Lesión granulomatosa en encía insertada-metástasis de carcinoma renal de células claras. Presentación de caso / Granulomatous Lesion in Inserted Gum-Metastasis of Renal Clear Cell Carcinoma. Case Presentation

Resumen: A nivel mundial el carcinoma renal constituye el 3% de todas las formas de cáncer en el cuerpo humano. Su comportamiento biológico es variable dependiendo de la biología de cada individuo; tiende a realizar metástasis a sitios contiguos como glándulas suprarrenales, hígado, pulmón, hueso, ganglios linfáticos sin embargo la presentación a distancia en cavidad bucal es poco frecuente más aún en encía insertada. Las lesiones granulomatosas del periodonto incluyen granulomas piógenos, granulomas de células gigantes entre otros. El objetivo principal de este caso clínico es describir las características clínicas e histopatológicas de las metástasis a cavidad bucal como lesiones granulomatosas. Se presenta el caso de una paciente femenina de 60 años de edad con antecedente de carcinoma renal de células papilares en riñón derecho tratado mediante nefrectomía en el año 2017, en el año 2019 presenta metástasis a pulmón izquierdo y a cavidad bucal. En la actualidad se encuentra bajo protocolo de tratamiento para metástasis de células claras renales.

Abstract: Worldwide, renal carcinoma constitutes 3% of all forms of cancer in the human body. Its biological behavior is variable depending on the biology of each individual; it tends to metastasize to contiguous sites such as adrenal glands, liver, lung, bone, lymph nodes, however, remote presentation in the oral cavity is less frequent, even in inserted gums. Granulomatous lesions of the periodontium include pyogenic granulomas, giant cell granulomas among others. The main objective of this clinical case is to describe the clinical and histopathological characteristics of oral cavity metastases as granulomatous lesions. The case of a 60-year-old female patient with a history of renal cell papillary carcinoma in the right kidney treated by nephrectomy in 2017 is presented, in 2019 she presented metastases to the left lung and oral cavity. It is currently under treatment protocol for renal clear cell metastases.

Variante "no clásica" o "atípica" del síndrome de Stauffer en paciente con carcinoma renal de células claras: reporte de caso / "Non-classical" or "atypical" variant of Stauffer syndrome in a patient with clear cell renal carcinoma: a case report

La manifestación paraneoplásica conocida como síndrome de Stauffer tiene una presentación atípica, caracterizada por ictericia y colestasis intrahepática. Presentamos el caso de un paciente de 53 años de edad, con antecedente de una masa renal derecha en plan de resección quirúrgica programada, con cuadro de evolución de dolor abdominal en hipocondrio derecho e ictericia. A su ingreso se documentó hepatoesplenomegalia, elevación de bilirrubinas a expensas de la directa, y de fosfatasa alcalina junto con elevación de transaminasas. Se descartaron causas obstructivas a nivel de vía biliar intra y extrahepática. No se documentaron metástasis o lesiones focales a nivel de parénquima, ni lesiones de etiología vascular que explicaran el cuadro. También se descartó hepatitis B, C e infección por VIH, por lo cual se consideró un probable síndrome de Stauffer. Fue llevado a nefrectomía intrahospitalaria, con posterior diagnóstico patológico compatible con carcinoma de células claras. Luego del procedimiento se normalizó la bioquímica hepática y se corrigió la ictericia. Es importante reconocer que la afectación hepática en el contexto de neoplasias, no es solo atribuida a metástasis a distancia, sino también a la existencia de síndromes paraneoplásicos como condicionantes.

