|Year : 2006 | Volume
| Issue : 2 | Page : 154-155
Locally recurrent renal cell carcinoma: 25 years later
Nilesh Patil, Prakash Shetty, Maulesh Dholakia, V Srinivas
Department of Urology, P. D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai - 400016, India
Department of Urology, P. D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai - 400016, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Local recurrence after radical nephrectomy for renal cell carcinoma (RCC) occurs in about 2% cases within the first 5 years. However, isolated local recurrence in RCC after 10 years is very rare. We report a case of local recurrence, twenty-five years after radical nephrectomy.
Keywords: Late recurrence, renal cell carcinoma
|How to cite this article:|
Patil N, Shetty P, Dholakia M, Srinivas V. Locally recurrent renal cell carcinoma: 25 years later. Indian J Urol 2006;22:154-5
| Case Report|| |
A 75 year old female had a left radical nephrectomy in 1977 for a renal cell carcinoma (RCC). Clinical staging was Robsons I. Thereafter, periodic follow up was performed for five years.
In January 2003, she developed vague abdominal pain, for which she was investigated and found to have a left renal fossa mass. CT identified a vascular soft tissue mass measuring 9 x 8 cms in the renal bed, obliterating the fat planes between tumor and psoas muscle [Figure - 1]. There was no evidence of distant metastatic disease on chest X-ray and bone scan.
Since the previous surgery was through a midline incision, it as necessary to approach such a vascular mass through a virgin area. Hence, she underwent exploration through a wide oblique abdominal incision. At exploration, there was a very vascular, friable mass adherent to the psoas. The bowel had to be protected, as it was in very close proximity to them. The vascular mass was dissected, just as one would dissect a pheochromocytoma. En mass resection was carried out and intraoperative frozen section analysis was done to determine complete excision in the renal bed. Final histological examination revealed a clear cell RCC of nuclear grade 2 (Fuhrmann's grading). Prominent blood vessels were visualized [Figure - 2]. Margins were free of malignancy.
| Comment|| |
78% of recurrent RCC present within the first 5 years and a majority of these are at a distant site. Late recurrence (>10 yrs) is rare and in a series of 506 patients, was found to be less than 11%. Late recurrences are usually multiple, but if solitary, can be in the renal bed, lung or bone. Other rare sites such as brain, duodenum, colon and eye have also been involved. Solitary recurrence in the renal bed, 25 yrs post - nephrectomy, is extremely rare.
Renal fossa recurrence occurs because of tumor cell spillage during surgery or disease arising from lymph nodes or cells that have remained dormant, until host immunity allows proliferation. Local recurrence often does not produce symptoms, until it has invaded adjacent structures. However, some may present with symptoms of fatigue, weight loss or abdominal pain. CT is the most accurate diagnostic modality to detect local recurrence. The prognosis is better for patients with isolated, renal fossa recurrence, in whom the interval between nephrectomy and development of recurrence is longer. Surgical excision appears to be the ideal therapy in such cases of recurrences, since these tumors are not radiosensitive. Itano et al reported a 28% 5 yrs survival in their series of 30 patients treated surgically. The benefit from use of immunotherapy in recurrent disease, is as yet unclear.
A case of recurrent RCC after 45 yrs who presented with symptoms of fatigue, anorexia and weight loss has been documented. Investigations revealed local spread and metastatic disease to liver and lungs. Our patient had no metastatic disease. Since it was a localized lesion, she subsequently underwent total excision of the mass and is alive and well with no evidence of disease two years since surgery.
RCC remains an unpredictable tumor. Our case demonstrates the fact that recurrence in RCC can occur even twenty-five years after nephrectomy. Aggressive surgical approach is advocated in cases of late local recurrence and can lead to prolonged disease free survival. It also demonstrates the importance of long term follow up in cases of RCC.
| References|| |
|1.||Itano NB, Blute ML, Spotts B. Zincke H. Outcome of isolated renal cell carcinoma fossa recurrence after nephrectomy. Urology 2001;164:322-5. |
|2.||Mc Nichols DW, Segura JW, De Weerd JH. Renal cell carcinoma: Long term survival and late recurrence. J Urol 1981;126:17-23. |
|3.||Tapper H, Klein H, Rubenstein W, Intriere L, Choi Y, Kazam E. Recurrent renal cell carcinoma after 45 years. Clin Imaging 1997;21:273-5. [PUBMED] [FULLTEXT]|
|4.||Sandhu SS, Symes A, A' Hern R, Sohaib SA, Eisen T, Gore M, et al . Surgical excision of isolated renal bed recurrence after radical nephrectomy for renal cell carcinoma. BJU Int 2005;95:522-5. |
[Figure - 1], [Figure - 2]