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Case Report

etastatic Melanoma to the Kidneyresenting with Renal Vein Tumor Thrombus

obias Klatte, Jian Yu Rao, Antoni Ribas, and Allan J. Pantuck

e report on a patient with metastatic melanoma to the kidney who presented with a renal vein thrombus to thenferior vena cava. Three years after his initial lesion of the scalp, a 34-year-old Egyptian man was found to have tworain metastases and an 11-cm left renal metastasis with a tumor thrombus in the renal vein. After resection of therain metastases, with no evidence of additional metastases, the patient underwent left radical nephrectomy and tumorenous thrombectomy. The patient later had tumor recurrence at multiple sites. He did not respond to systemic

reatment and died 5 months later. UROLOGY 69: 982.e7–982.e9, 2007. © 2007 Elsevier Inc.

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he kidney is a rare site of metastatic implantation.Metastases to the kidney most frequently origi-nate from lymphomas and carcinomas of the

ung, breast, and colon.1 Renal metastases of malignantelanoma, when they occur, usually reflect end-stage

isease.2A tumor thrombus in the renal vein is a typical finding

f renal cell carcinoma, although it has been describedarely in other primary renal tumors such as transitionalell carcinoma, Wilms’ tumor, and angiomyolipoma. Tour knowledge, a tumor thrombus in the renal veinriginating from a secondary melanoma has never previ-usly been described. We present the first case thereof.

ASE REPORT34-year-old Egyptian man first presented with malig-

ant melanoma of the scalp. The patient underwentide local excision. The sentinel lymph node dissec-

ion and radiologic metastatic workup findings wereegative at that time. Local adjuvant radiotherapy wasdministered. The patient did well for 3 years, when heas hospitalized complaining of grand mal seizures and

eft flank pain.The patient denied hematuria and melanuria. The

hysical examination revealed a palpable left-sided ab-ominal mass and left flank tenderness. The laboratoryata from the blood sample were within normal limits.rinalysis demonstrated microhematuria and protein-

ria. Urinary cytology was negative for neoplastic cells.he radiologic workup disclosed two brain lesions of 4 cmnd 2 cm in the greatest dimension and an 11-cm leftenal mass that completely filled and occluded the left

rom the Departments of Urology, Pathology and Laboratory Medicine, and Medicine,niversity of California—Los Angeles, David Geffen School of Medicine, Los Angeles,aliforniaAddress for correspondence: Allan J. Pantuck, M.D., Department of Urology, Univer-

ity of California—Los Angeles, David Geffen School of Medicine, 66-124 CHS, Box

fi51738, Los Angeles, CA 90095-1738. E-mail: apantuck@mednet.ucla.edu

Submitted: October 10, 2006; accepted (with revisions): February 16, 2007

2007 Elsevier Inc.ll Rights Reserved

enal vein (Fig. 1). The patient underwent completeurgical resection of the brain lesions, and the histologic

igure 1. Computed tomography scan of abdomen demon-trating large left-sided renal mass with occlusion of entireenal vein by malignant tumor thrombus.

igure 2. Macroscopic appearance of tumor encompass-ng more than 90% of renal parenchyma.

ndings were consistent with malignant melanoma.

0090-4295/07/$32.00 982.e7doi:10.1016/j.urology.2007.02.032

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The patient recovered well after surgery. Magneticesonance imaging of the brain showed complete resec-ion of the lesions. A newly performed metastatic workupevealed findings negative for new lesions, and the onlyemaining site of disease was the left kidney. With hisymptoms persisting and no other demonstrable lesions,he patient underwent left radical nephrectomy through

thoracoabdominal approach. The patient’s postopera-ive course was uncomplicated, and he was dischargedome on postoperative day 5.The final pathologic examination demonstrated a

