Rare Metastatic Sites in mrcc: A Different Disease? Gerald H. Mickisch Center of Operative Urology Bremen, Germany

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1 Rare Metastatic Sites in mrcc: A Different Disease? Gerald H. Mickisch Center of Operative Urology Bremen, Germany

2 Incidence of RCC in Europe Approx 12 per Variation from geographic region, country, gender, age etc. RCC is a rare disease. mrcc is an even more rare disease (40-50%) of all cases over the years... and rare metastatic sites are usually described in form of case reports. An non-comprehensive list of rare sites include: skin metastasis, pancreatic metastasis, orbita metastasis, ovarian and vulva metastasis, subungual lesions etc. Ljungberg et al., Europ. Urol., 2011,60:215, Sountoulidis et al., J. Med. Case Reports, 2011,5:429

3 Surgical Therapy of RCC Resection of Local Recurrence V. renalis Aorta V. cava

4 Surgical Therapy of RCC Specimen of Local Recurrence V. renalis Aorta V. cava

5 Cutaneous Metastasis of RCC 1985 radical TX right side for crcc pt2pn0m cutaneous lesion (thought to be a local recurrence). Since then every 1 2 years solitary skin lesions, surgically removed skin metastasis to forehead. Surgically excised plus plastic dermal grafting solitary subungual lesion digital 3 left hand, removed by partial amputation exitus lethalis by cardiac infarction, apparently (no autopsy) free of disease.

6 Pancreas Metastasis of RCC 1989 radical TX right side for crcc pt3apn0m partly solid partly cystic lesion tail of pancreas 2,2 cm by CT scan. Origin unknown, but growing (2,5 cm 4 months later). Finally removed by tail resection. RCC metastasis, solitary new small lesions pancreas very close to previous resection line. Removed by partial pancreatectomy 2007 new lesion pancreas head, removed by Whipple s operation. NED since then.

7 Orbita Metastasis of RCC 63 year old white male, healthy Intermittant hematuria First presentation because of vision disturbances/exophtalmus Multiple metastatic sites, Lab.values within normal range

8 Orbita Metastasis of RCC CT brain 3 D CT

9 Orbita Metastasis of RCC CT abdomen-rcc CT thorax bony lesion

10 Diagnostic Procedures in RCC Limits of Caval Thrombus: US

11 Therapeutic Procedures in RCC Limits of Caval Thrombus

12 Surgical Therapy of RCC Lymphnode Dissection V. renalis Aorta V. cava

13 Targeted Therapy: efficacy in lymphnode metastasis 63 year old patient Prior to therapy under therapy

14 Targeted Therapy: efficacy in lung metastasis CT thorax - before therapy CT thorax under therapy

15 Targeted Therapy: efficacy in soft tissue and bony lesions Patient under therapy CT thorax under therapy

16 Targeted Therapy: efficacy in orbita metastasis CT-brain: before therapy after 6 month therapy

17 Orbita Metastasis of RCC Synchronous RRC right side, multiple metastasis plus orbita lesion which led to detection by visual disturbances. Tumornephrectomy plus lymph node dissection Targeted therapy with impressive response, orbita metastasis disappeared. First line TT 10 month, second line 7 month followed by BSC Exitus lethalis after of total of 24 month after initial diagnosis

18 Rare Metastatic Sites of RCC: Principles If this is the only organ site: Long-term survival possible, and therapy should include surgical removal wherever appropriate. If multiple organs are involved, prognosis follows the general rules of M+ disease. Rare sites have to be included in the treatment plan (signs and symptoms). Surgical therapy may be supportive in some cases, but back bone of therapy will be targeted therapy. There seems to be no reliable evidence that rare metastatic sites are a different disease.

19 Urgent Problems - Urologists help