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doi:10.1111/jog.12405
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1828–1830, June 2014
Case report: Renal cell carcinoma with metastasis to the myometrium Haider M. Rahbar1, Ramesh K. Kumar1, Deepansh Dalela1, Rabbie Hanna2, Nilesh Gupta3 and Craig G. Rogers1 1 Vattikuti Urology Institute, Henry Ford Health System, 2Department of Women’s Health Services, Henry Ford Medical Group, and 3Department of Pathology, Henry Ford Hospital, Detroit, USA
Abstract Renal cell carcinoma (RCC) is well known for its ability to metastasize to different organs, but the involvement of gynecological organs is rare. Our case represents the first case of bilateral RCC with metastasis to the myometrium. The patient was a 60-year-old woman who underwent bilateral robotic partial nephrectomy surgeries for clear cell RCC, low-grade, low-stage with negative margins. Her 1-year postoperative computed tomography scan showed an enlarging necrotic uterine mass. She underwent a debulking excision, including hysterectomy, with pathology showing metastatic RCC to the uterus. The patient developed widespread metastatic disease, and died months later of metastatic RCC. Key words: metastasis, myometrium, renal cell carcinoma.
Introduction Renal cell carcinoma (RCC) represents 3% of adult tumors.1 Metastasis is a common finding at diagnosis. Up to 33% of RCC have metastasized at the time of diagnosis.2 Common sites of metastasis include the lungs, liver, adrenals, skin and bone.1,3 The involvement of female reproductive organs is rare, and the involvement of the uterus is extremely rare; to our knowledge only 10 cases of RCC with metastasis to the uterine endometrium/cervix have been published in the current literature.2,4–6 Our case represents the first case of RCC with metastasis to the myometrium.
Case Report A 60-year-old African–American female patient initially presented to us with vague abdominal pain. Computed tomography (CT) revealed bilateral small renal masses suspicious for RCC. She underwent an uneventful robotic right partial nephrectomy followed
by a left robotic partial nephrectomy 2 months later. Final pathology from both tumors showed clear cell RCC with negative resection margins (stage pT1a), right: 3.1 cm, Fuhrman Grade 2; left: 0.7 cm, Fuhrman grade 1. A follow-up CT scan showed a partially necrotic 6-cm mass within the uterus. Based on her history of pelvic pain and her initial CT, which showed a calcified 3.9-cm mass in the left uterus (Fig. 1a), a presumed diagnosis of an enlarging uterine fibroid was made. Twenty-one months after her initial kidney surgery, the patient was complaining of worsening pelvic discomfort. A CT scan showed a 15-cm left pelvic mass with cystic and solid components. The mass was indistinct from the uterus, and it extended to the mid-abdomen (Fig. 1b). The patient was referred to gynecology–oncology and underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and resection of pelvic mass, for a presumed primary ovarian tumor. Final pathology demonstrated metastatic clear cell RCC involving the myometrium
Received: September 19 2013. Accepted: January 15 2014. Reprint request to: Mr Haider M. Rahbar, Vattikuti Urology Institute, Henry Ford Health System, 2799 W. Grand Boulevard, Detroit, Michigan 48202, USA. Email: [email protected]
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RCC with metastasis to myometrium
a
Figure 2 Histopathology slide demonstrating metastatic clear cell renal cell carcinoma involving the myometrium (hematoxylin–eosin).
b
Postoperatively, the patient was initiated on sunitinib malate (Sutent) for metastatic RCC. Her disease progressed over the next several months to widespread metastatic disease involving the chest, abdomen, and pelvis. The patient was transferred to hospice care and died of metastatic RCC.
Discussion
Figure 1 (a) Contrast computed tomography (CT) scan showing 3.9 cm × 2.9-cm calcified mass in the uterus (initially presumed to be a uterine fibroid). (b) Noncontrast CT showing partially necrotic hypodense lesion measuring 15 cm × 12 cm × 13 cm, indistinct from the uterus.
(Fig. 2). The para-ovarian and small bowel mesentery were also positive for metastatic RCC. The ovaries, fallopian tubes, cervix, endometrium, pelvic and paraaortic lymph nodes were negative for malignancy.
