REGRESSION OF PULMONARY

METASTASES FROM

RENAL CARCINOMA ROBERT

WASKO,

M.D.

From the Department of Urology, Allentown General Hospital, Allentown, Pennsylvania

ABSTRACT - This article describes a patient who had a nephrectomy and hormone therapy fn- renal carcinoma. There was roentgenographic evidence of pulmonary metastases at the time of surgery. He was alive and showed no clinical or roentgenographic evidence of pulmonary metastases six and onehalf years after treatment.

Regression of pulmonary metastases from renal carcinoma is an uncommon event but has been reported in 40 instances.” Some controversy exists regarding the performance of nephrectomy in the presence of metastatic disease. Many authors believe nephrectomy is of little benefit with regard to prolongation of survival when metastases are present. Nonetheless, the following case report illustrates an apparent long-term survival with complete regression of pulmonary metastases following nephrectomy and hormone therapy. At present, the patient is alive six and one-half years after surgery and exhibits no signs or symptoms of tumor involvement either locally or in any other organ system. Case Report A fifty-nine-year-old Caucasian male was admitted to Allentown General Hospital January 20, 1969, because of fever of unknown origin, anemia, and a 36-pound weight loss over several months. Pulmonary symptoms were absent except for an infrequent, nonproductive cough. There was no flank or abdominal pain, and hematuria was not present. On initial physical examination the patient appeared chronically ill with a temperature of 101” F. Palpation revealed a mass in the right upper abdomen. During his hospital stay, the patient had daily temperature spikes to 102” F. for two weeks prior to surgery. Hemoglobin was 10 Gm. per 100 ml. on admission. Radiographic study of the kidneys

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revealed a large tumor of the lower pole of the right kidney approximately 10 cm. in diameter. Roentgenogram of the chest revealed several lesions compatible with metastases from renal carcinoma. Because of the patient’s deterioration, toxic fevers, and anemia it was decided to perform right nephrectomy despite the presence of presumed pulmonary metastases. At surgery a large carcinoma of the lower pole of the right kidney was found, and there was gross renal vein involvement. The liver was free of metastatic disease, and there were no local nodes involved with tumor. Histologically, the tumor was clear cell carcinoma of the right kidney. Postoperatively, the patient did remarkably well. His temperature became normal, and he was discharged on February 14, 1969, ten days after surgery. After discharge there was gradual clinical improvement, and on May 5, 1969, the patient was started on medroxyprogesterone (Depo-Provera), 500 mg. intramuscularly weekly. While on estrogen therapy, the pulmonary lesions appeared to enlarge and become more numerous. On July 31, 1969, the chest x-ray film revealed many “cannon ball” lesions compatible with metastases of pulmonary renal cell carcinoma (Fig. 1A). At this point estrogens were discontinued, and testosterone cypionate (Depo-Testosterone), 400 mg. intramuscularly weekly, was begun on August 27, 1969. Soon after the patient began to improve clinically. By November 6, 1969, regression of the pulmonary lesions was noted on

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FIGURE 1. Roentgenograms of chest. (A) Six months after surgery; patient on estrogen therapy. (B) Seventeen months after surgery and hormone therapy. (C) ]anuay 15, 1975, almost six years after surgery and hormone therapy.

This patient represents an unusual case of regression of pulmonary metastatic renal tumor with long-term survival. Although the chest lesions were not biopsied, the radiographs were extensively reviewed and were considered to be typical of metastatic renal tumor. Any explanation of the basis for the apparent tumor regression is speculative. Regression of pulmonary lesions has

been reported without nephrectomy as well as with radiation of suspected renal tumors.2-5 The role of hormone therapy in this patient is of interest in that large dose estrogen therapy was associated with proliferation of pulmonary lesions. Garfield and Kennedy6 cite experimental evidence that estrogens may be a factor in the cause of renal carcinoma. Because of possible hormone interaction with renal carcinoma, both androgens and estrogens have been used in the treatment of metastatic disease. Utilization of hormone therapy was undertaken in this patient in view of previously reported experiences which have shown some objective response in as high as 17.6 per cent of patients.‘** The possibility of immunologic factors and tumor regression must also be considered. Apparently, evidence is accumulating that certain patients with renal carcinoma have an immunocellular response which is specific to their own tumor.9 Additionally, infectious antibodies and a serum factor have been described with relation to the immunologic process and regression of renal tumor.1*6

