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CASE REPORT
Year : 2017  |  Volume : 44  |  Issue : 1  |  Page : 49-51

Isolated pleural metastasis in a postoperative case of renal cell carcinoma


Department of Radiodiagnosis and Imaging, SKIMS, Srinagar, Jammu and Kashmir, India

Date of Web Publication20-Mar-2017

Correspondence Address:
Saika Amreen
H. No 28, Humza Colony, Sonawar, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.202538

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  Abstract 

Renal cell carcinoma is a common malignancy with nephrectomy as a promising treatment. However, it has predisposition toward distant metastasis. This case highlights the significance of active surveillance in these patients to detect rare sites of metastasis such as isolated pleural metastasis.

Keywords: Nephrectomy, pleural metastasis, renal cell carcinoma, surveillance


How to cite this article:
Amreen S, Bashir S. Isolated pleural metastasis in a postoperative case of renal cell carcinoma. J Sci Soc 2017;44:49-51

How to cite this URL:
Amreen S, Bashir S. Isolated pleural metastasis in a postoperative case of renal cell carcinoma. J Sci Soc [serial online] 2017 [cited 2017 Mar 24];44:49-51. Available from: http://www.jscisociety.com/text.asp?2017/44/1/49/202538


  Introduction Top


Renal cell carcinoma (RCC) represents 2%–3% of all cancers with the highest incidence occurring in the Western countries.[1] While renal cell cancer commonly metastasizes to the lung, pleural metastasis is a rare clinical entity. Pleural lesions develop as a part of systemic metastases of renal cell cancer and are usually accompanied by parenchymal spread.[2] We report a case, in which pleural metastatic disease was the sole intrathoracic abnormality in a patient who underwent nephrectomy for RCC. The metastasis was seen within 6–12 months of initial diagnosis.


  Case Report Top


A 56-year-old female, known case of hypothyroidism for 6 years on 50 µg levothyroxine, presented in October 2013 with chief complaints of abdominal discomfort and burning sensation on micturition for 4 months. The patient had one episode of hematuria about 1 week back. On gray-scale ultrasonography, a 4.1 cm × 2.9 cm lesion with heterogenous echopattern was found in relation to the middle calyx of the right kidney. The patient underwent contrast-enhanced computed tomography (CT) evaluation which revealed a 5.8 cm × 3.7 cm well-defined mass at midpole of the right kidney with mean attenuation value of 32 HU precontrast. The mass showed heterogenous enhancement on contrast administration with mean postcontrast attenuation value of 90–127 HU. A hypodense avascular area with mean attenuation value of 44 HU was seen within the mass likely representing necrotic tissue. Renal veins and inferior vena cava were found to be patient with no evidence of any thrombosis. There was no adrenal invasion. The patient underwent Tc99 diethylenetriaminepentaacetic acid scan which revealed normal cortical functioning in the left kidney. The right kidney showed normal cortical functioning with a nonfunctioning area at midpole (T1b N0 M0).

The patient underwent laparoscopic right radical nephrectomy in November 2013. Histopathological examination revealed a 5 cm × 3.4 cm mass with yellow to grayish solid component with few areas of necrosis. The tumor was limited to the kidney. No renal vein or renal pelvis invasion was found. Capsule easily slipped off. Microscopy revealed clear cell carcinoma limited to the kidney [Figure 1].
Figure 1: Axial contrast-enhanced computed tomography image revealing postright nephrectomy status with normal left kidney

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The patient was on follow-up when in March 2014, when a plain chest radiograph revealed a nodule in the left lung field. Ultrasonography and CT abdomen were unremarkable [Figure 2] and [Figure 3]. All laboratory data were within normal limits. High-resolution CT chest revealed a pleural-based left lung nodule. CT-guided biopsy of the nodule was carried out in the same month and histology showed metastatic clear cell carcinoma.
Figure 2: Mediastinal window axial contrast-enhanced computed tomography image at the level of carina revealing a well-defined, pleural-based soft tissue lesion along the left costal pleura. Biopsy proven metastasis

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Figure 3: Lung window axial image just inferior to the previous image revealing pleural-based lesion. The rest of the lung parenchyma was normal