RCC is well known for its ability to metastasize to any organ, but the involvement of gynecological organs is rare.2 The lower third of the vagina is the most commonly involved gynecological organ, with only 85 cases reported in the literature.2,7 Involvement of the ovaries and uterus is particularly rare, but it has been reported in the published work. To our knowledge, RCC metastasis to the myometrium has not been previously published.2 The endometrium and the cervix were spared in this patient. The finding of a mass within the myometrium is most consistent with leiomyoma and rarely leiomyosarcoma.8 Based on 1-year follow-up CT scan, the mass within the uterus was believed to be leiomyoma, but subsequently the mass was confirmed to be metastatic RCC. The rarity of metastatic RCC to the uterus made the initial diagnosis of metastatic disease unlikely; additionally the mass was within the myometrium. The mechanism of metastasis to the female reproductive tract is unknown. There are four proposed methods of metastasis to the reproductive tract: retrograde venous, hematogenous via systemic circulation,
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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retrograde lymphogenic, and migration of tumor via the urinary tract.2,9 Retrograde venous spread is the most likely method, and the proposed method is the direct connection between the left renal vein and the left ovarian vein and subsequent ovarian– uterovaginal venous plexus.2,4 This proposed mechanism is supported by the fact that left-side RCC is more likely to spread to the female reproductive tract.3,4 Valappil et al. showed that 66% of metastasis to the ovaries was from left-side RCC.10 Early ligation of the gonadal vein might prevent migration of neoplastic cells to gynecological organs.3,7 In our patient, this was not performed because she underwent nephronsparing surgery; the ligation of the ovarian vein is not standard practice. Hematogenous and lymphogenic spread are more likely options if the liver and lung are involved.9 Hematogenous spread cannot be ruled out in our patient as she developed lung metastasis. The ideal treatment and prognosis are unknown due to the rarity of metastatic RCC to the uterus. Overall, metastatic RCC has a poor outcome with an overall 5-year survival of 35% even with aggressive treatment for solitary metastasis.3 Surgical treatment seems the most plausible option in the absence of other metastatic lesions.6 Chemotherapeutic agents can be an option in more widespread disease. Our case represents the first case of a patient with bilateral conventional clear cell RCC with metastasis to the myometrium that was initially diagnosed as leiomyoma, and consequently was found to be metastatic RCC.
References 1. Guney S, Guney N, Ozcan D, Sayilgan T, Ozakin E. Ovarian metastasis of a primary renal cell carcinoma: Case report and review of literature. Eur J Gynaecol Oncol 2010; 31: 339–341. 2. Seseke F, Kugler A, Hemmerlein B, Gross AJ, Ringert RH. Metastasis from renal cell carcinoma to the cervix uteri. Scand J Urol Nephrol 1998; 32: 290–292. 3. Yokoyama Y, Sato S, Kawaguchi T, Saito Y. A case of concurrent uterine cervical adenocarcinoma and renal-cell carcinoma, and subsequent vaginal metastasis from the renal-cell carcinoma. J Obstet Gynaecol Res 1998; 24: 37–43. 4. Bozaci EA, Atabekoglu C, Sertçelik A, Unlü C, Ortaç F. Metachronous metastases from renal cell carcinoma to uterine cervix and vagina: Case report and review of literature. Gynecol Oncol 2005; 99: 232–235. 5. Tretheway D, Gebhardt J, Dogra V, Schiffhauer L. Metastatic versus primary oncocytic papillary adenocarcinoma of the endometrium: A report of a case and review of the literature. Int J Gynecol Pathol 2009; 28: 256–261. 6. Zafrakas M, Papanikolaou A, Venizelos I, Kellartzis D, Agorastos T, Bontis J. A rare case of renal cell carcinoma metastasizing to the uterine cervix. Eur J Gynaecol Oncol 2009; 30: 239–240. 7. Benbrahim Z, Chouaib A, Mazeron R et al. Gynecologic bleeding revealing vaginal metastasis of renal cell carcinoma. Pan Afr Med J 2013; 14: 62. 8. Van den Bosch T, Coosemans A, Morina M, Timmerman D, Amant F. Screening for uterine tumours. Best Pract Res Clin Obstet Gynaecol 2012; 26: 257–266. 9. Fossa S, Schjolseth D, Miller A. Multiple urothelial tumours with metastases to uterus and left ovary. A case report. Scand J Urol Nephrol 1977; 11: 81–84. 10. Valappil S, Toon P, Anandaram PS. Ovarian metastasis from primary renal cell carcinoma: Report of a case and review of literature. Gynecol Oncol 2004; 94: 846–849.
Disclosure None declared.
