SOLITARY LATE RECURRENCE OFRENAL 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 theJames Buchanan Brady Urological Institute, The Johns Hopkins

Medical Institutions . Baltimore, Maryland

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

Approximately 25,000 new cases of renal cellcarcinoma will he diagnosed in the United Statesthis year.' Metastatic disease will be present in 25percent of patients at the time of diagnosis . 2 An-other 20-50 percent of patients who were thoughtto have localized disease will subsequently showmetastases,' usually within a few years . Only a mi-nority of patients will experience a late recurrence .Even more unusual is the solitary late occurrenceof tumor in the nephrectomy scar. We report a caseof this unusual presentation and discuss its signif-icance .

CASE REPORTA twenty-two-year-old woman in her seventh

month of pregnancy presented with intermittentgross hematuria . Initially, she was treated with an-tibiotics, which resulted in temporary resolution ofher symptoms. When hematuria recurred, an ul-trasound examination demonstrated a left renalmass. A limited computed tomographic (CT) ex-arnination confirmed a solid renal mass . Needle as-pirate of the kidney revealed papillary fronds withmarkedly enlarged nuclei and prominent nucleoli,consistent with a renal cell carcinoma (Fig . 1) .Metastanc evaluation was negative . Left radical

Submitted : October 14. 1993 . accepted (with revisions) : l7eeern-brr 10 . 199.3

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CASE REPORT

nephrectomy was performed through a teuth-iuter-space flank incision . There was no gross tumorspillage at surgery (i .e ., the capsule was not en-tered and the specimen margins were free oftumor) . The specimen included a large necrotic,soft golden yellow tumor mass replacing approxi-mately 90 percent of the kidney. The tumor wasconfined to the renal capsule and did not involvethe adrenal gland, ureter, or the renal vein . 1listo-logically, the tumor showed tubular and papillaryfeatures with clear and granular cytoplasm (Fig .2) . The nuclei were enlarged with prominentnucleoli (nuclear grade 3) . The cytology of the

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

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FIGURE 2. Radical nephrectomy specimen showsrenal cell carcinoma (original magnification x 250) .

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FIGURE 3. Patient with flank tumor

resected specimen was identical to that of the priorneedle aspirate . Seven hilar lymph nodes were freeof tumor. Postoperatively, the patient went intolabor prematurely, necessitating cesarean sectionfive days later. The patient recuperated unevent-fully and the child recovered after a prolonged stayin the intensive care unit . Subsequently, the pa-tient was evaluated annually for seven years withno evidence of recurrent disease. A second preg-nancy six years later was uneventful .Pour years after that she presented with a large

left subcutaneous flank mass, left flank pain, andnausea . The patient had noted the lesion threemonths previously but deferred examination untilthe size and discomfort worsened. Physical exam-ination revealed a large mass beneath her flank scararising from and fixed to the abdominal and chestwalls (Fig . 3). Laboratory findings included a whiteblood cell count of 8,300/cc', hematocrit 33 per-cent, urea nitrogen 10 mg/dL, creatinine 1 .1mg/dL, and alkaline phosphatase 62 IU/L . A CT

FIGURE 4, Axial CT scan demonstrates possible rib in-volvement by the flank mass . Extension into the peri-toneal cavity could not be excluded .

scan of the abdomen demonstrated a 12 by 12 cmwell-circumscribed heterogeneous mass arisingfrom the left posterolateral abdominal wall . Al-though the mass appeared predominantly extra-cavitary, several axial images suggested that rib en-casement and intraperitoneal spread could not beexcluded (Fig . 4) . Magnetic resonance imaging(MRI) was subsequently performed, clearly defin-ing the mass as entirely extracavitary (Fig . 5A, B) .Percutaneous needle biopsy provided only necrotictissue. Metastatic evaluation including chest CTwas negative .

A wide surgical excision of the involved area, in-cluding the adjacent eleventh rib, was performed .The lesion did not penetrate the peritoneum . Theabdominal wall defect was closed with Marlexmesh. Convalescence was uneventful . Histopatho-logic evaluation of the soft tissue mass revealedpapillary tumor with identical nuclear and cyto-plasmic features to the patient's prior renal cell car-cinoma (Fig. 6) . She has been evaluated for sixmonths and has been without evidence of recur-rent disease .

COMMENTLate solitary recurrence of renal cell carcinoma

more than ten years following nephrectomy is un-usual. Bloom and associates' reviewed the litera-ture and found 11 such cases . The lesions de-scribed were either locally recurrent to the renalfossa and wound or were metastatic to the tra-cheobronchial tree, thyroid, lung, bone, intestine,and muscle . While in some cases follow-up datawere not reported, in cases that provided this in-formation, which varied from eight months toeight years, there was no evidence of subsequentmetastatic disease following surgical extirpation .They concluded that resection of these lesions is

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FIGURE 5 . (A) Corona) T i -weighted MRI. Large leftflank mass appears to displace intact peritoneum medi-ally . (B) Axial T1weighted MRI shows increased signalintensity of abdominal wall mass . The region of in-creased signal intensity is clearly limited by the ab-dominal wall and does not extend into the peritonealcavity.

warranted and that survival is related to the site ofrecurrence . McNichols and associates' reviewed729 patients with renal cell carcinoma treated atthe Mayo Clinic over a fifteen-year period . Of 481patients who underwent nephrectomy, 158 werealive at ten years and a late recurrence occurred in18 patients (11%)- Of these 18 patients, 3 under-went resection of a solitary pulmonary recurrenceand 2 were alive six and nine years postoperatively.Those patients who did not undergo surgical re-section were dead within two years .The success of surgical management of solitary

renal cell metastases has been questioned . Dineenand associates° retrospectively evaluated 29 patients