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  Discussion Top


RCC is a very unpredictable tumor. Once the diagnosis of RCC is proved, a patient can never be considered cured.[3] In their natural clinical course, RCCs remain asymptomatic and nonpalpable until late. The classic triad of flank pain, gross hematuria, and palpable abdominal mass is seldom found (6%–10%). Clinical symptoms include macroscopic hematuria, palpable mass, arising varicocele, or bilateral lower extremity edema; these symptoms should initiate radiological examinations.[1] Spontaneous regression of metastatic RCC is rare but a well-documented event, most often involving pulmonary metastases.[4]

Fuhrman nuclear grade is the most commonly used grading system. The most aggressive pattern observed defines the Fuhrman grade. RCC comprises four different subtypes with genetic and histological differences: clear cell RCC (80%–90%), papillary RCC (10%–15%), chromophobe RCC (4%–5%), and collecting duct carcinoma (1%).[1]

The kidney receives about 25% of the circulating blood volume per minute, and RCC is a very vascular tumor. Cancer cells are also known to have a good adaptive potential in a diverse array of microenvironments. Hence, RCC has a high metastatic potential.[5]

RCC has been shown to metastasize to almost all soft tissues in the body, but most commonly to the lung, followed by bone, liver, brain, and local recurrence.[6] The Early metastatic disease is a result of the unique accessibility of the kidney to lymphohematogenous pathways, the thorax being particularly vulnerable.[7] In 1959–1977, one study reported that 12% of 1451 necropsied cases of renal carcinoma had pleural metastases, but none had solitary pleural metastases.[8] Spreading of sole pleural metastases to the contralateral pleura can be explained by hematogenous spreading through Batson's plexus which consist of a plexus of valveless veins surrounding the spinal cord and vertebral column with connections to azygos vein, hemiazygos vein, bronchial vein, and intercostal veins. To reach the parietal pleura without passing through the lung blood flow is directed extrathoracic which is dependent on intrathoracic and intra-abdominal pressure.[9] Isolated pleural metastasis has even been described 10 years after the original malignancy was treated.[10]


  Conclusion Top


Isolated pleural metastases from RCC are rare, and this case demonstrates the need for vigilant imaging follow-up in patients with RCC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ljungberg B, Cowan N, Hanbury DC, Hora M. Guidelines on renal cell carcinoma. Eur Urol 2007;51:1502-10.  Back to cited text no. 1
    
2.
Bennington JL, Kradjian RM. Distribution of metastases from renal cell carcinoma. Renal Carcinoma. Philadelphia, PA: Saunders; 1967. p. 156-61.  Back to cited text no. 2
    
3.
de Riese W, Goldenberg K, Allhoff E, Stief C, Schlick R, Liedke S, et al. Metastatic renal cell carcinoma (RCC): Spontaneous regression, long-term survival and late recurrence. Int Urol Nephrol 1991;23:13-25.  Back to cited text no. 3
    
4.
Thoroddsen A, Gudbjartsson T, Geirsson G, Agnarsson BA, Magnusson K. Spontaneous regression of pleural metastases after nephrectomy for renal cell carcinoma – A histologically verified case with nine-year follow-up. Scand J Urol Nephrol 2002;36:396-8.  Back to cited text no. 4
    
5.
Moudouni SM, Tligui M, Doublet JD, Haab F, Gattegno B, Thibault P. Late metastasis of renal cell carcinoma to the submaxillary gland 10 years after radical nephrectomy. Int J Urol 2006;13:431-2.  Back to cited text no. 5
    
6.
Lam JS, Leppert JT, Figlin RA, Belldegrun AS. Surveillance following radical or partial nephrectomy for renal cell carcinoma. Curr Urol Rep 2005;6:7-18.  Back to cited text no. 6
    
7.
Latour A, Shulman HS. Thoracic manifestations of renal cell carcinoma. Radiology 1976;121:43-8.  Back to cited text no. 7
    
8.
Saitoh H. Distant metastasis of renal adenocarcinoma. Cancer 1981;48:1487-91.  Back to cited text no. 8
    
9.
Eckardt J, Ladegaard L, Licht PB. Isolated pleural metastases from renal cell carcinoma. Interact Cardiovasc Thorac Surg 2011;12:301-2.  Back to cited text no. 9
    
10.
Yasuda Y, Tobino K, Ko Y, Asaji M, Yamaji Y, Tsuruno K, et al. Localized Pleural Metastases of renal cell carcinoma after nephrectomy: A case report and literature review. J Bronchology Interv Pulmonol 2016;23:59-62.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Abstract
Introduction
Case Report
Discussion
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