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The Kidney as Host in Cancer-to-Cancer Metastasis
Vol. \JK, Dec Printed in c:.8.,J
THE JOURNAL OF UROLOGY
Copyright (£I 1968 by The \Villia.ms & \V.ilkins Co.
THE IGDI\EY AS HOST IN CANCER-TO-CANCER J\JETASTASIS JOHN D l\IALONEY*
AND
MARK L\L\lETIGUTt
Frmn the Depal'i'rncnt of Surgery, Division of Urology, Ohio Slate Uniue1·sily Hospilal,
Colmnbus, Ohio
It is not unusual for a patient with malignant tL1mor to suffer a second, separate, primary cancer.1-:1 The incidence of multiple malignancies is approximately 4.2 per cent. 4 It is thus a rare occurrence when one primary cancer metastasizes to a second primary cancer and it is of interest to ,1rologists that hypernephroma is the host tumor in more than two thirds of the reported cases. In 1902 Berent reported the first example of cancer-to-cancer metastasis (a patient with a squamous cell carcinoma of the jaw which had spread to a hypernephrouia of the right kidney'). 1Iammann described a second case 25 years later (a patient with carcinoma of the thyroid who suffered metastasis to a renal malignancy 6). In 1958 Gore and Barr reviewed the literature of cancer-to-cancer metasta~is and found 21 cases, including two of their own. 5 - 15 A renal tumor was
the recipient malignancy in 1:5 o[ ilwse 21 pa tients. These author.s carefoll:' limited their review to ca.~es in 1Yhich 2 malignant were present. J\letastasis from a carcinoma to n. benign tumor has been notecl freq1wutl,1 mid may be a chance occmTence_lli- 18 Since H1.58 ;3 additional case,c; have appeared in the litera ture. 1 M 1 One of the,se desnibes the only in whom a renal malignancy ,,-as the metasta.oi½ing turnor, the host tumor being a carciuourn o[ the thyroid. 19 The following case ducurnc11fa the twenty-fifth reported patient in \Yhom eanccr·-tocancer metastasis has been noted ancl the ~even teenth patient in whom a hypernephroma was ihc host for a metastasis from a primary rn another part of the body table.).
Accepted for publication December G. 1966. l{ea.d at annual meeting of North Centrnl Section, American Urological Association, Inc., Minneapolis, Minnesot.11, September 15-18, 19G5. * Present address: 2 W. Gorham Street, Madison, Wisconsin. I Present address: Department of Urology, University Hospital, Iowa City, Iowa. 1 Watson, T. A.: Incidence of mnltiple cancer. Cancer, 6: 365-371, 1953. 2 Moertel, C. G., Dockerty, M. B. and Baggenstoss, A. II.: Multiple primary malignant neoplasms. 1. Introduction and presentation of data. Cancer, 14: 221-230, 1961. "Warren,. S. and Ehrenreich, T.: JVIultiple primary malignant tumors and SL1sceptibility to cancer. Cancer Res., 4: 554, 1944 ,)Thoma, G. W.: Incidence and significance of mul Liple primary malignant tumors. A stndy of 2340 necropsies from a cancer research hospital. Amer. ,J. Med. Sci., 247: 427-430, 19G4. 5 Berent, W.: Seltene metastasenbildLmg. CenLrnlbl. £. Allgem Path. U. Path. Anat., 13: 40G-410, 1902. "Hammann, E.: Ungewohnliche metastasierung eines sarkoms bei bestehen zweier tumoren. Ztschr. £. Path., 35: 256-264, 1927. 7 Gore, I. and Barr, IL: Metastasis of cancer to cancer. Arch. Path., 66: 293, 1958. 8 Schneider, L. A.· l\,1etastasis of cancer to cancer; report of case. Amer. J. Clin. Path., 25: 1288, 1955. 9 Berg, J. W.: Angiolipomyosarcoma of kidney (malignant hamartomatous angiolipomyoma) in case with solitary metastasis from bronchiogenic carcinoma. Cancer, 8: 75\J, 1955. 10 Walter, A.: Ein fall v011 metastasen des ,1teruscarcinoms in ein nierenhypernephrom. Ztschr. f. Krebsforsch., 27: 451, 1928.