The paraneoplastic manifestation known as Stauffer syndrome has an atypical presentation, characterized by jaundice and intrahepatic cholestasis. We present the case of a 53-year-old patient, with a history of a right renal mass with a planned surgical resection, who developed abdominal pain in the right upper quadrant and jaundice. Upon admission, hepatosplenomegaly, elevated bilirubin, at the expense of direct bilirubin, alkaline phosphatase and elevated transaminases were documented. Intra- and extrahepatic bile ducts obstruction were ruled out. There were no documented metastases or focal lesions at the level of the parenchyma, or lesions of vascular etiology that could explain the condition. Hepatitis B, C and HIV infection were also ruled out, and a probable Stauffer syndrome was considered. In-hospital nephrectomy was performed, with subsequent pathology compatible with clear cell carcinoma. After the procedure, liver biochemistry was normalized and jaundice was corrected. It is important to recognize that liver involvement in the context of neoplasms is not only attributed to distant metastases but to the existence of paraneoplastic syndromes as determining factors.

Epistaxis: the cause found beyond the nose

Renal cell carcinoma (RCC) is a malignant disease that is often diagnosed at a metastatic stage. The head and neck represent up to 3% of the metastatic RCC, and the paranasal sinus area is one of the least involved sites. Here, we introduce the case of a 74-year-old female patient who presented with a history of traumatic nasal bleed. A cranial computed tomography scan and magnetic resonance imaging showed a fronto-ethmoidal mass with pachymeningeal involvement. A nasal biopsy from the paranasal sinuses was taken. On histopathological examination, metastatic clear cell carcinoma was the main hypothesis, which later was confirmed to be RCC on immunohistochemistry. On further radiological examination, an exophytic mass was depicted in the kidney's upper and middle pole. The patient had no renal complaints and was asymptomatic. Fronto-ethmoidal sinus is a rare site for metastatic RCC, especially in cases where the patient is asymptomatic. Early detection by keeping RCC metastasis as the differential diagnosis in such cases can lead to early treatment and improve the overall survival of the patient.

Sarcopenia predicts prognosis of patients with renal cell carcinoma: A systematic review and meta-analysis

ABSTRACT Sarcopenia, a concept reflecting the loss of skeletal muscle mass, was reported to be associated with the prognosis of several tumors. However, the prognostic value of sarcopenia in patients with renal cancer remains unclear. We carried out this metaanalysis and systematic review to evaluate the prognostic value of sarcopenia in patients with renal cell carcinomas. We comprehensively searched PubMed, Embase, and Cochrane Library from inception to December 2018. Hazard ratio (HR) and 95% confidence interval (CI) were pooled together. A total of 5 studies consisting of 771 patients were enrolled in this quantitative analysis, 347 (45.0%) of which had sarcopenia. Patients with sarcopenia had a worse OS compared with those without sarcopenia (HR=1.76; 95%CI, 1.35-2.31; P <0.001). In the subgroup of patients with localized and advanced/metastatic diseases, sarcopenia was also associated with poor OS (HR=1.48, P=0.039; HR=2.14, P <0.001; respectively). With a limited sample size, we did not observe difference of PFS between two groups (HR=1.56, 95% CI, 0.69-3.50, P=0.282). In the present meta-analysis, we observed that patients with sarcopenia had a worse OS compared with those without sarcopenia in RCC. Larger, preferably prospective studies, are needed to confirm and update our findings.

Metástasis bilateral de húmero, en paciente con cáncer renal, tratado con inmunoterapia y cirugía: reporte de un caso / Bilateral Humeral metastases, in a patient with renal cancer, treated with immunotherapy and surgery: case report

El carcinoma de células renales es el 7mo cáncer en frecuencia a nivel mundial con más de 300.000 casos nuevos al año y es la 3era malignidad genitourinaria más frecuente. El sitio más común de metástasis es el pulmón mientras que el esqueleto ocupa el segundo lugar con una frecuencia que varía entre un 20% a un 35%. Se ha reportado una sobrevida de 12 meses en promedio luego de la aparición de metástasis óseas. Reporte del caso de un paciente con diagnóstico de cáncer renal de células claras y metástasis óseas (en columna, pelvis y ambos húmeros), que evoluciona con fractura de ambos brazos. El paciente es aceptado en un ensayo clínico de tratamiento con inmunoterapia y además se somete a una reducción y osteosíntesis bilateral de húmero con clavo endomedular, logrando la consolidación de ambas fracturas y, por ende, la regresión de la enfermedad.

