Seeding Metastasis of Chromophobe Renal Cell Carcinoma after Robot-Assisted Laparoscopic Partial Nephrectomy

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1 pissn eissn imri 2017;21: Seeding Metstsis of Chromophoe Renl Cell Crcinom fter Root-Assisted Lproscopic Prtil Nephrectomy Knghun Lee, Moon Hyung Choi Deprtment of Rdiology, Seoul St. Mry s Hospitl, College of Medicine, The Ctholic University of Kore, Seoul, Kore Cse Report Received: April 27, 2017 Revised: My 15, 2017 Accepted: My 25, 2017 Correspondence to: Moon Hyung Choi, M.D. Deprtment of Rdiology, Seoul St. Mry s Hospitl, College of Medicine, The Ctholic University of Kore, #222 Bnpodero, Seocho-gu, Seoul 06591, Kore. Tel Fx E-mil: cmh@ctholic.c.kr This is n Open Access rticle distriuted under the terms of the Cretive Commons Attriution Non-Commercil License ( y-nc/3.0/) which permits unrestricted non-commercil use, distriution, nd reproduction in ny medium, provided the originl work is properly cited. Copyright 2017 Koren Society of Mgnetic Resonnce in Medicine (KSMRM) Chromophoe renl cell crcinom (RCC) is n uncommon sutype of RCC hving etter prognosis thn cler cell RCC. Although there re severl reports of seeding metstsis of RCC fter iopsy, seeding metstsis of chromophoe RCC fter surgicl resection hs seldom een reported. Here, we descrie cse of multiple seeding metstses in the domen nd pelvis 78 months fter root-ssisted lproscopic prtil nephrectomy, without prior history of iopsy for chromophoe RCC in the right kidney. As mgnetic resonnce imging (MRI) of the pelvic mss showed similr ppernce to the primry renl mss nd displyed seprte mrgins with the rectum nd prostte glnd, we were le to mke dignosis efore pthologic confirmtion. Keywords: Chromophoe renl cell crcinom; Seeding metstsis; Prtil nephrectomy; Mgnetic resonnce imging INTRODUCTION Chromophoe renl cell crcinom (RCC) is the third most common sutype, ccounting for out 5% of ll RCCs. As metstsis is rre in this sutype, chromophoe RCC hs more fvorle prognosis thn other RCC sutypes (1). Although seeding metstsis is very rre in RCC, severl cses of metstsis hve een reported, due to seeding of RCCs long the needle trct fter iopsy (2). However, there hs een no such report of metstsis in chromophoe RCC. Cses of seeding metstsis of RCC detected efore or fter resection of tumor hve een reported previously (3). Although one cse of chromophoe RCC with seeding metstsis ws included in tht rticle, timing of the dignosis of seeding metstsis nd surgicl resection method were not specified. There is one report out seeding metstsis of ppillry RCC fter prtil nephrectomy due to intropertive disruption of hemtom, where preopertive iopsy ws performed. In this study, we report rre cse of seeding metstsis of chromophoe RCC following root-ssisted lproscopic prtil nephrectomy without prior iopsy history. We further exmine the role of mgnetic resonnce imging (MRI) in differentiting metstses from pelvis tumors efore surgery. 119