lVI No. 63-7388, a 59-year-old white mait. was admitted to the thoracic surger)- service of University Hospital with a 2-month history of chest pain. He had had a dry, hacking, nonproductive cough for 1 year and had smoked pack of cigarettes daily for 43 years. He had no
CASE RloPORT
11 Schmorl, G.: Pa1,hological s1mly of burg lung cancer. Report of Conference of Cancer. London, HJ28, pp. 272-274. 12 Simard, C. and Saucier, J.: J\ietastase d'tm epi thelioma de la prostate clans un sarcorne ,\ cellules geantes du mesentcre. Bull. cle l' Assor:. franc. p. J'etude du cancer, 19: M4, 19:30. 13 Rabson, S. JVI., Rtier, P. L .. Baumgartner, J. C. and Rosenbanm, D.: l\iletastasis of cancer to cancer. Amer. J. Clin. Path., 24: .572. 1D54. 14 Ortega, P., Jr., Li, I. Y. and Shimkin, M. B. · JVIetastasis of neoplasms to other neoplasms. Ann. West. Med. & Surg., 5: GOl, 1951. 15 Walther, H. E.· Krebsmetasta.sen. Ba.sel· Schwabe & Co., 1948, p. 172. 16 Wallach, J.B. and Edberg, S.: J\'let,astases of cancer to primary intracra.nial tumor. Arch. Neurol., 1: 191, 1959. 7 Osterberg, D. H.: Ivietastases of cnrciuomn to meningioma. J. Nenrosurg., 14: :337, 1957. 18 Fried, B. J\1L · Metastatic inoculat.ion of meningioma by cancer cells from bronchiogcnic carcinoma. Amer. ,J. Path., 6: 47-·52, 19:30. 19 Pribek. R. A.: JVIetastasis of cancer to cancer. A case report. J.A.M.A., 179: 1G8, 1962. 20 Dobbing, J.: Cancer to cancer. Guy's Ho~pRep., 107: 60-G5, 1958. 21 Towers, R. P.: Unusual metastatic of double primary tumours of prostate J. Irish Med. Assoc., 48: 79-80, 1901. 1.
657
658
MALONEY AND IMMERGUT
Metastasis of cancer to cancer, review of literature Age-Race-Sex
58-W-M 5 41-W-M 6 65-W-F 10 _11
M'' 47-W-M 15
lvietastasizing J\tlalignancy
Squamous Ca. of lower jaw Ca. of thyroid Ca. of endometrium Ca. of lu,ng Adeno-Ca. of prostate Ca. of lung
67-W-M 13
Adeno-Ca. of stomach Ca. of pyriform sinus Adeno-Ca. of thyroid Ca. of lung
55-W-M 13
Ca. of lung
64-W-F 14
58-W-M 13
Melanoma of eye Adeno-Ca. of cecum Ca. of lung
65-W-M 13
Ca. of lung
72-W-M 13
Adeno-Ca. of prostate Adeno-Ca. of prostate Adeno-Ca. of prostate Ca. of lung
66-W-F 15 58-W-M 15 58-W-F 13
72-W-F 13
56-W-M 13 60-W-JW
59-W-F'
52-W-F 7
Adeno-Ca. of prostate Ca. of breast
71-.W-M 20
Ca. of lung
66-W-M 21
Oat cell Ca. of lung Hypernephroma, rt. Ca. of lung
57-W-M'
68-W-M 19 59-W-M*
* Case herein reported.
