline phosphatase 62 IU/L . A CT 726

scan of the abdomen demonstrated a 12 by 12 cm well-circumscribed heterogeneous mass arising from the left posterolateral abdominal wall . Although the mass appeared predominantly extracavitary, several axial images suggested that rib encasement and intraperitoneal spread could not be excluded (Fig . 4) . Magnetic resonance imaging (MRI) was subsequently performed, clearly defining the mass as entirely extracavitary (Fig . 5A, B) . Percutaneous needle biopsy provided only necrotic tissue . Metastatic evaluation including chest CT was negative . A wide surgical excision of the involved area, including the adjacent eleventh rib, was performed . The lesion did not penetrate the peritoneum . The abdominal wall defect was closed with Marlex mesh . Convalescence was uneventful . Histopathologic evaluation of the soft tissue mass revealed papillary tumor with identical nuclear and cytoplasmic features to the patient's prior renal cell carcinoma (Fig . 6) . She has been evaluated for six months and has been without evidence of recurrent disease . COMMENT Late solitary recurrence of renal cell carcinoma more than ten years following nephrectomy is unusual . Bloom and associates' reviewed the literature and found 11 such cases . The lesions described were either locally recurrent to the renal fossa and wound or were metastatic to the tracheobronchial tree, thyroid, lung, bone, intestine, and muscle . While in some cases follow-up data were not reported, in cases that provided this information, which varied from eight months to eight years, there was no evidence of subsequent metastatic disease following surgical extirpation . They concluded that resection of these lesions is

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FIGURE f . Histologic appearance of subcutaneous renal cell carcinoma (original magnification x 450))

FIGURE 5 . (A) Corona) T i -weighted MRI. Large left flank mass appears to displace intact peritoneum medially . (B) Axial T1 weighted MRI shows increased signal intensity of abdominal wall mass . The region of increased signal intensity is clearly limited by the abdominal wall and does not extend into the peritoneal cavity.

warranted and that survival is related to the site of recurrence . McNichols and associates' reviewed 729 patients with renal cell carcinoma treated at the Mayo Clinic over a fifteen-year period . Of 481 patients who underwent nephrectomy, 158 were alive at ten years and a late recurrence occurred in 18 patients (11%)- Of these 18 patients, 3 underwent resection of a solitary pulmonary recurrence and 2 were alive six and nine years postoperatively. Those patients who did not undergo surgical resection were dead within two years . The success of surgical management of solitary renal cell metastases has been questioned . Dineen and associates° retrospectively evaluated 29 patients UROI OGY !

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who underwent excision of a solitary inctastatic lesion of renal cell carcinoma . In iihese 29 cases, eleven metastases were recognized prior to nephrectomy and 18 patients were diagnosed with distant metastatic disease two months to eleven years following nephrectomy . The estimated overall survival rate for the group was 41 percent at two years and 13 percent at five years following resection of the metastatic lesion . Moreover . neither the presence or absence of metastasis at diagnosis nor the interval between nephrectomy and diagnosis of the metastatic lesion appeared to influence survival . They concluded that surgical treatment of solitary metastases is of only limited value . Cutaneous involvement by renal carcinoma is rare . Rosenthal and Lever' determined the incidence of these cutaneous lesions to he 2 .8 percent, of which 20 percent were diagnosed at presentation . The majority of these lesions were multiple . Of 16 patients with metastatic involvement of the nephrectomy scar, only 1 was found to have a solitary recurrence . None of the patients reported on experienced a recurrence tell or more years after initial surgery. Solitary recurrent renal carcinoma to the surgical incision is very rare . Unlike solitary metastases to the renal bed or distant sites, tumor recurrence in the nephrectomy scar responds favorably to surgical excision . Frontz' reported papillary cystadenoma recurrent to the wound four years after surgery. No follow-up was mentioned ; however, the lesion was completely excised . In the series reported by McNichols and associates,' I patient experienced a recurrence in the abdominal wound one year following nephrectomy and was alive nineteen years following resection Only 1 case of 727