5-cm tumor occupying more than 90% of the renalarenchyma. The mass was multinodular and heteroge-eously pigmented (Fig. 2). Microscopic examinationhowed solid sheets of tumor cells with moderate amountf cytoplasm, some of which contained brown pigmentsnd prominent nucleoli (Fig. 3A). Immunohistochemicaltaining with positive melanoma antigen recognized by Tells (MART-1) (Fig. 3B) and negative pancytokeratinFig. 3C) confirmed the diagnosis of malignant mela-oma. The renal vein thrombus consisted of malignantelanoma cells. The surgical margins were negative. The

ymph nodes were free of tumors.Three months later, radiologic evaluation showed tu-or recurrence at multiple sites, including the lungs,

pleen, portal vein, and intraabdominal lymph nodes.he patient underwent chemotherapy and high-dose in-

erleukin-2, but did not respond, and died 5 months later

igure 3. Microscopic appearance (original magnification �taining positive for MART-1 and (C) negative for pancytoke

f his disease. t

82.e8

OMMENTidney metastases of malignant melanoma are rare find-

ngs. Abeshouse3 reviewed 142 cases of melanoma in theenitourinary tract, including 56 primary and 86 second-ry melanomas. Eighty percent of melanoma metastaseso the kidney had the primary lesion arising from thekin. Most kidney metastases were less than 1 cm, asymp-omatic, and disclosed at autopsy. The presented case is,herefore, unusual in that the tumor was large (15 cm),ymptomatic, and diagnosed in the evaluation of clinicalymptoms.

Renal vein and inferior vena caval tumor thrombi areell-known entities occurring in the context of renal cellarcinoma.4 However, reports have indicated that otherrimary renal tumors, such as transitional cell carcinomaf the renal pelvis,5 Wilms’ tumor,6 and benign angio-yolipoma,7 are able to form venous tumor thrombi asell. Tumor thrombus of the renal vein has been de-

cribed anecdotally in association with secondary metas-ases to the kidney. For example, Weiner8 reported on aatient with solitary renal metastasis from a small cellung cancer who presented with renal vein thrombus. Ithould be emphasized, however, that a renal venoushrombus in malignancy could result not only from theumor itself, but also from external compression andecondary coagulation disorders.9

A review of published reports was performed, and, tour knowledge, no other cases of metastatic melanoma to

). (A) Hematoxylin-eosin stain. (B) Immunohistochemical.

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he kidney with tumor thrombus of the renal vein throm-

UROLOGY 69 (5), 2007

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us have been described. Together, these findings showhat a tumor thrombus of the renal vein can occur in bothrimary and secondary malignant renal tumors, as well as inssociation with benign tumors. Hence, we speculate thathe renal microenvironment, rather than the tumor itself,ay influence tumor thrombus formation.

ONCLUSIONSrenal vein thrombus can be detected on computed

omography or magnetic resonance imaging with highensitivity and specificity. Although secondary renal tu-ors are rare entities, a careful evaluation of such pa-

ients is warranted with abdominal imaging, includingbdominal computed tomography and, possibly, magneticesonance imaging. A percutaneous renal biopsy mighte warranted to evaluate cases of suspected secondaryetastatic lesions to the kidney. In our case, however,

he results of biopsy would not have affected the decisionor nephrectomy because the patient was symptomatic

nd the kidney was the only site of disease.

ROLOGY 69 (5), 2007

eferences. Choyke PL, White EM, Zeman RK, et al: Renal metastases: clini-

copathologic and radiologic correlation. Radiology 162: 359–363,1987.

. Lenisa L, Tragni G, Belli F, et al: Solitary melanoma metastasis ofthe kidney: a case report. Tumori 82: 614–615, 1996.

. Abeshouse BS: Primary and secondary melanoma of the genitouri-nary tract. South Med J 51: 994–1005, 1958.

. Zisman A, Wieder JA, Pantuck AJ, et al: Renal cell carcinoma withtumor thrombus extension: biology, role of nephrectomy and re-sponse to immunotherapy. J Urol 169: 909–916, 2003.

. Miyazato M, Yonou H, Sugaya K, et al: Transitional cell carcinomaof the renal pelvis forming tumor thrombus in the vena cava. IntJ Urol 8: 575–577, 2001.

. Ribeiro RC, Schettini ST, De Campos Vieira Abib S, et al: Cavec-tomy for the treatment of Wilms tumor with vascular extension.J Urol 176: 279–283, 2006.

. Wilson SS, Clark PE, and Stein JP: Angiomyolipoma with venacaval extension. Urology 60: 695–696, 2002.

. Weiner SN: Intraluminal renal vein thrombus secondary to meta-static disease to the kidney: a case report. J Urol 128: 372–373,1982.

. Keating MA, and Althausen AF: The clinical spectrum of renal vein

thrombosis. J Urol 133: 938–945, 1985.

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