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doi:10.1111/jog.12405
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1828–1830, June 2014
Case report: Renal cell carcinoma with metastasis to the myometrium Haider M. Rahbar1, Ramesh K. Kumar1, Deepansh Dalela1, Rabbie Hanna2, Nilesh Gupta3 and Craig G. Rogers1 1 Vattikuti Urology Institute, Henry Ford Health System, 2Department of Women’s Health Services, Henry Ford Medical Group, and 3Department of Pathology, Henry Ford Hospital, Detroit, USA
Abstract Renal cell carcinoma (RCC) is well known for its ability to metastasize to different organs, but the involvement of gynecological organs is rare. Our case represents the first case of bilateral RCC with metastasis to the myometrium. The patient was a 60-year-old woman who underwent bilateral robotic partial nephrectomy surgeries for clear cell RCC, low-grade, low-stage with negative margins. Her 1-year postoperative computed tomography scan showed an enlarging necrotic uterine mass. She underwent a debulking excision, including hysterectomy, with pathology showing metastatic RCC to the uterus. The patient developed widespread metastatic disease, and died months later of metastatic RCC. Key words: metastasis, myometrium, renal cell carcinoma.
Introduction Renal cell carcinoma (RCC) represents 3% of adult tumors.1 Metastasis is a common finding at diagnosis. Up to 33% of RCC have metastasized at the time of diagnosis.2 Common sites of metastasis include the lungs, liver, adrenals, skin and bone.1,3 The involvement of female reproductive organs is rare, and the involvement of the uterus is extremely rare; to our knowledge only 10 cases of RCC with metastasis to the uterine endometrium/cervix have been published in the current literature.2,4–6 Our case represents the first case of RCC with metastasis to the myometrium.
Case Report A 60-year-old African–American female patient initially presented to us with vague abdominal pain. Computed tomography (CT) revealed bilateral small renal masses suspicious for RCC. She underwent an uneventful robotic right partial nephrectomy followed
by a left robotic partial nephrectomy 2 months later. Final pathology from both tumors showed clear cell RCC with negative resection margins (stage pT1a), right: 3.1 cm, Fuhrman Grade 2; left: 0.7 cm, Fuhrman grade 1. A follow-up CT scan showed a partially necrotic 6-cm mass within the uterus. Based on her history of pelvic pain and her initial CT, which showed a calcified 3.9-cm mass in the left uterus (Fig. 1a), a presumed diagnosis of an enlarging uterine fibroid was made. Twenty-one months after her initial kidney surgery, the patient was complaining of worsening pelvic discomfort. A CT scan showed a 15-cm left pelvic mass with cystic and solid components. The mass was indistinct from the uterus, and it extended to the mid-abdomen (Fig. 1b). The patient was referred to gynecology–oncology and underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and resection of pelvic mass, for a presumed primary ovarian tumor. Final pathology demonstrated metastatic clear cell RCC involving the myometrium
Received: September 19 2013. Accepted: January 15 2014. Reprint request to: Mr Haider M. Rahbar, Vattikuti Urology Institute, Henry Ford Health System, 2799 W. Grand Boulevard, Detroit, Michigan 48202, USA. Email: [email protected]
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© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
RCC with metastasis to myometrium
a
Figure 2 Histopathology slide demonstrating metastatic clear cell renal cell carcinoma involving the myometrium (hematoxylin–eosin).
b
Postoperatively, the patient was initiated on sunitinib malate (Sutent) for metastatic RCC. Her disease progressed over the next several months to widespread metastatic disease involving the chest, abdomen, and pelvis. The patient was transferred to hospice care and died of metastatic RCC.
Discussion
Figure 1 (a) Contrast computed tomography (CT) scan showing 3.9 cm × 2.9-cm calcified mass in the uterus (initially presumed to be a uterine fibroid). (b) Noncontrast CT showing partially necrotic hypodense lesion measuring 15 cm × 12 cm × 13 cm, indistinct from the uterus.
(Fig. 2). The para-ovarian and small bowel mesentery were also positive for metastatic RCC. The ovaries, fallopian tubes, cervix, endometrium, pelvic and paraaortic lymph nodes were negative for malignancy.
