CASE 9537 Published on 16.08.2011
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The great mime: late recurrence of renal cell carcinoma 23 years after nephrectomy

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Valentina Iotti 1, Federica Fiocchi 1, Daniele Rinaldi 1, Mariachiara Ferrari 2, Francesco Rivasi 3, Pietro Torricelli 1

1 Dipartimento Integrato dei Servizi Diagnostici e per Immagine
2 Dipartimento di Medicina e Specialità Mediche
3 Dipartimento Integrato di Laboratori, Anatomia Patologica e Medicina Legale

Azienda Ospedaliero-Universitaria Policlinico di Modena -
Università degli Studi di Modena e Reggio Emilia;
del Pozzo 71 41123 Modena, Italy;
Email: federica.fiocchi@gmail.com
Connected authors
Patient

68 years, female

Categories
Area of Interest Abdomen, Colon, Pancreas ; Imaging Technique Ultrasound, CT, RIS, Percutaneous
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Clinical History
A 68-year-old female patient was admitted to the emergency department with fever of unknown origin and sweating for the past 2 months: physical examination and blood work-up revealed inflammatory state, without signs of hematologic disorder. In 1987 she had undergone right nephrectomy for c-RCC, from which she had fully recovered.
Imaging Findings
Ultrasound (US) examination showed two hepatic lesions and a pseudo-kidney mass in epigastric fossa, suspicious for colorectal origin (Fig. 1).
Subsequent Computed Tomography (CT) demonstrated that all lesions were target type, the latter belonging to pancreatic body (Fig. 2). No other lesions were detected, especially in residual kidney.
First diagnostic hypothesis was colorectal metastasis due to CT morphological and contrast enhancement behaviour (Fig. 3).
Colonoscopy was performed but showed no colonic pathologies (Fig. 4).
Neoplastic markers CEA and Ca 19.9 were negative.
US-guided biopsy of all lesions was performed three-time finding only necrotic tissue and chronic active inflammation without evidence of malignant cells.
Considering clinical and histological findings new hypothesis of chronic abscess was proposed, but imaging findings did not support this hypothesis (Fig. 5).
Explorative laparotomy with intra-operatory biopsy lead (Fig. 6) to diagnosis of metastases from RCC in both sites, with round cells and positive to CD10 antigen.
Discussion
The majority (78%) of recurrent c-RCC occurs within the first 5 years post-operatively, but late recurrence, defined as more than 10 years after nephrectomy [1], is not uncommon and occurs in more than 10% of patients [2]. There is a predominance of women among patients with late recurrence and it occurs also in individuals with well-differentiated tumours [3].
The majority of patients with metastatic renal cell carcinoma have multiple liver metastases and associated involvement of other organs in accordance with the pattern of hematogenous dissemination [4].
RCC tends to metastasise to the lungs in 70-76% of patients, lymph nodes in 50%, skeleton in 40% and to the liver in 20% [2, 4]. Pancreas is an uncommon site for metastasis from renal cell carcinoma and is asymptomatic in about 50% of cases [1, 8].
Patients with this cancer can present with local or systemic symptoms, although most presentations are incidental with the widespread use of abdominal imaging.
Local signs and symptoms include haematuria, flank pain, or a palpable abdominal mass, all of which have negative prognostic implications. Systemic symptoms can be due to metastases or paraneoplastic events largely related to secreted proteins, such as parathyroid-hormone-related protein (causing hyper calcaemia), rennin (causing hypertension), erthyropoietin (causing erythrocytosis), and fever or wasting syndromes. The diversity of paraneoplastic syndromes associated with this cancer is remarkable [9].
Early recurrences may present with rapid progression of disease; on the other hand, tumour-free intervals of more than 20 years have been observed with a slow growth pattern, especially for pancreatic metastasis [10].
Our case report supports this concept, as late recurrence of C-RCC shows slow growth pattern and systemic non specific symptoms.
In conclusion special attention should be paid to potential late recurrence of RCC after apparent curative treatment since it is not a rare event and lifelong follow-up is necessary, considering that RCC is known to be ‘a great mime’.
Imaging techniques such as US and CT are useful non-invasive modalities and should be employed during follow-up to detect asymptomatic metastases at an early stage.
Differential Diagnosis List
Intra-operatory biopsy lead to final diagnosis of c-RCC localisation.
Metastases of colorectal cancer
Chronic abscess
Metastases of clear-cell renal carcinoma
Final Diagnosis
Intra-operatory biopsy lead to final diagnosis of c-RCC localisation.
Case information
URL: https://www.eurorad.org/case/9537
DOI: 10.1594/EURORAD/CASE.9537
ISSN: 1563-4086
Figure 1

Ultrasound

Ultrasound
Abdominal US showed two hepatic lesions (a, b) and a pseudo-kidney mass in epigastric fossa (c).
Figure 2

CT

CT
Abdominal CT showed hepatic target lesion in arterial phase (a, b) and in portal phase (d, e) and demonstrated that the third lesion (c: arterial phase; f: portal phase) belonged to the pancreatic body.
Figure 3

CT

CT
Comparison on abdominal CT imaging between the hepatic target lesion in arterial (a) and portal phase (c) and a case of proven colo-rectal metastases in arterial (b) and portal phase (d).
Figure 4

RIS

RIS
Negative colonoscopy.
Figure 5

CT

CT
Comparison on abdominal CT imaging between the hepatic target lesion in arterial (a) and portal phase (c) and a case of proven hepatic abscess in arterial (b) and portal phase (d).
Figure 6

Biopsy

Biopsy
Histopathological and immunohistochemical examination on intra-operatory biopsy of pancreatic mass demonstrated a metastatic clear cell carcinoma with round cells with high grade nuclear atypia (a, b: haematoxylin–eosin); (c: immunoperoxidase reaction with anti-CD10 ab).