Renal cell carcinoma is ranked 7th in frequent cancer worldwide with more than 3000.000 new cases per year, as well as it's ranked 3rd in frequent genitourinary malignancy. The most common area of metastases is lung followed by skeleton in second place. The frequency of skeleton metastases varies from 20% to 35%. A survival average time of 12 months is generally observed after the appearance of bone metastases. This case report is about a patient diagnosed with clear cell renal cancer and bone metastases (in the spine, pelvis and both humerus) that evolves with fracture of both arms. The patient undergoes a clinical trial with immunotherapy and also a reduction and osteosynthesis of both arms with intramedullary nail, achieving consolidation of both fractures and regression of the disease.

Metástasis poco frecuente del carcinoma renal de células claras / Unusual metastasis of clear cell renal cell carcinoma

El ligamento falciforme es una reflexión peritoneal abdominal relacionada con la superficie anterior del hígado, que en su borde inferior libre contiene el ligamento redondo (LR); las lesiones únicas en este son infrecuentes. Presentamos un caso de metástasis única en el ligamento redondo en un paciente con antecedente de carcinoma renal de células claras. Realizamos una búsqueda bibliográfica para identificar casos similares. Nuestro paciente es un varón de 71 años con antecedente de carcinoma renal de células tratado con nefrectomía radical izquierda laparoscópica (estadio pT3a). En tomografía computarizada (TC) control a los 5 años se evidencia lesión focal en la periferia del segmento IVa, ante la sospecha de malignidad, se realiza laparotomía exploradora revisando toda la cavidad abdominal sin evidenciar otros implantes peritoneales. Se halla un nódulo de 1 cm en el ligamento redondo y se realiza su exéresis completa, con diagnóstico anatomopatológico de metástasis de células claras. El LR generalmente está afectado en casos de carcinomatosis peritoneal y solo existen dos casos publicados de metástasis únicas.

The falciform ligament is a peritoneal reflection that attaches the liver to the anterior abdominal wall; its lower edge contains the round ligament (RL). Single lesions in the RL are rare and usually correspond to perivascular epithelioid cell tumors. We present a case report of a single metastasis in the RL in a patient with clear cell renal cell carcinoma who underwent surgery five years ago. We conducted a literature review to identify similar cases and we found two case reports of single metastasis in the RL. Our patient was a 71-year-old man with a history of renal cell carcinoma who underwent left laparoscopic radical nephrectomy (stage pT3a), laparoscopic right adrenalectomy and total thyroidectomy due to multinodular goiter. The pathological examination revealed metastases of renal cell carcinoma. A computed tomography (CT) scan performed at 5-year follow-up showed a focal lesion in segment IVa with no FDG uptake in the PET scan, but as malignancy was suspected, the patient underwent exploratory laparatomy with no evidence of peritoneal implants. A 1-cm node was found in the round ligament that was completely resected. The pathological examination revealed metastatic clear cell renal cell carcinoma. The RL is involved in cases of peritoneal carcinomatosis and only two cases of single metastasis have been reported: in one patient with papillary renal cell carcinoma pT1aN0 and another one with left breast adenocarcinoma.