Recipient Malignancy
Hypernephroma, rt., non-metastas1zmg Hypernephroma, rt., non-metastasizing Hypernephroma, lt., non-metastas1zmg Hypernephroma, non-metastasizing Rhabdomyosarcoma(?) of mesentery, non-metastasizing Hypernephroma, lt., non-metastasizing Hypernephroma, lt., non-metastas1zmg Hypernephroma, lt., non-metastas1zmg Adeno-Ca. of stomach, extent of growth not available Adeno-Ca. of prostate, extent of growth not available Adeno-Ca. of pancreas, extent of growth not available Hypernephroma, lt., non-metastaS1zmg Pre-existent lymphosarcoma at metastatic sites Hypernephroma, lt., non-metastasizing Hypernephroma, lt., non-metastasizing Hypernephroma, rt., with pulmonary metastasis Hypernephroma, rt., non-metastasizing Hypernephroma, rt., non-metastasizing Angiolipomyosarcoma of lt. kidney, non-metastasizing Hypernephroma, rt., non-metastas1zmg Hypernephroma, lt., non-metastasizing Hypernephroma, lt., non-metastasizing Adeno-Ca. of prostate Papillary Ca. thyroid non-metastasizing Hypernephroma, rt., non-metastasizing
Extent of Metastasis
Local lymph nodes and recipient tumor Widespread Capillaries of recipient tumor Widespread, only kidney metastasis in hypernephroma Recipient tumor Widespread, only kidney metastasis in hypernephroma Widespread, only kidney metastasis in hypernephroma Widespread, only kidney metastasis in hypernephroma Widespread Widespread Widespread Widespread, only kidney metastasis in hypernephroma Both widespread Widespread, only kidney metastasis in hypernephroma Recipient tumor & extension to epicardium Rt. kidney & recipient tumor Widespread, only kidney metastasis in hypernephroma Recipient tumor Widespread, only kidney metastasis in recipient tumor Widespread, only kidney metastasis in hypernephroma Widespread, only kidney metastasis in hypernephroma Widespread, only kidney metastasis in hypernephroma Lung, widespread Prostate to lt. adrenal only Widespread, only thyroid, metastasis in thyroid carcinoma Widespread, only kidney metastasis in hypernephroma
KIDNEY AS HOST IN CANCER-TO-CANCER NIETAS'l'ASIS
Uudiflerentiated c,1rcimmrn at left growing within well-differentiated clea.r cell carcinoma of kidney
other signs or syn1ptoms a.nd the ]lhysical examination was within normal limits. Laboratory studies showed a hemoglobin of 14.5 gm., a hematocrit of 4::l.5 per eent, a white blood count of 8,253 and a normal urinalysis. The alkaline phosphatase was 22.2 King-Armstrong units and the creatinine was 1.1 mg. per cent. A chest x-ray revealed a density in t.he left. upper Jobe with wme widening of the mediastinum. An excretory urogram showed a 3 cm. mass in the superior pole of the right. kidney. A transfemoral renal angiograrn demonstrated a tumor stain in the area of t.he upper pole of the right kidney. Bronchoscopy and bronchial aspiration did not produce' a tissue diagnosis. The preoperative diagnosis was a primary renal neoplasm with probable metastasis to the left lung. A right nephrectomy was performed on September 14, 1963. The liver and adrenal gland 1vere biopsied during the procedure. Postoperatively the patient did well initially but became progressively jaundiced and died 2 weeks after the operation. l\·Iicroscopic sections of the renal t.umm showed a background mass of well-differentiated clear cell
carcinom.a iuternpersed with large and small areas of undifferentiated carcinoma illustration). Multiple sections failed t.o demon.,t.rat.e a. transition from the clear cell type to the undifferentiated type of tumor, indicating that t.lwrc were two independently growing tumors, one within the other. Thne were microscopic implaHL~ of undifferentiated ean:inoma in the small blood vessels and in the interstitium of the renal tumor but not within the normal kidney Biopsies of the liver and adrenal glands both contained undifforentiatecl carcinoma but 110rn, of the clear cell type tumor. At autopsy a bronchogenic carcinoma of the left upper lobe was found with metastasis to the lungs, stomach, esophagus, liver, pancrea:,, adrenals and lymph nodes. There wa~ no eYiclenee of metastasis from the hypernephrom:.i. which had been removed at the operation. DISCUSSION
The metastasi.~ of one cancer to another is an infrequent occurrence despite the ma,uy patients with multiple malignancie:,. Rr1b~on suggested that neoplasms prnduce sub~tanecs
660
MALONEY AND IMMERGUT
locally antagonistic to other new growths, thus discouraging their deposition in an already cancerous focus. 13 ·warburg stated that the requirements of a rapidly growing tumor are so great that it provides an unfavorable environment for the implantation and development of a nutritively competitive cellular growth. 22 Even though a cancer may be widely disseminated it rarely spreads to the site of a second primary neoplasm. However, 25 cases of cancerto-cancer metastasis have been reported and a hypernephroma has been the recipient tumor in 17 cases. Explanations of this curious phenomenon have been extremely varied. Willis suggested that the high content of lipid present in clear cell carcinoma of the kidney and the adrenal cortex may permit preferential growth of a metastatic tumor at these sites. 23 Rabson stated that the rich blood supply of the kidney tumor accounts for its role as the host malignancy. 13 Osterberg attributed the host role of the renal neoplasm to pure chance. 17 Gore and Barr advocate the Warburg theory that the kidney tumor is a relatively dormant form of cancer and may have less stringent metabolic requirements than the more aggressive neoplasms. 7 Therefore, there would be less competition for essential nutrients and, commensurately, a greater likelihood for successful implantation and growth of a metastatic tumor. 22 22 Warburg, 0.: On origin of cancer cells. Science, 123: 309, 1956. 23 Willis, R. A.: The Spread of Tumors in the Human Body. London: Butterworth & Co., 1952, 2nd edit.
