Solitary vertebral metastasis of unknown primary renal cell carcinoma treated with surgical resection plus tyrosine kinase inhibitor: A case report.

INTRODUCTION: Although 25-30 % of renal cell carcinomas (RCC) might be diagnosed in metastatic stage, occurrence of metastatic renal cell carcinoma (mRCC) as a cancer of unknown primary site (CUP-mRCC) is extremely rare. Here, we present a case of vertebral mass causing radicular pain that has been diagnosed to be mRCC through core needle biopsy while no renal mass has been found during serial imaging. CASE PRESENTATION: A 60-year-old woman presented with severe lumbar pain radiating to left leg. Lumbar X-ray suggested a mass in second lumbar vertebra which was confirmed by MRI. Biopsy showed that the mass was clear cell RCC. Abdominopelvic CT scan and other metastatic work-up found no primary source for the cancer -in kidneys- nor any other metastasis. Tumor resection was performed followed by sunitinib administration. 3 months after the surgery, she is symptom free with no signs of disease progression nor kidney tumor. DISCUSSION: 26 cases of CUP-mRCC has been reported in literature. Lymph nodes are the most commonly involved organ in CUP-mRCC. Exclusive bone involvement -similar to our case- have been reported in only 3 cases. No specific treatment guideline exists but surgery, systemic therapy, combination therapy, and radiotherapy have been used, with the first two items being the most commonly used ones. CONCLUSION: Tumor resection plus sunitinib seems to be a reasonable option in solitary CUP-mRCC involving vertebral column. Our patient is symptom free and there are no signs of disease progression nor kidney cancer in follow-up imaging after 3 months of surgery.

Asymptomatic ureteral metastasis of chromophobe renal cell carcinoma after radical nephrectomy: A case report and review of literature.

INTRODUCTION: Standard treatment for renal cell carcinomas (RCCs) is radical/partial nephrectomy and unlike upper urothelial carcinoma, complete ureteral removal is not necessary nor is advised in RCCs as tumor recurrence in ureteral remnant has scarcely been reported. Here, we present a rare case of chromophobe RCC (ChRCC) metastasis in remnant ureter following radical nephrectomy and perform a literature review in this regard. CASE PRESENTATION: A 66-year-old man presented with a CT scan-as a surveillance protocol imaging- showing a mass in ipsilateral remnant ureter 9 months after radical nephrectomy due to ChRCC while being completely asymptomatic. Cystoscopy revealed a polypoid mass protruding from right ureterovesical junction and transurethral resection of tumor revealed it to be a ChRCC. Distal ureterectomy was performed confirming pathology without any lymph node involvement. 12 months after ureterectomy, he remained asymptomatic with no sign of metastasis or recurrence in his follow up CT scan. DISCUSSION: RCC metastasis to distal ureter after radical nephrectomy has been rarely reported and only 2 cases of them were ChRCC. Gross hematuria has been the main presentation of such disease. However, our case was completely asymptomatic, highlighting necessity of surveillance imaging. No specific treatment guideline exists for such presentation but tumor resection has been the most common treatment modality. CONCLUSION: Metachronous RCC metastasis may occur in remnant ureter which can be completely asymptomatic, highlighting necessity of surveillance imaging and reviewing them meticulously. Surgical resection of the metastasis by distal ureterectomy seems to be the best treatment option.

Migration of nephrostomy tube into right atrium during percutaneous nephrolithotomy: A case report.

INTRODUCTION AND IMPORTANCE: Percutaneous nephrolithotomy (PCNL) is one of the most commonly performed surgeries in urology. Due to blind nature of the procedure unexpected events are inevitable. Misplacement of percutaneous nephrostomy (PCN) during PCNL into the venous system is one of the rarest complications causing great stress to both physician and the patient. Due to scarcity of data, no standard treatment has been proposed. Here, we present a case with misplaced PCN into venous system moving up to the right atrium and discuss its management with a review of the literature. CASE PRESENTATION: After stone removal of a 65-year old man by PCNL, PCN was passed through access sheath supposedly into renal pelvis but it actually misplaced into venous system and traversed into right atrium. The complication was diagnosed by immediate CT scan and managed by PCN pulling back without the need to perform open surgery. CLINICAL DISCUSSION: Blind nature of PCNL makes it susceptible to inadvertent complications. Misplaced PCN into venous system is very rare, happening in about 13 patients worldwide. While some ended up open surgery, all of them were managed by pulling the PCN backwards. Our case is the first case in whom PCN traversed through IVC and reached right atrium during PCNL. Pulling back the PCN was a successful treatment in our case either. CONCLUSION: While horrifying, misplaced PCN into venous system can be managed conservatively by pulling it backwards, even if it reaches the right atrium as happened in our case.