2 Seeding Metstsis of Chromophoe RCC Knghun Lee, et l. CASE REPORT A 71-yer-old mn presented with n cute urinry trct ostruction nd difficulty defecting. The ptient hd history of root-ssisted lproscopic prtil nephrectomy for chromophoe RCC in the right kidney, 78 months previously. The RCC ws completely removed, nd the pthologic stge ws determined to e T1. There ws no recurrence on follow-up computed tomogrphy (CT) performed two yers fter surgery. Upon presenttion, dominl nd pelvic CT reveled n 11.4-cm-sized mss in the pelvic cvity. This lesion ws thought to e the cuse of the symptoms due to compression of the urinry ldder nd rectum. The lesion hd loulted contour with heterogeneous enhncement, nd non-enhncing portion in the center. A second similr tumor, 5.6 cm in size, ws found ner the gstric ntrum in the right upper qudrnt (RUQ) of the domen (Fig. 1). As the pelvic mss ws locted etween the urinry ldder nd rectum, nd the prostte glnd ws not visile on the CT scn, we suspected tht the mss originted from the prostte glnd or the exophytic rectl mss. The RUQ mss ws thus considered to e seeding metstsis from the pelvic mss. Evluting further, pelvic MRI ws performed using 3-T MRI unit (MAGNETOM Verio, Siemens Helthcre, Erlngen, Germny). The pelvic mss hd loulted contour nd heterogeneous signl intensities (SIs), which were low in the peripherl portion (similr to the signl intensities of the muscles), nd high in the centrl portion on T2-weighted imging (T2WI). A thin, low-signl intensity cpsule surrounded the mss. On contrst-enhnced T1- wighted imging (T1WI), the mss showed spoke-wheel-like enhncement t the peripherl T2-low SI portion, with no enhncement t the centrl T2-high SI re. The peripherl solid portion of the tumor showed high SI on diffusionweighted imging (DWI) nd low pprent diffusion coefficient (ADC) vlue. Sgittl imges showed tht the mss ws clerly distinguished from the nteriorly displced prostte glnd nd posteriorly displced rectum (Fig. 2). As MRI of the kidney hd een performed efore the prtil nephrectomy, we were le to compre chrcteristics of the resected RCC nd those of the newly developed pelvic mss. The primry RCC hd similr SI to the muscle lower thn the renl prenchym, with centrl high SI nd thin low SI cpsule on T2WI. A liner enhncement extending from the centrl portion with the spoke-wheel ppernce ws noted on contrst-enhnced T1WI (Fig. 3). We strongly suspected the possiility of seeding metstsis of the primry chromophoe RCC to the pelvic cvity, despite the extremely low incidence, since very similr MRI findings were oserved in the primry RCC nd the newly noted pelvic mss. To confirm this dignosis with histopthology, n ultrsound-guided trnsrectl iopsy ws performed. Hemtoxylin & Eosin (HE) stining showed typicl fetures Fig. 1. A 71-yer-old mn with n 11.4-cm-sized mss in the pelvic cvity. () Pelvic CT scn showed mss with loulted contour with heterogeneous enhncement nd non-enhncing portion in the center. The mss compressed the urinry ldder nd the rectum. () Adominl CT scn showed nother similr mss (rrow) in the right upper qudrnt (RUQ) of the domen. 120

3 d c Fig. 2. A 71-yer-old mn with n 11.4-cm-sized mss in the pelvic cvity. () T2-wegithed sgittl imge showed tht huge mss compressed the prostte glnd, wheres the rectum hd cler mrgin. () T2-weighted xil imge showed low signl intensity in peripherl portion nd high signl intensity in centrl portion of the mss, with thin low signl intensity cpsule. (c) Contrst-enhnced T1-weighted xil imge displyed heterogeneous enhncement of the mss. Diffusion-weighted imge (d) nd pprent diffusion coefficient (ADC) mp (e) showed definite diffusion restriction in peripherl solid portion. e 121

4 Seeding Metstsis of Chromophoe RCC Knghun Lee, et l. Fig. 3. Initil MRI of right kidney mss tht ws confirmed s chromophoe renl cell crcinom. The mss showed lower signl intensity thn the renl prenchym, with centrl high signl intensity portion nd thin low signl intensity cpsule, on T2-weighted coronl imge (). Contrst-enhnced T1-weighted coronl imge () showed the spoke-wheel-like enhncement in the mss (rrow). Fig. 4. The specimens otined y prtil resection of right kidney () nd ultrsound-guided trnsrectl iopsy (). The tumor showed typicl fetures of chromophoe RCC, including ple eosinophilic cytoplsm with distinct cell memrnes nd perinucler hlos (Hemtoxylin & Eosin stining, 400). of chromophoe RCC, including ple eosinophilic cytoplsm with distinct cell memrnes nd perinucler hlos. The pthologic fetures of the iopsied tissue were identicl to those of the primry chromophoe RCC (Fig. 4). Two seeding metstses were surgiclly removed, nd no recurrence ws detected six months fter surgery. DISCUSSION RCC encpsultes the mjority of mlignnt kidney tumors in dults. There re vrying sutypes of RCC, sed on their histologicl findings, ntomicl loction, nd moleculr ltertions (4). The most common sutypes re cler cell, ppillry, nd chromophoe RCCs, which represent 70%, 10-15%, nd 5% of ll RCC cses, respectively. The chromophoe sutype hs etter prognosis thn cler cell RCC. RCC usully metstsizes to the lung, one, lymph node, liver, drenl glnd, nd rin through hemtogenous nd lymphtic pthwys (5). Seeding metstses of RCC re rre, with previous study reporting merely 1% incidence of seeding metstsis of RCC (25 cses of metstsis of 122