Ortega agrees that the proclivity of the kidney to receive metastatic deposits may be due to its unusually excellent blood supply but niay also be related to a delicate, well preserved stroma which readily permits a second expansile growth. 14 A second interesting characteristic of cancerto-cancer metastasis is that the host malignancy is known to have spread beyond the organ in which it originated in only 2 cases. The metastasizing neoplasm was invariably widely disseminated throughout the body, except for the organ in which the second primary tumor was located. Here the metastatic lesions were confined to the site of the host cancer and were not found in the normal tissue of the host organ. No tumor appeared more likely to metastasize to another malignancy, but primary neoplasms more commonly originated in epithelial tissues such as lung and prostate. SUMMARY
The metastasis of one cancer to a second cancer in another part of the body is an infrequent event. The host neoplasm has been a kidney tumor in 17 of 25 reported cases. The host neoplasm usually produces no metastasis. However, the metastasizing growth is usually widely disseminated and metastasizes to the host malignancy and not to any other part of the organ in which the host malignancy is arising. Several etiological theories are presented to explain the role of the kidney in cancer-to-cancer metastasis. The literature is reviewed and a case is reported.
THE JOURNAL OF UROLOGY
Copyright (£I 1968 by The \Villia.ms & \V.ilkins Co.
THE IGDI\EY AS HOST IN CANCER-TO-CANCER J\JETASTASIS JOHN D l\IALONEY*
AND
MARK L\L\lETIGUTt
Frmn the Depal'i'rncnt of Surgery, Division of Urology, Ohio Slate Uniue1·sily Hospilal,
Colmnbus, Ohio
It is not unusual for a patient with malignant tL1mor to suffer a second, separate, primary cancer.1-:1 The incidence of multiple malignancies is approximately 4.2 per cent. 4 It is thus a rare occurrence when one primary cancer metastasizes to a second primary cancer and it is of interest to ,1rologists that hypernephroma is the host tumor in more than two thirds of the reported cases. In 1902 Berent reported the first example of cancer-to-cancer metastasis (a patient with a squamous cell carcinoma of the jaw which had spread to a hypernephrouia of the right kidney'). 1Iammann described a second case 25 years later (a patient with carcinoma of the thyroid who suffered metastasis to a renal malignancy 6). In 1958 Gore and Barr reviewed the literature of cancer-to-cancer metasta~is and found 21 cases, including two of their own. 5 - 15 A renal tumor was
the recipient malignancy in 1:5 o[ ilwse 21 pa tients. These author.s carefoll:' limited their review to ca.~es in 1Yhich 2 malignant were present. J\letastasis from a carcinoma to n. benign tumor has been notecl freq1wutl,1 mid may be a chance occmTence_lli- 18 Since H1.58 ;3 additional case,c; have appeared in the litera ture. 1 M 1 One of the,se desnibes the only in whom a renal malignancy ,,-as the metasta.oi½ing turnor, the host tumor being a carciuourn o[ the thyroid. 19 The following case ducurnc11fa the twenty-fifth reported patient in \Yhom eanccr·-tocancer metastasis has been noted ancl the ~even teenth patient in whom a hypernephroma was ihc host for a metastasis from a primary rn another part of the body table.).
