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A rare case of bilateral synchronous renal tumors with different histology successfully treated with bilateral partial nephrectomy


1 Department of Urology, NRS Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Biomedical Engineering, MIET, Bhubaneswar, Odisha, India

Correspondence Address:
Shashanka Dhanuka,
19B, Broad Street, Akshara Petals, 3rd Floor, Ballygunje, Kolkata - 700 019, West Bengal
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_605_18

 > Abstract 


Renal cell carcinoma (RCC) accounts for about 85% of all renal neoplasms, 60% of which are diagnosed incidentally. Most are unilateral, but bilateral tumors, synchronous or asynchronous, have been found in 2%–4% of reported sporadic cases. The occurrence of synchronous bilateral renal neoplasms with different histology in the same individual is very rare. We report one such case in a 45-year-old male patient, who was successfully managed by performing bilateral partial nephrectomy in two sittings. The histopathological examination revealed different histology on each side. Both preservations of renal parenchyma and tumor eradication should be considered in bilateral synchronous sporadic RCC before formulating a therapeutic regime. Management by nephron-sparing surgery approach performed in a staged manner offers adequate cancer-specific survival while ensuring good renal function.

Keywords: Histopathology, nephron-sparing surgery, renal cell carcinoma, synchronous tumors



How to cite this URL:
Dhanuka S, Kayal A, Mandal TK, Dhanuka J. A rare case of bilateral synchronous renal tumors with different histology successfully treated with bilateral partial nephrectomy. J Can Res Ther [Epub ahead of print] [cited 2019 Oct 19]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=264225




 > Introduction Top


With the improved availability and usage of noninvasive imaging, renal tumors are diagnosed incidentally in about 60% of cases. Renal cell carcinoma (RCC) accounts for about 85% of all renal neoplasms. Most are unilateral, but bilateral tumors, synchronous or asynchronous, have been found in 2%–4% of reported sporadic cases.

The occurrence of synchronous bilateral renal neoplasms with different histology in the same individual is very rare. In a study of 698 patients operated for RCC, only 29 (4%) had sporadic bilateral disease and only one patient had different histology on either side.[1] We report one such case in a 45-year-old male patient, who was successfully managed by performing bilateral partial nephrectomy in two sittings. The histopathological examination revealed different histology on each side. A similar approach has been reported by Kiremit et al.[2] Both preservation of renal parenchyma and tumor eradication should be considered in bilateral synchronous sporadic RCC before formulating a therapeutic regime.[3]


 > Case Report Top


A 45-year-old male presented with a history of bilateral flank pain for the last 3 months. The pain was dull aching in nature with no obvious radiation. He had no history of hematuria, fever with chills, or alteration in bowel or bladder habits. There was no significant past or family history. He had no significant medical comorbidities. On the general survey, the patient was of average built and nourishment with a normal general examination. Abdominal examination revealed a soft, scaphoid abdomen with no mass palpable. Digital rectal examination was within normal limits, and no abnormality was detected on other systemic examinations.

Ultrasonography of the abdomen revealed bilateral renal masses averaging about 3 cm in size each with heterogeneous echotexture and a few cystic areas within it. Serum urea was 25 mg/dl and creatinine was 1.2 mg/dl. Triphasic contrast-enhanced computed tomography (CT) scan of the whole abdomen revealed bilateral heterogeneous hypervascular space-occupying lesions measuring about 3–3.5 cm each, located at the mid-pole of each kidney [Figure 1] and [Figure 2]. Calcification was noted within the masses. Both renal masses had significant postcontrast enhancement – left renal mass = +77.3 HU and right renal mass = +37 HU.
Figure 1: Preoperative contrast-enhanced computed tomography showing bilateral renal masses

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Figure 2: Preoperative contrast-enhanced computed tomography showing bilateral renal masses-coronal section

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Renal angiography revealed single renal artery on each side with no prehilar branching and single renal vein on each side with no evidence of delayed confluence and no thrombus in them.

After routine investigations and preanesthetic checkup, under general anesthesia, the patient underwent right-sided partial nephrectomy. During surgery, the renal vessels were clamped for 24 min. Postoperative recovery was uneventful. The histopathological examination of the right renal specimen revealed multilocular cystic renal neoplasm of low malignant potential [Figure 3]. The resection margins were free from tumor. Postoperative serum urea was 17 mg/dl, and creatinine was 1.0 mg/dl.
Figure 3: Gross specimen of the right-sided partial nephrectomy

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The patient was followed up with a technetium-99m diethylenetriaminepentaacetate (DTPA) renogram and contrast-enhanced CT scan of the kidney, ureter, and bladder region 6 weeks after surgery [Figure 4]. The DTPA scan revealed a global glomerular filtration rate of 98.2 ml/min with the split function of 57.4% on the left side and 42.6% on the right side. The contrast-enhanced CT scan demonstrated normal density and enhancement pattern without any focal abnormalities in the right kidney. The left kidney showed a heterogeneous mass lesion of size 3.5 cm × 2.7 cm in the interpolar region of the left kidney with significant contrast enhancement, confined in the renal fascia with no involvement of renal pelvis or vascular pedicle.
Figure 4: Computed tomography scan showing left renal mass after the right-sided partial nephrectomy