Renal adverse effects of sunitinib and its clinical significance: a single-center experience in Korea

BACKGROUND/AIMS: Sunitinib is an oral multitargeted tyrosine kinase inhibitor used mainly for the treatment of metastatic renal cell carcinoma. The renal adverse effects (RAEs) of sunitinib have not been investigated. The aim of this study was to determine the incidence and risk factors of RAEs (proteinuria [PU] and renal insufficiency [RI]) and to investigate the relationship between PU and antitumor efficacy. METHODS: We performed a retrospective review of medical records of patients who had received sunitinib for more than 3 months. RESULTS: One hundred and fifty-five patients (mean age, 58.7 +/- 12.6 years) were enrolled, and the mean baseline creatinine level was 1.24 mg/dL. PU developed in 15 of 111 patients, and preexisting PU was aggravated in six of 111 patients. Only one patient developed typical nephrotic syndrome. Following discontinuation of sunitinib, PU was improved in 12 of 17 patients but persisted in five of 17 patients. RI occurred in 12 of 155 patients, and the maximum creatinine level was 3.31 mg/dL. RI improved in two of 12 patients but persisted in 10 of 12 patients. Risk factors for PU were hypertension, dyslipidemia, and chronic kidney disease. Older age was a risk factor for RI. The median progression-free survival was significantly better for patients who showed PU. CONCLUSIONS: The incidence of RAEs associated with sunitinib was lower than those of previous reports. The severity of RAEs was mild to moderate, and partially reversible after cessation of sunitinib. We suggest that blood pressure, urinalysis, and renal function in patients receiving sunitinib should be monitored closely.

A synchronous hepatocellular carcinoma and renal cell carcinoma treated with radio-frequency ablation

Radio-frequency ablation (RFA) is a curative treatment for hepatocellular carcinoma (HCC). Percutaneous RFA has been shown to be beneficial for patients with small renal cell carcinoma (RCC) lacking indications for resection. We experienced the case of a 53-year-old male who had conditions that suggested HCC, RCC, and alcoholic liver cirrhosis. Abdominal contrast-enhanced computed tomography (CT) and magnetic resonance image showed liver cirrhosis with 2.8 cm ill-defined mass in segment 2 of the liver and 1.9 cm hypervascular mass in the left kidney. These findings were compatible with the double primary cancers of HCC and RCC. Transarterial chemoembolization (TACE) was performed to treat the HCC. After the TACE, a focal lipiodol uptake defect was noticed on a follow up CT images and loco-regional treatment was recommended. Therefore, we performed RFAs to treat HCC and RCC. There was no evidence of recurrence in the follow up image after 1 month.

Immune thrombocytopenic purpura in a patient with renal cell carcinoma

No abstract available.

[ rare case of breast metastasis from a renal cell carcinoma]

Renal cell carcinoma [RCC] is responsible for 90-95% of malignant renal neoplasms. Peak incidence is between the 5[th] and 7[th]decades of life. Metastatic RCC to the breast is extremely rare. A 55-year-old woman presented with a mass in her right breast. Mammography demonstrated a 22x32 mm mass with increased density associated with spiculation and microcalcification areas. Biopsy of the mass reported an invasive ductal carcinoma. During the evaluation of metastasis and staging, another mass [38x33x27 mm] was detected in the inferior pole of the right kidney with heterogeneous appearance. Nephrectomy was performed and the pathological evaluation of the kidney mass reported a clear cell renal carcinoma. Breast mass was vimentin-positive carcinoma that was consistent with metastasis from RCC. Breast metastasis from RCC was diagnosed and the patient treated with immunotherapy [Interferon alfa]. It can be concluded that the breast tissue can be a site for RCC metastasis. Therefore, after detecting a malignant breast mass, a comprehensive evaluation is necessary to differentiate between the primary and metastatic breast cancers

Adenoma metanéfrico del riñon asociado a policitemia y eritromelalgia: caso clínico / Metanephric adenoma of the kidney associated with polycythemia and erythromelalgia: Report of one case

Background: We report a 21-year-old male, presenting with erythromelalgia and polycythe-mia. A solid renal mass of the lower pole of the right kidney was discovered. The patient was subjected to a right open partial nephrectomy. The pathological study of the surgical specimen showed a metanephric adenoma of the kidney. The patient had an uneventful postoperative evolution. Currently the patient is in good health without evidence of recurrence of the tumor and normal hematological parameters.