a late solitary recurrence to the nephrectomy scar has been previously described . Kradjian and Bennington 9 reported a solitary recurrence of renal carcinoma in the nephrectomy scar discovered thirtyone years after surgery . The contralateral kidney was not evaluated . Following excision of the lesion, the patient was well eight months later . In the present case, a solitary recurrence in the nephrectomy scar was identified ten years after surgery Metastatic evaluation was performed utilizing abdominal CT and MRI scans . These studies demonstrated that the lesion extended into but not through the abdominal wall, with minimal involvement of the chest wall . Without involvement of the contralateral kidney or other metastatic sites, complete surgical excision of the lesion could be performed . The cause of this lesion is unknown . Possibly the lesion is a result of unrecognized tumor spillage at the initial operation ; however, the lesion was confined within the renal capsule . Kradjian and Bennington 9 suggested that tumor spillage may be more common than believed ; however, the surgical scar provides an unfavorable environment for tumor growth . As an alternative, this recurrence could be explained by needle tract seeding from the percutaneous biopsy This finding is a very rare occurrence, however . Von Schreeb and associates 10 failed to identify needle tract seeding in a series of 150 patients with renal carcinoma, half of whom underwent diagnostic renal puncture . Gibbons and associates" reported the first documented case of needle tract seeding more than thirty-five years after the aspiration of renal cysts became common practice . One can never assume that a patient with renal carcinoma is free of disease . Late recurrence of renal carcinoma is an unusual manifestation of this tumor but can occur in as many as 11 percent of patients surviving at least ten years . Solitary le-

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sions in the surgical scar are rare and respond favorably to aggressive surgical treatment . The use of advanced imaging techniques such as CT and MRI can greatly assist in delineating the extent of the lesion and planning future surgical treatment . Jay R. Newmark, M .D . Methodist Hospital Institute for Kidney Stone Disease 1801 N. Senate Blvd., Suite 655 Indianapolis, Indiana 46202 REFERENCES 1 . Boring CC, Squires TS, and Tong T : Cancer statistics, 1993 . CA Cancer I Clin 43 :7-26,1993 . 2 . Giuliani L, Giberti C, Martorana G, and Rovida S : Radical extensive surgery for renal cell carcinoma : long-term results and prognostic factors . J Urol 143 : 468-474, 1990 . 3 . de Kernion JB : Renal tumors, in Walsh PC, Gities RE Perlmutter AD, and Stamey TA (Eds) : Campbell's Urology, Philadelphia, WB Saunders, vol 2, 1986, pp 1294-1342 . 4 . Bloom DA, Kaufman JJ, and Smith RB : Late recurrence of renal tubular carcinoma . J Urol 126 : 546-548,1981 . 5 . McNichols DW, Segura JW and DeWeerd JH : Renal cell carcinoma : long-term survival and late recurrence . J Urot 126 :17-23,1981 . 6 . Dineen MK, Pastore RD, Emrich LJ, and Huben RP: Results of surgical treatment of renal cell carcinoma with solitary metastasis . J Urol 140 : 277-279, 1988 . 7 . Rosenthal AL, and Lever WF : Involvement of the skin in renal carcinoma : report of two cases with review of the literature . Arch Dermatol 76 : 96-102, 1957 . 8 . Frontz WA: Unusual case of tumor implantation following nephrectomy for papillary cystadenoma . J Urol 17 : 121-125,1927 . 9 . Kradjian RM, and Bennington JL : Renal carcinoma recurrent 31 years after nephrectomy. Arch Surg 90 : 192-195, 1965 . 10 . von Schreeb T, Amer 0, Skovsted G, and Wikstad N : Renal adenocarcinoma : is there a risk of spreading tumour cells in diagnostic puncture? Scand J Urol Nephrol 1 : 270276,1967 . 11 . Gibbons RP, Bush WH Jr, and Burnett LL : Needle tract seeding following aspiration of renal cell carcinoma . J Urol 118 :865-867,1977 .

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