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By: Paul Bowlin, MD; E. David Crawford, MD
A 72-year-old male presents with fatigue and shortness of breath. On initial laboratory evaluation, he is found to have a hematocrit level of 55%. His past medical history is significant for hypertension, hyperlipidemia, coronary artery disease, and gastroesophageal reflux disease. Surgical history is only notable for cardiac stenting and tonsillectomy. He underwent contrast-enhanced CT, which revealed a large right renal mass with tumor thrombus extension into the renal vein (Slide 2) and a mass within the liver that was suspicious for a metastatic focus (Slide 3).
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Initial Management
The patient initially underwent embolization of the right kidney with Interventional Radiology.
Interventional Radiology Imaging
This was performed using a combination of alcohol (main renal artery) and coils (upper pole artery). Main renal artery (Slide 4), upper pole artery (Slide 5), and coils placed in upper pole renal artery (Slide 6).
Subsequent Management
Surgery was performed 6 weeks post-embolization, to allow time for the mass to regress and edema secondary to the infarction to subside. The patient was placed in a modified right flank position and a thoracoabdominal incision was made over the 9th rib. The 9th rib was resected and the right chest entered along with the peritoneal cavity. The entire kidney was mobilized, and the vena cava superior and inferior to the renal vein was isolated. The renal vasculature was identified and ligated. There was no palpable or visible evidence of renal vein tumor thrombus. The liver lesion was palpated and biopsied. Frozen section analysis was highly suspicious for malignancy and thus the liver lesion was resected (Slide 1). The chest and abdomen were individually closed, leaving a chest tube and abdominal drain in place.
Pathology
Kidney: renal cell carcinoma, clear cell type, Fuhrman nuclear grade 2/4, clear margins
Liver: metastatic renal cell carcinoma, clear margins
Discussion
Renal cell carcinoma accounts for around 3.5% of all adult malignancies and is the third most common cancer of the urinary tract.1 An estimated 58,240 new cases are diagnosed every year, and 8,210 cancer-related deaths result.2 Paraneoplastic syndromes often accompany presentation in as many as 20% of patients. These syndromes most commonly lead to elevated erythrocyte sedimentation rate, hypertension, anemia, weight loss, pyrexia, abnormal liver function tests, hypercalcemia, polycythemia, neuromyopathy, and amyloidosis.3
Embolization is a well recognized adjunctive management strategy often used in the setting of: prenephrectomy, preradiofrequency ablation, management of angiomyelopoma, palliation for unresectable renal tumors, and stabilization of life threatening renal tumor hemorrhage.4 Angioinfarction can improve cardiac symptomology such as CHF. Nearly 20% of the cardiac output is directed to the kidneys, and with large cancers, there is extensive AV shunting which can precipitate failure. The angioinfraction can improve this and improve the presurgical status. It is important to wait at least 4 to 6 weeks to achieve an effect. The procedure is relatively safe, and complications include coil migration, incomplete embolization, and groin hematoma occurring in less that 2% of patients.5 Postinfarction syndrome is a recognized and common event following embolization, with up to 90% of patients experiencing some form of the syndrome. Symptoms include nausea, vomiting, flank pain, fever, and leukocytosis. The process is generally self-limiting, but often requires symptomatic treatment in the form of antipyritics, antiemetics, and analgesics.6
References
1. Chen DY, Uzzo RG. Optimal management of localized renal cell carcinoma: surgery, ablation, or active surveillance. J Natl Compr Canc Netw. 2009;7(6):635-642; quiz 643.
2. Jemal A, Siegel R, Xu J, Ward E. Cancer statistics, 2010. CA Cancer J Clin. 2010;60(5):277-300. Epub 2010 Jul 7. Erratum in: CA Cancer J Clin. 2011;61(2):133-4.
3. Gold PJ, Fefer A, Thompson JA. Paraneoplastic manifestations of renal cell carcinoma. Semin Urol Oncol. 1996;14(4):216-222.
4. Ginat DT, Saad WE, Turba UC. Transcatheter renal artery embolization for management of renal and adrenal tumors. Tech Vasc Interv Radiol. 2010;13(2):75-88.
5. Schwartz MJ, Smith EB, Trost DW, Vaughan ED Jr. Renal artery embolization: clinical indications and experience from over 100 cases. BJU Int. 2007;99(4):881-886.
6. Cox GG, Lee KR, Price HI, et al. Colonic infarction following ethanol embolization of renal-cell carcinoma. Radiology. 1982;145(2):343-345.
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