Hemocromatose associada a carcinoma hepatocelular e neoplasias extra-hepáticas / Hemochromatosis combined with hepatocellular carcinoma and extrahepatic neoplasms

A hemocromatose caracteriza-se pelo acúmulo excessivo de ferro no organismo, que é depositado redominantemente no fígado, e resulta ou de um defeito genético determinando uma absorção excessiva de ferro ou da administração parenteral deste íon. O ferro em excesso determina alterações celulares através da peroxidação lipídica, estímulo da deposição de colágeno e interação com o oxigênio reativo e DNA. Os autores relatam um caso de hemocromatose em paciente portador de cirrose hepática associada ao desenvolvimento de hepatocarcinoma, hemangioma hepático, adenocarcinoma prostático e carcinoma renal, e apresentam uma discussão geral deste processo, frequentemente associado ao desenvolvimento de neoplasias.

Hemochromatosis is characterized by excessive accumulation of iron in the body, which is deposited primarily in the liver. It results either from a genetic defect determining an excessive absorption of iron or from parenteral administration of this ion. The excess iron determines cellular changes through lipid peroxidation, stimulation of collagen deposition, and interaction with reactive oxygen and DNA. The authors report a case of hemochromatosis in a patient with liver cirrhosis associated with development of hepatocellular carcinoma, hepatic hemangioma, prostate adenocarcinoma and renal cell carcinoma, and provide a general discussion of this process often associated with the development of neoplasias.

Renal cell carcinoma and systemic onset juvenile idiopathic arthritis.

Renal cell carcinoma (RCC) accounts for majority of malignancies arising out of the kidney. Paraneoplastic rheumatologic manifestations; myositis, vasculitis, and arthritis have been described in a few cases with RCC. Systemic onset juvenile idiopathic arthritis (JIA) is characterized by intermittent fever, arthritis, reticulo-endothelial cell hyperplasia and absence of rheumatoid factor and antinuclear antibodies. Herein, we report a 16-year-old boy with systemic onset JIA for 5 years who developed RCC and his systemic and articular symptoms paralleled the course of RCC. The common pathophysiologic influence of the cytokine Interleukin-6 possibly played a role in the exacerbation of symptoms of systemic onset JIA during the relapse of the RCC. The case is presented to highlight the rare co-occurrence of these two diseases and their influence on each other.

Evaluación de un paciente operado de hipernefroma hace 3 años con diagnóstico enfermedad renal crónica / Evaluation of a renal cell carcinoma operative patient since three years with chronic kidney disease diagnosis

La presencia de carcinoma de células renales durante la evolución de una enfermedad poliquística renal autosómica dominante es muy rara y poco reportada en la literatura internacional. El carcinoma renal suele manifestarse clínicamente de forma tardía, por lo que aproximadamente un tercio de los pacientes presentan metástasis a distancia en el momento del diagnóstico. Se reporta un caso de enfermedad poliquística renal asociado con carcinoma de células renales operado hace 3 años con tratamiento clínico conservador, además de diagnosticado con una enfermedad renal crónica avanzada el cual ha mantenido una evolución estable.

The presence of renal cell carcinoma during the evolution of an autosomal dominant polycystic kidney disease is very rare and little reported in international literature. Clinical manifestations of renal cell carcinoma are often late, so that approximately one-third of patients have metastatic disease at the time of diagnosis. It is reported a case of polycystic renal disease associated with renal cell carcinoma operated three years ago with conservative clinical treatment, besides he had been diagnosticated with an advanced chronic kidney disease who had mantained an stable evolution.

