|Year : 2017 | Volume
| Issue : 6 | Page : 1068-1069
Incision site metastasis: Adding insult to injury
Ranil Johann Boaz1, Tanush Vig2, Ramani Manojkumar2, Antony Devasia1
1 Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
2 Department of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
|Date of Web Publication||13-Dec-2017|
Dr. Ranil Johann Boaz
Department of Urology, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Incision site metastasis is a rare yet well-recognized complication of oncologic operations. We describe the case of a 60-year-old man with a large mass at the site of abdominal incision for a nephrectomy. The operation was performed for infection in an obstructed kidney, which in retrospect harbored malignancy. Percutaneous core biopsy of the mass revealed metastatic conventional renal cell carcinoma (RCC). Surgical resection was obviated by the presence of nodal disease on imaging. Palliative targeted therapy with tyrosine kinase inhibitor was initiated. RCC can not only mimic an inflammatory renal mass radiologically but also coexist with infective renal conditions. Diligent histopathological examination as a routine following nephrectomy for complicated diagnoses is imperative.
Keywords: Incision site metastasis, renal abscess, renal cell carcinoma
|How to cite this article:|
Boaz RJ, Vig T, Manojkumar R, Devasia A. Incision site metastasis: Adding insult to injury. J Can Res Ther 2017;13:1068-9
| > Introduction|| |
Incision site metastasis (ISM) following open surgery for renal malignancy is a rare event. Surveillance of surgical scar for metastasis following radical nephrectomy for renal cell carcinoma (RCC) is an essential component of oncological follow-up. RCC can both mimic an inflammatory renal mass radiologically as well as coexist with infective renal conditions.
| > Case Report|| |
A 60-year-old man presented with worsening pain and swelling at the right flank. He had undergone an open right nephrectomy a year ago at a rural hospital. Records indicated evaluation for fever and operation for pyelonephritis and renal abscess secondary to obstructive ureteric calculi. Histopathological examination reported pyonephrosis with renal abscess. His postoperative course was uneventful. A year on, clinical examination revealed a warm, tender mass in the right hypochondrium and lumbar region that was fixed to the lower ribs. The scar of the previous incision lay across the palpable mass [Figure 1]. Contrast-enhanced computed tomography revealed a 15 cm × 9 cm × 13 cm, heterogeneously enhancing mass in the right anterior abdominal wall encasing ribs 10–12 and protruding into the abdominal cavity [Figure 2]. The right kidney was absent, and the contralateral kidney was normal. Enlarged retrocrural and paravertebral nodes were noted. Of interest; multiple calculi were found in the right ureteric stump, corroborating previous records. Percutaneous core biopsy revealed tumor arranged in nests separated by fibrovascular septae with infiltration of fibroadipose and fibrocollagenous tissue [Figure 3]a. Tumor cells were polygonal with abundant clear cytoplasm, vesicular nuclei, and distinct nucleoli [Figure 3]b. Immunohistochemistry revealed diffusely positivity for markers epithelial membrane antigen and CD10 [Figure 3]c and [Figure 3]d; confirming metastatic conventional RCC.
|Figure 1: (a) Visible mass in the right hypochondrium and lumbar region. (b) Scar of the incision seen overlying the palpable mass|
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|Figure 2: Contrast-enhanced computed tomogram. (a) Coronal image showing a large, multilobulated, heterogeneously enhancing mass involving the abdominal wall in the right lumbar region. (b) Axial image showing the abdominal wall mass with infiltration of the overlying skin and a normal left kidney. (c) Axial image showing a retained 11 mm calculus in the right ureteric stump (arrow)|
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|Figure 3: (a) Tumor arranged in sheets and nests demarcated by delicate fibrovascular septae (H and E, ×100). (b) Polygonal tumor cells, displaying hyperchromatic nuclei, and abundant clear cytoplasm (H and E, ×200). (c) Immunostaining positive for epithelial membrane antigen, ×200. (d) Immunostaining positive for CD10, ×200|
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Surgical resection would have entailed loss of a significant section of the anterior abdominal wall and lower rib cage followed by a major reconstructive procedure. Another factor against surgical intervention was the presence of metastatic nodal disease. Considering the high risk and morbidity of such an operation along with poor prognosis overall, an informed decision was made to proceed with palliative targeted therapy; tyrosine kinase inhibitor – pazopanib. At 3 months of treatment, there was no apparent progression of disease.
| > Discussion|| |
Tumor cells access the surgical wound either by direct contamination or by hematogenous and lymphatic seeding. Regardless of the mode of entry, it is proposed that the ischemic microenvironment of the healing wound offers favorable characteristics for tumor cell selection and replication. ISM is widely reported following open operations for colorectal and gallbladder malignancy; however, description following open radical nephrectomy is restricted to a few reports., While port site metastasis (PSM) after laparoscopic radical nephrectomy has been widely studied, there is a paucity of data on ISM after open radical nephrectomy. One series quoted incidence of PSM and ISM at 1.5% and 0.8%, respectively. Measures to decrease the risk of ISM are enshrined in oncosurgical principles-minimizing tissue handling, preventing tumor spillage, and protecting the surgical wound. The recommendation for isolated ISM from RCC is resection whenever feasible.
Multiple reports describe RCC manifesting radiologically as an inflammatory mass or renal abscess. Fever can represent a paraneoplastic phenomenon. Coexistence of pyonephrosis and abscess with renal malignancy has also been described. The importance of meticulous histopathologic examination in complicated cases cannot be overstated. Had the primary diagnosis been made, it is likely that this metastasis would have been recognized earlier by either clinical or radiological examination at appropriate oncological follow-up.
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Conflicts of interest
There are no conflicts of interest.
| > References|| |
Höckel M, Dornhöfer N. The hydra phenomenon of cancer: Why tumors recur locally after microscopically complete resection. Cancer Res 2005;65:2997-3002.
Ledesma EJ, Tseng M, Mittelman A. Surgical treatment of isolated abdominal wall metastasis in colorectal cancer. Cancer 1982;50:1884-7.
Chaturvedi S, Bansal V, Kapoor R, Mandhani A. Is port site metastasis a result of systemic involvement? Indian J Urol 2012;28:169-73. [Full text]
Bhat S. Role of surgery in advanced/metastatic renal cell carcinoma. Indian J Urol 2010;26:167-76.
] [Full text]
Eltahawy E, Kamel M, Ezzet M. Management of renal cell carcinoma presenting as inflammatory renal mass. Urol Ann 2015;7:330-3.
] [Full text]
Perimenis P. Pyonephrosis and renal abscess associated with kidney tumours. Br J Urol 1991;68:463-5.
[Figure 1], [Figure 2], [Figure 3]