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roentgenogram of the chest. On January 20, 1970, there was almost complete resolution of metastases. A representative chest x-ray film taken July 17, 1970, revealed no metastatic tumor (Fig. 1B). A roentgenogram ofthe chest taken January 15, 1975, showed no neoplasm (Fig. 1C). After ten months of intramuscular testosterone cypionate, oral testosterone therapy was begun, and he has been maintained on this hormone without any ill effects. His general health has remained reasonably good although episodes of congestive heart failure associated with azotemia have occurred intermittently over two years. Comment

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Conclusion

References

The mechanism for tumor regression in this patient is unknown. Nephrectomy and hormone therapy were utilized as treatment in a desperate situation. There is disagreement regarding the management of obviously metastatic renal tumor. 1o-12Whether this patient’s course would have been similar without nephrectomy and hormone therapy cannot be determined. However, considering his clinical condition prior to treatment, death from overwhelming renal carcinoma appeared imminent. At this writing, six and one-half years after treatment, he is alive and exhibits no signs of renal tumor either locally or in a metastatic location. Addendum On October 23, 1975, the patient died suddenly from acute myocardial infarction. Autopsy revealed no gross or microscopic evidence of residual or metastatic renal adenocarcinoma. 1111North 19th Street Allentown,

Pennsylvania

18104

ACKNOWLEDGMENT. Thanks to Mr. Jack Dittbrenner, Director, Biomedical Photography Department, Allentown and Sacred Heart Hospital Center, for his assistance in photographing the roentgenograms.

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1. HOLLAND, J. : Natural history and staging of renal cell carcinoma, CA 25: 121 (1975). Urol. 2. ADOLFSSON, G. : Regression of hypernephroma, Int. 21: 365 (1966). 3. EVERSON, T. C., and COLE, W. H.: Spontaneous Regression of Cancer, Philadelphia, W. B. Saunders Co., 1966, p. 11. 4. MARKEWITZ, M., TAYLOR, D. A., and VEENEMA, R. J. : Spontaneous regression ofpulmonary metastases following palliative nephrectomy, Cancer 20: 1147 (1967). regression of 5. RIDINGS, G. R. : Renal adenocarcinoma: pulmonary metastasis following irradiation of primary tumor, ibid. 27: 936 (1971). 6. GARFIELD, D. H., and KENNEDY, B. J.: Regression of metastatic renal cell carcinoma following nephrectomy, ibid 30: 190 (1972). tract: 7. BLOOM, H. J. G.: Cancer of the urogenital kidney. The basis for hormonal therapy, J.A.M.A. 204: 605 (1968). 8. TALLEY, R. W., et al. : Treatment of metastatic hypernephroma, ibid. 207: 322 (1969). cellular 9. STJERNSW~D, J., et al. : Tumor-distinctive immunity to renal carcinoma, Clin. Exp. Immunol. 6: 963 (1970). 10. MIDDLETON, R. G. : The value of surgery in metastatic renal carcinoma, in King, J. S., Jr., Ed.: Renal Neoplasia, Boston, Little Brown and Co., 1967, p. 483. 11. RAFLA, S. : Renal cell carcinoma; natural history and results of treatment, Cancer 25: 26 (1970). 12. JOHNSON, D., KAESLER, K., and SAMUELS, M.: Is nephrectomy justified in patients with metastatic renal carcinoma? J. Urol. 114: 27 (1975).

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Regression of pulmonary metastases from renal carcinoma.

This article describes a patient who had a nephrectomy and hormone therapy for renal carcinoma. There was roentgenographic evidence of pulmonary metas...
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