Renal cell carcinoma extending into the inferior caval vein: report of two cases

Renal cell carcinoma [RCC] is rare neoplasm and rarely extends to IVC. Perinephric and venous system invasion is an important prognostic sign for RCC. The tumor may grow intraluminally into the renal vein and Inferior Vena Cava [IVC] as an extension of primary tumor. In this report, we present two unusual case of venous system involvement, invasion of RCC into SVC. RCC with tumor thrombus extension into the IVC remains a difficult operative challenge. However surgical intervention should be performed. Our cases were successfully operated and their post operative recovery was uneventful

Sinais de hipervascularização em imagens de ressonância magnética em metástases ósseas de carcinoma de células renais / Signs of hypervascularization at magnetic resonance imaging in bone metastases from renal cell carcinoma

OBJETIVO: Avaliar a frequência de hipervascularização pela visualização de vasos no interior ou ao redor de metástases ósseas de carcinoma de células renais. MATERIAIS E MÉTODOS: Foram avaliados, retrospectivamente, exames de ressonância magnética de 13 pacientes com diagnóstico de carcinoma de células renais, com 15 lesões ósseas metastáticas, que não haviam sido submetidos a nenhum tratamento. RESULTADOS: Foram encontrados sinais de hipervascularização em 12 das 15 lesões (80%), sendo 6 na coluna lombar, 3 na bacia, 1 na coluna torácica, 1 na ulna e 1 na tíbia. CONCLUSÃO: A alta frequência de hipervascularização em metástases ósseas de carcinoma de células renais encontrada neste trabalho pode sugerir a etiologia renal, tornando-se muito útil na apresentação clínica usual de lesão óssea única com neoplasia primária desconhecida.

OBJECTIVE: To evaluate the frequency of hypervascularization by visualizing vascular structures inside or around bone metastases from renal cell carcinoma. MATERIALS AND METHODS: Magnetic resonance imaging studies of 13 untreated patients with diagnosis of renal cell carcinoma and 15 metastatic bone lesions were retrospectively evaluated. RESULTS: Signs of hypervascularization were found in 12 of the 15 bone lesions (80%), 6 of them localized in the lumbar spine, 3 in the hip, 3 in the thoracic spine, 1 in the ulna and 1 in the tibia. CONCLUSION: The high frequency of hypervascularization of bone metastases from renal cell carcinoma found in the present study may suggest that the renal etiology is a useful parameter in the evaluation of a usual clinical presentation of a single bone lesion with unknown primary neoplasm.

Cáncer de riñón con metástasis a colon: un sitio poco frecuente de metástasis / Renal cell carcinoma with colon metastases: an infrequent site for metastases

BACKGROUND: Renal cell carcinoma (RCC) represents approximately 3% of malignant tumors in adults and occurs in a M:F ratio of 1.5:1.0. Although in most cases it occurs in persons 50 to 70 years of age, there are also reports in children. Clear cell carcinoma is the most frequent histological type, and 30% of renal carcinomas have metastasized at the time of diagnosis. The objective of the present study is to report colon metastasis of clear cell carcinoma that required surgery and chemotherapy. CLINICAL CASE: We report the case of a 60-year-old male with a history of metastatic RCC. His treatment consisted of cytoreductive radical nephrectomy and interferon because of pulmonary disease. He was followed-up for 8 years. Nevertheless, he presented with hematochezia and underwent colonoscopy where a splenic flexure tumor was demonstrated. Biopsy reported a clear cell tumor. We performed a left hemicolectomy. Pathology report was clear cell carcinoma with involvement of the colon from the mucosa to serosa. The patient again received interferon. Currently, there is no evidence of tumor activity and the patient is being followed-up. CONCLUSIONS: RCC metastases are most frequent in lung, liver, and bone and less frequent in brain, skin, and soft tissue. Metachromic metastases are identified in the first to second year after nephrectomy in most cases. Survival of patients who present metastasis <1 year after nephrectomy is 33 months vs. patients who present metastasis after 1 year from nephrectomy (55 months). Metastatic clear cell carcinoma requires surgery and immunotherapy. Surgery is the first step for disease control and metastatecomies are indicated in localized disease or when one organ is affected and surgically accessible.