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Three months after the first surgery, left-sided partial nephrectomy was carried out. We had to clamp the renal vessels for 21 min during the surgery. Postoperative recovery was uneventful. Histopathological examination of the specimen revealed clear cell RCC with cystic change (WHO Nuclear Grade I) [Figure 5]. Resection margins were tumor-free. After surgery, serum urea was 24 mg/dl and creatinine was 1.1 mg/dl.
Figure 5: Histopathological slides of bilateral partial nephrectomy

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The patient was followed up at 3 months, 6 months, and 1 year and was asymptomatic. He was having good renal function and normal ultrasonographic evaluation.


 > Discussion Top


RCC is the most lethal urologic cancer, and its incidence has increased by an average of 3%–4% per year, largely related to the more prevalent use of ultrasonography and CT for the evaluation of a variety of abdominal conditions. Although a disease of older adults, it can occur at a relatively younger age, as in our case report. Moreover, the occurrence of bilateral renal tumors although quite rare can still occur. Rothman et al.[4] in their evaluation of pathologic concordance rates of sporadic bilateral synchronous renal tumors based on the Surveillance, Epidemiology, and End Results data revealed a histologic concordance rate of 93% (256 of 274). Systematic management using a nephron-sparing surgery (NSS) approach in the form of partial nephrectomy ensures equivalent tumor-free survival with better renal function when compared to radical nephrectomy (RN), more so in bilateral cases. Blute et al.[5] noted that there were no statistically significant differences in cancer-specific and distant metastasis-free survival in patients with bilateral synchronous RCC and unilateral RCC of the same histological subtype. Pahernik et al.[6] in their long-term data support the concept that NSS, whenever possible bilateral, is the treatment of choice for bilateral synchronous sporadic RCC. NSS provides adequate local tumor control and cancer-specific survival. The preservation of renal function is more efficient with bilateral NSS than with unilateral NSS and contralateral RN. The occurrence of synchronous bilateral RCC of different histology is a rare finding as it has been often appreciated that each subtype of RCC is distinct and derived from a different part of the nephron, with a unique genetic basis and tumor biology. In the presence of bilateral sporadic synchronous renal masses, a diagnosis of ipsilateral RCC of any type is associated with contralateral RCC in the vast majority of patients.[7] Clear cell RCC and multilocular cystic renal neoplasm of low malignant potential represent two distinct histologic entities in the current WHO classification of renal tumors.


 > Conclusion Top


The occurrence of bilateral synchronous sporadic RCC is rare, and the finding of different histology on either side is very rare. Imaging helps to detect these masses early even in the asymptomatic patient but fails to differentiate the histologic subtype. Management by NSS approach performed in a staged manner offers adequate cancer-specific survival while ensuring good renal function.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Grimaldi G, Reuter V, Russo P. Bilateral non-familial renal cell carcinoma. Ann Surg Oncol 1998;5:548-52.  Back to cited text no. 1
    
2.
Kiremit MC, Acar Ö, Saǧlıcan Y, Esen T. Bilateral renal cell carcinoma with leiomyomatous stroma: A rare entity diagnosed synchronously and treated surgically in a staged fashion. Turk J Urol 2017;43:566-70.  Back to cited text no. 2
    
3.
Hu XY, Xu L, Guo JM, Wang H. Surgical strategy of bilateral synchronous sporadic renal cell carcinoma-experience of a Chinese university hospital. World J Surg Oncol 2017;15:53.  Back to cited text no. 3
    
4.
Rothman J, Crispen PL, Wong YN, Al-Saleem T, Fox E, Uzzo RG, et al. Pathologic concordance of sporadic synchronous bilateral renal masses. Urology 2008;72:138-42.  Back to cited text no. 4
    
5.
Blute ML, Itano NB, Cheville JC, Weaver AL, Lohse CM, Zincke H, et al. The effect of bilaterality, pathological features and surgical outcome in nonhereditary renal cell carcinoma. J Urol 2003;169:1276-81.  Back to cited text no. 5
    
6.
Pahernik S, Cudovic D, Roos F, Melchior SW, Thüroff JW. Bilateral synchronous sporadic renal cell carcinoma: Surgical management, oncological and functional outcomes. BJU Int 2007;100:26-9.  Back to cited text no. 6
    
7.
Soylu Boy FN, Yuksel OH, Verit A. Bilateral sporadic synchronous renal clear-cell carcinoma treated by bilateral partial laparoscopic nephrectomy: Report of two cases. Arch Esp Urol 2015;68:718-21.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

 
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