Malignant rhabdoid tumor of kidney in an adult patient with positive family history of rhabdoid tumor: A case report and review of literature.

INTRODUCTION AND IMPORTANCE: Malignant rhabdoid tumor of kidney (MRTK) is almost exclusive to children. Only 10 cases of adult MRTK have been reported. Here, we present a case of MRTK in an adult patient and discuss its clinical findings, diagnostic challenges, and treatment outcome. We also perform literature review on this issue. CASE PRESENTATION: Our patient was a 29-year-old woman presented with fever and hematuria. She also mentioned atypical teratoid/rhabdoid tumor of cerebellum in her deceased child. Initial diagnostic work up led to left partial nephrectomy with the pathology report of high grade undifferentiated tumor. Early tumor recurrence necessitated left radical nephrectomy with extensive excision of adjacent tissues. Pathology for second specimen considering disease course and family history was MRTK. Even though chemotherapy was administered, she died few months later due to multiple metastases. CLINICAL DISCUSSION: Although diagnosis is challenging in all 11 reported cases -including our case- of adult MRTK, immunohistochemistry (i.e., negative reaction for INI-1) in conjunction with clinical and radiological findings are the main tool to reach diagnosis. Treatment options are much more diverse, ranging from surgery to immunotherapy, tyrosine kinase inhibitors, chemotherapy, and combination of these modalities. Prognosis remains dismal with the mean survival period of 7 months. CONCLUSION: Although extremely rare, MRTK might happen in adults. We report the first case of adult MRTK with positive family history of rhabdoid tumor of CNS, underscoring the importance of family history in reaching the diagnosis and highlighting the role of genetics in this rare disease.

Cushing's syndrome as a paraneoplastic feature of renal cell carcinoma: A case report.

Cushing's syndrome has been believed to be a paraneoplastic syndrome of renal cell carcinomas. However, there appears to be a dearth of compelling evidence to substantiate this notion. The only eligible documentation of Cushing's syndrome due to ectopic adrenocorticotropic hormone secretion by renal cancer in English literature dates back to 1988, and it pertains to a deceased patient discovered during an autopsy. Here, we present the first case of Cushing's syndrome as a paraneoplastic feature of renal cancer which showed complete resolution following surgical removal of the tumor. Additionally, we conduct review of the literature on this particular subject.

Pharmaceutical industry funding and chemotherapy trials for prostate cancer: A systematic review.

INTRODUCTION: Clinical trials are increasingly supported by industries while previous studies have shown that industry-supported studies have more favorable results than studies with other sources of funding. In the present study, we investigated the association of industrial funding on the results of clinical trials regarding chemotherapy in prostate cancer. METHODS: A systematic literature search was performed in the Cochrane Library, MEDLINE, and EMBASE to identify clinical trials comparing chemotherapy with treatments such as hormone therapy, surgery, radiotherapy, and placebo in patients with metastatic or non-metastatic prostate cancer. Data were extracted by two reviewers on the financial resources and the positive or negative results of chemotherapy in each study. The quality of articles was evaluated and compared based on Cochrane Critical Appraisal Tool. The trials were divided into two groups; industry funded and those not funded by industry. Association of industry funding and positive outcome was presented as odds ratio. RESULTS: In this study, out of the 91 studies, 80.2% were funded by pharmaceutical companies and 19.8% were funded by government agencies. The end result of 61.6% of the studies funded by pharmaceutical companies was an increase in survival due to chemotherapy, whereas only 27.8% of the studies sponsored by government agencies reported positive results (P-value=0.010). In fact, industry-funded trials more often presented statistically significant positive results for survival (OR: 4.17; CI, 1.34-12.99). In general, there was no significant difference in the degree of bias between the two groups. CONCLUSION: According to this study, despite of the similar quality of studies funded by pharmaceutical companies and government agencies, positive results were more common in studies related to pharmaceutical companies. Therefore, this point should be taken into account when making a decision on the best treatment approach.

Incarceration of small bowel following percutaneous nephrostomy tube insertion.