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

who underwent excision of a solitary inctastatic le-sion of renal cell carcinoma . In iihese 29 cases,eleven metastases were recognized prior tonephrectomy and 18 patients were diagnosed withdistant metastatic disease two months to elevenyears following nephrectomy . The estimated overallsurvival rate for the group was 41 percent at twoyears and 13 percent at five years following resec-tion of the metastatic lesion . Moreover. neither thepresence or absence of metastasis at diagnosis northe interval between nephrectomy and diagnosis ofthe metastatic lesion appeared to influence survival .They concluded that surgical treatment of solitarymetastases is of only limited value .Cutaneous involvement by renal carcinoma is

rare. Rosenthal and Lever' determined the inci-dence of these cutaneous lesions to he 2 .8 percent,of which 20 percent were diagnosed at presenta-tion. The majority of these lesions were multiple .Of 16 patients with metastatic involvement of thenephrectomy scar, only 1 was found to have a soli-tary recurrence . None of the patients reported onexperienced a recurrence tell or more years afterinitial surgery.

Solitary recurrent renal carcinoma to the surgicalincision is very rare . Unlike solitary metastases tothe renal bed or distant sites, tumor recurrence inthe nephrectomy scar responds favorably to surgi-cal excision . Frontz' reported papillary cystade-noma recurrent to the wound four years aftersurgery. No follow-up was mentioned ; however,the lesion was completely excised . In the series re-ported by McNichols and associates,' I patient ex-perienced a recurrence in the abdominal woundone year following nephrectomy and was alivenineteen years following resection Only 1 case of

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a late solitary recurrence to the nephrectomy scarhas been previously described . Kradjian and Ben-nington 9 reported a solitary recurrence of renal car-cinoma in the nephrectomy scar discovered thirty-one years after surgery. The contralateral kidneywas not evaluated . Following excision of the le-sion, the patient was well eight months later .

In the present case, a solitary recurrence in thenephrectomy scar was identified ten years aftersurgery Metastatic evaluation was performed uti-lizing abdominal CT and MRI scans . These studiesdemonstrated that the lesion extended into but notthrough the abdominal wall, with minimal in-volvement of the chest wall. Without involvementof the contralateral kidney or other metastatic sites,complete surgical excision of the lesion could beperformed .The cause of this lesion is unknown . Possibly

the lesion is a result of unrecognized tumorspillage at the initial operation ; however, the le-sion was confined within the renal capsule . Krad-jian and Bennington9 suggested that tumor spillagemay be more common than believed ; however, thesurgical scar provides an unfavorable environmentfor tumor growth . As an alternative, this recur-rence could be explained by needle tract seedingfrom the percutaneous biopsy This finding is avery rare occurrence, however. Von Schreeb andassociates 10 failed to identify needle tract seeding ina series of 150 patients with renal carcinoma, halfof whom underwent diagnostic renal puncture .Gibbons and associates" reported the first docu-mented case of needle tract seeding more thanthirty-five years after the aspiration of renal cystsbecame common practice .

One can never assume that a patient with renalcarcinoma is free of disease . Late recurrence ofrenal carcinoma is an unusual manifestation of thistumor but can occur in as many as 11 percent ofpatients surviving at least ten years . Solitary le-

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sions in the surgical scar are rare and respond fa-vorably to aggressive surgical treatment. The use ofadvanced imaging techniques such as CT and MRIcan greatly assist in delineating the extent of the le-sion and planning future surgical treatment .

Jay R. Newmark, M .D .Methodist Hospital Institute

for Kidney Stone Disease1801 N. Senate Blvd., Suite 655

Indianapolis, Indiana 46202

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1993. CA Cancer I Clin 43:7-26,1993 .2. Giuliani L, Giberti C, Martorana G, and Rovida S : Radi-

cal extensive surgery for renal cell carcinoma : long-term re-sults and prognostic factors . J Urol 143 : 468-474, 1990 .

3. de Kernion JB: Renal tumors, in Walsh PC, Gities REPerlmutter 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 recurrenceof renal tubular carcinoma . J Urol 126 : 546-548,1981 .

5. McNichols DW, Segura JW and DeWeerd JH : Renal cellcarcinoma : long-term survival and late recurrence . J Urot126:17-23,1981 .

6. Dineen MK, Pastore RD, Emrich LJ, and Huben RP:Results of surgical treatment of renal cell carcinoma with soli-tary metastasis . J Urol 140 : 277-279, 1988 .

7. Rosenthal AL, and Lever WF : Involvement of the skinin renal carcinoma: report of two cases with review of the lit-erature . Arch Dermatol 76 : 96-102, 1957 .

8. Frontz WA: Unusual case of tumor implantation fol-lowing nephrectomy for papillary cystadenoma . J Urol 17 :121-125,1927 .

9. Kradjian RM, and Bennington JL : Renal carcinoma re-current 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 tumourcells in diagnostic puncture? Scand J Urol Nephrol 1 : 270-276,1967 .

11 . Gibbons RP, Bush WH Jr, and Burnett LL : Needle tractseeding following aspiration of renal cell carcinoma . J Urol118:865-867,1977 .

UROLOGY / Mm 1994 / VOLUME 43, NUMBER 5