RCC is well known for its ability to metastasize to any organ, but the involvement of gynecological organs is rare.2 The lower third of the vagina is the most commonly involved gynecological organ, with only 85 cases reported in the literature.2,7 Involvement of the ovaries and uterus is particularly rare, but it has been reported in the published work. To our knowledge, RCC metastasis to the myometrium has not been previously published.2 The endometrium and the cervix were spared in this patient. The finding of a mass within the myometrium is most consistent with leiomyoma and rarely leiomyosarcoma.8 Based on 1-year follow-up CT scan, the mass within the uterus was believed to be leiomyoma, but subsequently the mass was confirmed to be metastatic RCC. The rarity of metastatic RCC to the uterus made the initial diagnosis of metastatic disease unlikely; additionally the mass was within the myometrium. The mechanism of metastasis to the female reproductive tract is unknown. There are four proposed methods of metastasis to the reproductive tract: retrograde venous, hematogenous via systemic circulation,
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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H. M. Rahbar et al.
retrograde lymphogenic, and migration of tumor via the urinary tract.2,9 Retrograde venous spread is the most likely method, and the proposed method is the direct connection between the left renal vein and the left ovarian vein and subsequent ovarian– uterovaginal venous plexus.2,4 This proposed mechanism is supported by the fact that left-side RCC is more likely to spread to the female reproductive tract.3,4 Valappil et al. showed that 66% of metastasis to the ovaries was from left-side RCC.10 Early ligation of the gonadal vein might prevent migration of neoplastic cells to gynecological organs.3,7 In our patient, this was not performed because she underwent nephronsparing surgery; the ligation of the ovarian vein is not standard practice. Hematogenous and lymphogenic spread are more likely options if the liver and lung are involved.9 Hematogenous spread cannot be ruled out in our patient as she developed lung metastasis. The ideal treatment and prognosis are unknown due to the rarity of metastatic RCC to the uterus. Overall, metastatic RCC has a poor outcome with an overall 5-year survival of 35% even with aggressive treatment for solitary metastasis.3 Surgical treatment seems the most plausible option in the absence of other metastatic lesions.6 Chemotherapeutic agents can be an option in more widespread disease. Our case represents the first case of a patient with bilateral conventional clear cell RCC with metastasis to the myometrium that was initially diagnosed as leiomyoma, and consequently was found to be metastatic RCC.
References 1. Guney S, Guney N, Ozcan D, Sayilgan T, Ozakin E. Ovarian metastasis of a primary renal cell carcinoma: Case report and review of literature. Eur J Gynaecol Oncol 2010; 31: 339–341. 2. Seseke F, Kugler A, Hemmerlein B, Gross AJ, Ringert RH. Metastasis from renal cell carcinoma to the cervix uteri. Scand J Urol Nephrol 1998; 32: 290–292. 3. Yokoyama Y, Sato S, Kawaguchi T, Saito Y. A case of concurrent uterine cervical adenocarcinoma and renal-cell carcinoma, and subsequent vaginal metastasis from the renal-cell carcinoma. J Obstet Gynaecol Res 1998; 24: 37–43. 4. Bozaci EA, Atabekoglu C, Sertçelik A, Unlü C, Ortaç F. Metachronous metastases from renal cell carcinoma to uterine cervix and vagina: Case report and review of literature. Gynecol Oncol 2005; 99: 232–235. 5. Tretheway D, Gebhardt J, Dogra V, Schiffhauer L. Metastatic versus primary oncocytic papillary adenocarcinoma of the endometrium: A report of a case and review of the literature. Int J Gynecol Pathol 2009; 28: 256–261. 6. Zafrakas M, Papanikolaou A, Venizelos I, Kellartzis D, Agorastos T, Bontis J. A rare case of renal cell carcinoma metastasizing to the uterine cervix. Eur J Gynaecol Oncol 2009; 30: 239–240. 7. Benbrahim Z, Chouaib A, Mazeron R et al. Gynecologic bleeding revealing vaginal metastasis of renal cell carcinoma. Pan Afr Med J 2013; 14: 62. 8. Van den Bosch T, Coosemans A, Morina M, Timmerman D, Amant F. Screening for uterine tumours. Best Pract Res Clin Obstet Gynaecol 2012; 26: 257–266. 9. Fossa S, Schjolseth D, Miller A. Multiple urothelial tumours with metastases to uterus and left ovary. A case report. Scand J Urol Nephrol 1977; 11: 81–84. 10. Valappil S, Toon P, Anandaram PS. Ovarian metastasis from primary renal cell carcinoma: Report of a case and review of literature. Gynecol Oncol 2004; 94: 846–849.
Disclosure None declared.
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© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