5 ptients with RCC); there hs een only one reported cse of chromophoe RCC with seeding metstsis (3). These seeding metstses were detected within five months of the medin intervl fter surgery, nd most of them were locted on the ipsilterl side of the nephrectomy. Severl cses of seeding metstsis of RCC long the iopsy needle trct, nd seeding metstsis or port site metstses fter lproscopic urologicl surgery, hve rrely een reported (2, 6-8). High grde nd high stge of tumor proly hs role in tumor seeding. Seeding metstsis fter lproscopic surgery for RCC is rrer thn urothelil cell crcinom, especilly in cses of T1 pthologic stge or chromophoe RCC (3, 8-10). Although the mss in the RUQ re in our report could e port site metstsis, the pelvic mss ws not port site metstsis. As prtil nephrectomy could e chieved without morcelltion in our cse, chnces of seeding metstsis y tumor cell dissemintion ws extremely low. Moreover, to the est of our knowledge, there re no reported cses of seeding metstsis presenting s well-defined, lrge pelvic mss fter resection of chromophoe RCC. Here, we descrie the MRI findings of mss-forming seeding metstsis of chromophoe RCC fter root-ssisted lproscopic prtil nephrectomy. In our cse, the MRI ws very useful for differentil dignosis of the pelvic mss. On CT, the pelvic mss ws initilly considered to e primry tumor, nd the RUQ mss s seeding metstsis, despite the fct tht the ptient underwent surgery for RCC, in which seeding metstsis is extremely rre. Differentil dignoses of the huge pelvic mss locted posterior to the urinry ldder included unusul prostte srcom nd exophytic sumucosl rectl mss, such s gstrointestinl stroml tumor (GIST). MRI ws eneficil over CT in two wys. First, we could determine the reltionship of the tumor with djcent orgns. The prostte glnd, which could not e delineted on CT, ws clerly visile on MRI nd ws found to e flttened y the pelvic mss with distinct mrgin. The rectum ws posteriorly displced y the tumor, ut retined n intct rectl wll. Second, the chrcteristics of the pelvic mss could e compred with the initil MRI findings of the primry RCC. The pelvic mss exhiited very similr ppernce to the primry RCC, including loulted contour, low peripherl T2-SI with high centrl SI, thin T2-low SI cpsule, nd spoke-wheellike enhncement. These dt provide evidence for the occurrence of n extremely rre seeding metstsis from primry RCC. Different sutypes of kidney msses hve distinct MRI fetures. Chromophoe RCC usully hve heterogeneous hyper- or iso-signl intensity to the renl medull on T2WI (11). The common imging fetures of chromophoe RCC include peripherl loction, well-circumscried mrgin, nd hypovsculrity reltive to the renl cortex (12). Two different enhncement ptterns of chromophoe RCC were discovered in study on enhncement of renl tumors: 1) lower enhncement thn the renl medull in the corticomedullry phse with spoke-wheellike enhncement, nd 2) hyper-enhncement in the corticomedullry phse (11). In our cse, the primry RCC nd pelvic mss commonly showed lower enhncement thn the renl medull, s well s other typicl imging findings of chromophoe RCC. The well-circumscried mrgin of the seeding mss in our cse ws different from previous study tht showed ill-defined mrgins of seeding metstses of RCC (3). It is lso remrkle tht the intervl etween surgicl resection of the primry RCC nd detection of the seeding metstsis ws much longer, nd the size of the metstsis ws much lrger thn previously reported. These fetures could e explined y the lck of follow-up CT more thn two yers fter surgery, nd the reltively indolent ehvior of chromophoe RCC compred to other sutypes. The pelvic seeding metstsis seemed to grow slowly, with compression nd displcement of djcent orgns rther thn invsion. In conclusion, we report rre cse of seeding metstsis of chromophoe RCC presenting s lrge pelvic mss fter root-ssisted lproscopic prtil nephrectomy. Given its high soft tissue contrst, MRI proved useful for dignosis; the chrcteristic fetures of the new mss were found to e similr to those of the primry RCC. Awreness of the utility of MRI in dignosing these rre seeding metstses might prevent misdignosis nd llow for proper tumor mngement. REFERENCES 1. Cheville JC, Lohse CM, Zincke H, Wever AL, Blute ML. Comprisons of outcome nd prognostic fetures mong histologic sutypes of renl cell crcinom. Am J Surg Pthol 2003;27: Chng DT, Sur H, Lozinskiy M, Wllce DM. Needle trct seeding following percutneous iopsy of renl cell crcinom. Koren J Urol 2015;56: Prk SH, Oh YT, Jung DC, Cho NH, Choi YD, Prk SY. Adominl seeding of renl cell crcinom: rdiologic, 123

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