Accepted for publication December G. 1966. l{ea.d at annual meeting of North Centrnl Section, American Urological Association, Inc., Minneapolis, Minnesot.11, September 15-18, 19G5. * Present address: 2 W. Gorham Street, Madison, Wisconsin. I Present address: Department of Urology, University Hospital, Iowa City, Iowa. 1 Watson, T. A.: Incidence of mnltiple cancer. Cancer, 6: 365-371, 1953. 2 Moertel, C. G., Dockerty, M. B. and Baggenstoss, A. II.: Multiple primary malignant neoplasms. 1. Introduction and presentation of data. Cancer, 14: 221-230, 1961. "Warren,. S. and Ehrenreich, T.: JVIultiple primary malignant tumors and SL1sceptibility to cancer. Cancer Res., 4: 554, 1944 ,)Thoma, G. W.: Incidence and significance of mul Liple primary malignant tumors. A stndy of 2340 necropsies from a cancer research hospital. Amer. ,J. Med. Sci., 247: 427-430, 19G4. 5 Berent, W.: Seltene metastasenbildLmg. CenLrnlbl. £. Allgem Path. U. Path. Anat., 13: 40G-410, 1902. "Hammann, E.: Ungewohnliche metastasierung eines sarkoms bei bestehen zweier tumoren. Ztschr. £. Path., 35: 256-264, 1927. 7 Gore, I. and Barr, IL: Metastasis of cancer to cancer. Arch. Path., 66: 293, 1958. 8 Schneider, L. A.· l\,1etastasis of cancer to cancer; report of case. Amer. J. Clin. Path., 25: 1288, 1955. 9 Berg, J. W.: Angiolipomyosarcoma of kidney (malignant hamartomatous angiolipomyoma) in case with solitary metastasis from bronchiogenic carcinoma. Cancer, 8: 75\J, 1955. 10 Walter, A.: Ein fall v011 metastasen des ,1teruscarcinoms in ein nierenhypernephrom. Ztschr. f. Krebsforsch., 27: 451, 1928.
lVI No. 63-7388, a 59-year-old white mait. was admitted to the thoracic surger)- service of University Hospital with a 2-month history of chest pain. He had had a dry, hacking, nonproductive cough for 1 year and had smoked pack of cigarettes daily for 43 years. He had no
CASE RloPORT
11 Schmorl, G.: Pa1,hological s1mly of burg lung cancer. Report of Conference of Cancer. London, HJ28, pp. 272-274. 12 Simard, C. and Saucier, J.: J\ietastase d'tm epi thelioma de la prostate clans un sarcorne ,\ cellules geantes du mesentcre. Bull. cle l' Assor:. franc. p. J'etude du cancer, 19: M4, 19:30. 13 Rabson, S. JVI., Rtier, P. L .. Baumgartner, J. C. and Rosenbanm, D.: l\iletastasis of cancer to cancer. Amer. J. Clin. Path., 24: .572. 1D54. 14 Ortega, P., Jr., Li, I. Y. and Shimkin, M. B. · JVIetastasis of neoplasms to other neoplasms. Ann. West. Med. & Surg., 5: GOl, 1951. 15 Walther, H. E.· Krebsmetasta.sen. Ba.sel· Schwabe & Co., 1948, p. 172. 16 Wallach, J.B. and Edberg, S.: J\'let,astases of cancer to primary intracra.nial tumor. Arch. Neurol., 1: 191, 1959. 7 Osterberg, D. H.: Ivietastases of cnrciuomn to meningioma. J. Nenrosurg., 14: :337, 1957. 18 Fried, B. J\1L · Metastatic inoculat.ion of meningioma by cancer cells from bronchiogcnic carcinoma. Amer. ,J. Path., 6: 47-·52, 19:30. 19 Pribek. R. A.: JVIetastasis of cancer to cancer. A case report. J.A.M.A., 179: 1G8, 1962. 20 Dobbing, J.: Cancer to cancer. Guy's Ho~pRep., 107: 60-G5, 1958. 21 Towers, R. P.: Unusual metastatic of double primary tumours of prostate J. Irish Med. Assoc., 48: 79-80, 1901. 1.
