Renal Cell Carcinoma
53-year-old male complained of right flank discomfort. Scans revealed solid lesion with necrotic content in the left kidney, and radical nephrectomy with ipsilateral para-aortic lymph node dissection was performed. Pathology diagnosis was a clear cell renal carcinoma. The experts recommends a close routine follow up together with routine opthalmoscopy in order to detect retinal angiomas that can be an affect of VHL gene mutation.
The experts was consulted regarding any further treatment and future follow up.
Diagnosis : Renal Cell Carcinoma
The patient is a 53-year-old Caucasian man. He was healthy until a few months ago when he complained of right flank discomfort. An abdominal ultrasound had revealed a left renal lesion. Subsequent abdominal CT demonstrated a solid lesion with necrotic content at a size of 9X6.5cm. There were no other pathological findings on the scan and the patient had an abdominal radical nephrectomy.
Surgery took place few days after diagnosis; radical nephrectomy with ipsilateral para-aortic lymph node dissection was performed. Tissue was sent for routine histopathology as well as immediate freezing of some tumor tissue for future investigation, if needed.
Pathology diagnosis was a 9 cm clear cell renal carcinoma, nuclear grade Fuhrman 3, with the tumor infiltrating renal capsule and focally penetrating the perinephric fatty tissue (pT3a). Adrenal gland and lymph nodes were free of tumor.
Recovery was uneventful. Postoperative creatinine levels stabilized at 1.6mg/dl with normal LFT and CBC.
I was consulted regarding any further treatment and future follow up. At this stage the patient has no evidence of residual or recurrent disease therefore there is no place for adjuvant therapy. However, there are some investigative protocols dealing with vaccination of the patients against tumor antigens in cases like this. Results of these studies are pending and unless he will be recruited to such a study I do no recommend treating him.
Making use of recently published data regarding tumor free survival of patients with clear cell type renal carcinoma (Sorbellini et al, J Urol 173; 48-51, Jan 05)
The patient has a chance of about 80% recurrence free survival at 5 years. A close routine follow up should be done. This will comprise of history & physical examination, blood tests & chest X-ray every 6 months for the first three years of follow up and yearly thereafter. Abdominal CT should be done in a year time and every 2 years thereafter. Such a follow up performed on a timely fashion will enable early diagnosis of disease and prompt treatment.
Another aspect that should be addressed is the genetic aspect. It is well known that 8% of newly diagnosed sporadic cases of patients with clear cell renal carcinoma carry a VHL gene mutation. The patient has negative family history for cancer cases and has no clinical signs & symptoms or radiological findings of any other abdominal tumor. In the absence of neurological symptoms I do not recommend head CT to rule out CNS lesions. Seventy percent of VHL affected patients develop retinal angiomas. They may be asymptomatic and are easily detected on routine opthalmoscopy, which I recommend in the near future. If such lesions are found genetic counseling is warranted.