Percutaneous nephrostomy has become a well-established technique for providing permanent or temporary drainage of an obstructed urinary system for decades. Although it is generally considered a safe intervention, some complications might be life threatening. Here we present a case of bilateral nephrostomy insertion due to T-cell lymphoma, that presented with signs of bowel obstruction 3 weeks after intervention. Abdominal exploration showed bowel obstruction due to invagination of bowel loop between left nephrostomy tube and abdominal wall which resolved by release of bowel loop and changing nephrostomy route to pass through retroperitoneum only.

Evaluating the efficacy of bimanual compression of abdomen-flank to control postoperative bleeding after percutaneous nephrolithotomy: A randomized clinical trial.

PURPOSE: To investigate the influence of bimanual compression of abdomen-flank to control bleeding after completion of percutaneous nephrolithotomy (PCNL) including tubeless PCNL. MATERIALS AND METHODS: This study is a parallel-group randomized clinical trial with 1:1:1 randomization. Ninety patients who were candidates for PCNL during July to October 2019 were enrolled. After completion of PCNL operation, patients were randomized into three groups to receive bimanual abdomen-flank compression for 0, 3, and 7 min by the operating surgeon with the opening of sealed envelopes (groups 0, 3, and 7 min afterwards). Preoperative, 24, and 48 h postoperative hemoglobin (Hb) and electrolytes were collected. The primary endpoint of interest was the comparison of 48-h blood loss across study groups. Secondary endpoints included the percent drop in 24- and 48-h Hb, transfusion rates, and operation complications. This trial is registered at www.irct.ir with the following number: IRCT20190618043925N1 on 18 July 2019. RESULTS: There was no statistically significant difference in study groups regarding stone mass, stone location, access location, and patients' age (all p > 0.05). The medians (IQR) of 48-h blood loss were 490 mL (105-916), 338 mL (160-933), and 413 mL (71-650) in groups of 0, 3, and 7 min. The percent drop in 24-h postoperative Hb relative to preoperative Hb were 11.5 ± 8.6% versus 9.2 ± 7.3% versus 9.3 ± 6.8% (p = 0.44) and relative values for the percent drop in 48-h Hb relative to preoperative Hb were 8.6 ± 8.7% versus 9.5 ± 9.9% versus 7.2 ± 9.6% (p = 0.63) in groups of 0, 3, and 7 min respectively. Transfusion was needed in four patients in group 0 min, five patients in group 3 min, and three patients in group 7 min. CONCLUSIONS: The results of this study reveal that postoperative bimanual compression of abdomen-flank has no statistically significant influence on the control of bleeding after PCNL operations.

Introducing the POPVESL Score for Intrarenal Vascular Complications of Percutaneous Nephrolithotomy: Experience from a Single high-volume Referral Center.

PURPOSE: Percutaneous-nephrolithotomy (PCNL), is the current modality of choice for large renal stones. Delayed post-op bleeding may herald pseudo aneurysm (PA) or arteriovenous fistula (AVF) necessitating costly and inconsistently available angioembolization, or prolonged hospitalization. The goal of this study is to identify criteria that may predict response to conservative therapy, for delayed bleeding from post PCNL intrarenal vascular lesions. MATERIALS AND METHODS: We reviewed all data on patients re-admitted for post PCNL gross hematuria at our high volume center between 2011 and 2016. Perioperative findings, factors related to the stone and management details, were subjected to multifactorial analysis. Logistic regression for multivariable analysis and ROC curves to find thresholds predicting mandatory angioembolization. RESULTS: Of 4403 PCNLs, 83 (1.9%) with delayed bleeding were diagnosed with intrarenal vascular lesions: Arteriovenous fistulas in 54 (AVF, 65%) and pseudoaneurysm in 29 (PA, 35%). Overall 49 (59%) responded to conservative management but 34 (41%) eventually required angioembolization. On multivariable analysis, predictive factors for poor response to conservative treatment were requiring transfusion beyond initial stabilization, pseudoaneurysm, history of open renal surgery, longer interval-to-second-admission, and size of vascular lesion. The proposed POPVESL score (short for Post PNL Vascular Embolization selection) when below 11, correctly predicts success of conservative management with 81.6% sensitivity and 100% specificity. CONCLUSIONS: Our findings including the proposed POPVESL score have the potential for clinical application and enhancing practical guidelines on the management of post-PCNL bleeding.