657
658
MALONEY AND IMMERGUT
Metastasis of cancer to cancer, review of literature Age-Race-Sex
58-W-M 5 41-W-M 6 65-W-F 10 _11
M'' 47-W-M 15
lvietastasizing J\tlalignancy
Squamous Ca. of lower jaw Ca. of thyroid Ca. of endometrium Ca. of lu,ng Adeno-Ca. of prostate Ca. of lung
67-W-M 13
Adeno-Ca. of stomach Ca. of pyriform sinus Adeno-Ca. of thyroid Ca. of lung
55-W-M 13
Ca. of lung
64-W-F 14
58-W-M 13
Melanoma of eye Adeno-Ca. of cecum Ca. of lung
65-W-M 13
Ca. of lung
72-W-M 13
Adeno-Ca. of prostate Adeno-Ca. of prostate Adeno-Ca. of prostate Ca. of lung
66-W-F 15 58-W-M 15 58-W-F 13
72-W-F 13
56-W-M 13 60-W-JW
59-W-F'
52-W-F 7
Adeno-Ca. of prostate Ca. of breast
71-.W-M 20
Ca. of lung
66-W-M 21
Oat cell Ca. of lung Hypernephroma, rt. Ca. of lung
57-W-M'
68-W-M 19 59-W-M*
* Case herein reported.
Recipient Malignancy
Hypernephroma, rt., non-metastas1zmg Hypernephroma, rt., non-metastasizing Hypernephroma, lt., non-metastas1zmg Hypernephroma, non-metastasizing Rhabdomyosarcoma(?) of mesentery, non-metastasizing Hypernephroma, lt., non-metastasizing Hypernephroma, lt., non-metastas1zmg Hypernephroma, lt., non-metastas1zmg Adeno-Ca. of stomach, extent of growth not available Adeno-Ca. of prostate, extent of growth not available Adeno-Ca. of pancreas, extent of growth not available Hypernephroma, lt., non-metastaS1zmg Pre-existent lymphosarcoma at metastatic sites Hypernephroma, lt., non-metastasizing Hypernephroma, lt., non-metastasizing Hypernephroma, rt., with pulmonary metastasis Hypernephroma, rt., non-metastasizing Hypernephroma, rt., non-metastasizing Angiolipomyosarcoma of lt. kidney, non-metastasizing Hypernephroma, rt., non-metastas1zmg Hypernephroma, lt., non-metastasizing Hypernephroma, lt., non-metastasizing Adeno-Ca. of prostate Papillary Ca. thyroid non-metastasizing Hypernephroma, rt., non-metastasizing
Extent of Metastasis
Local lymph nodes and recipient tumor Widespread Capillaries of recipient tumor Widespread, only kidney metastasis in hypernephroma Recipient tumor Widespread, only kidney metastasis in hypernephroma Widespread, only kidney metastasis in hypernephroma Widespread, only kidney metastasis in hypernephroma Widespread Widespread Widespread Widespread, only kidney metastasis in hypernephroma Both widespread Widespread, only kidney metastasis in hypernephroma Recipient tumor & extension to epicardium Rt. kidney & recipient tumor Widespread, only kidney metastasis in hypernephroma Recipient tumor Widespread, only kidney metastasis in recipient tumor Widespread, only kidney metastasis in hypernephroma Widespread, only kidney metastasis in hypernephroma Widespread, only kidney metastasis in hypernephroma Lung, widespread Prostate to lt. adrenal only Widespread, only thyroid, metastasis in thyroid carcinoma Widespread, only kidney metastasis in hypernephroma
KIDNEY AS HOST IN CANCER-TO-CANCER NIETAS'l'ASIS
Uudiflerentiated c,1rcimmrn at left growing within well-differentiated clea.r cell carcinoma of kidney
other signs or syn1ptoms a.nd the ]lhysical examination was within normal limits. Laboratory studies showed a hemoglobin of 14.5 gm., a hematocrit of 4::l.5 per eent, a white blood count of 8,253 and a normal urinalysis. The alkaline phosphatase was 22.2 King-Armstrong units and the creatinine was 1.1 mg. per cent. A chest x-ray revealed a density in t.he left. upper Jobe with wme widening of the mediastinum. An excretory urogram showed a 3 cm. mass in the superior pole of the right. kidney. A transfemoral renal angiograrn demonstrated a tumor stain in the area of t.he upper pole of the right kidney. Bronchoscopy and bronchial aspiration did not produce' a tissue diagnosis. The preoperative diagnosis was a primary renal neoplasm with probable metastasis to the left lung. A right nephrectomy was performed on September 14, 1963. The liver and adrenal gland 1vere biopsied during the procedure. Postoperatively the patient did well initially but became progressively jaundiced and died 2 weeks after the operation. l\·Iicroscopic sections of the renal t.umm showed a background mass of well-differentiated clear cell
carcinom.a iuternpersed with large and small areas of undifferentiated carcinoma illustration). Multiple sections failed t.o demon.,t.rat.e a. transition from the clear cell type to the undifferentiated type of tumor, indicating that t.lwrc were two independently growing tumors, one within the other. Thne were microscopic implaHL~ of undifferentiated ean:inoma in the small blood vessels and in the interstitium of the renal tumor but not within the normal kidney Biopsies of the liver and adrenal glands both contained undifforentiatecl carcinoma but 110rn, of the clear cell type tumor. At autopsy a bronchogenic carcinoma of the left upper lobe was found with metastasis to the lungs, stomach, esophagus, liver, pancrea:,, adrenals and lymph nodes. There wa~ no eYiclenee of metastasis from the hypernephrom:.i. which had been removed at the operation. DISCUSSION
The metastasi.~ of one cancer to another is an infrequent occurrence despite the ma,uy patients with multiple malignancie:,. Rr1b~on suggested that neoplasms prnduce sub~tanecs
660
MALONEY AND IMMERGUT
locally antagonistic to other new growths, thus discouraging their deposition in an already cancerous focus. 13 ·warburg stated that the requirements of a rapidly growing tumor are so great that it provides an unfavorable environment for the implantation and development of a nutritively competitive cellular growth. 22 Even though a cancer may be widely disseminated it rarely spreads to the site of a second primary neoplasm. However, 25 cases of cancerto-cancer metastasis have been reported and a hypernephroma has been the recipient tumor in 17 cases. Explanations of this curious phenomenon have been extremely varied. Willis suggested that the high content of lipid present in clear cell carcinoma of the kidney and the adrenal cortex may permit preferential growth of a metastatic tumor at these sites. 23 Rabson stated that the rich blood supply of the kidney tumor accounts for its role as the host malignancy. 13 Osterberg attributed the host role of the renal neoplasm to pure chance. 17 Gore and Barr advocate the Warburg theory that the kidney tumor is a relatively dormant form of cancer and may have less stringent metabolic requirements than the more aggressive neoplasms. 7 Therefore, there would be less competition for essential nutrients and, commensurately, a greater likelihood for successful implantation and growth of a metastatic tumor. 22 22 Warburg, 0.: On origin of cancer cells. Science, 123: 309, 1956. 23 Willis, R. A.: The Spread of Tumors in the Human Body. London: Butterworth & Co., 1952, 2nd edit.
Ortega agrees that the proclivity of the kidney to receive metastatic deposits may be due to its unusually excellent blood supply but niay also be related to a delicate, well preserved stroma which readily permits a second expansile growth. 14 A second interesting characteristic of cancerto-cancer metastasis is that the host malignancy is known to have spread beyond the organ in which it originated in only 2 cases. The metastasizing neoplasm was invariably widely disseminated throughout the body, except for the organ in which the second primary tumor was located. Here the metastatic lesions were confined to the site of the host cancer and were not found in the normal tissue of the host organ. No tumor appeared more likely to metastasize to another malignancy, but primary neoplasms more commonly originated in epithelial tissues such as lung and prostate. SUMMARY
The metastasis of one cancer to a second cancer in another part of the body is an infrequent event. The host neoplasm has been a kidney tumor in 17 of 25 reported cases. The host neoplasm usually produces no metastasis. However, the metastasizing growth is usually widely disseminated and metastasizes to the host malignancy and not to any other part of the organ in which the host malignancy is arising. Several etiological theories are presented to explain the role of the kidney in cancer-to-cancer metastasis. The literature is reviewed and a case is reported.