Endoscopic management of kidney cancer solitary metastasis to the contralateral ureter: a case report and review of literature

Endoscopic management of kidney cancer solitary metastasis to the contralateral ureter: a case report and review of literature

Kristian Krpina¹, Juraj Ahel¹, Nino Rubinić¹, Ivan Vukelić¹, Mauro Materljan¹, Marin Trošelj¹, Dean Markić¹

1  Department of Urology, Clinical Hospital Center Rijeka, Croatia

Introduction
Kidney cancer accounts for approximately 2-3% of all the adult malignancies, and the incidence is increasing. Approximately one-third of patients experience disease relapse as either a local recurrence or distant metastasis, after the primary surgery for the renal tumors.
In population-based databases such as the Surveillance, Epidemiology, and End-Results Database (SEER) and the National Swedish Kidney Cancer Quality Register (NSKCR), the reported proportion of synchronous metastasis ( SM ) from the SEER database ranged from 3% to 6% and in the NSKCR study it was 7%. On the other hand, diagnosis of metastases precedes RCC diagnosis in only 5% of cases. The most frequent localizations, in order of frequency, are the lungs, bones, liver, lymph nodes, adrenals, and brain. However, RCC metastases have been described in virtually every organ of the human body.
Hereby, we present a case of a patient in whom diagnosis of metastatic lesion preceeded primary tumor diagnosis, and in whom only surgical treatment for mRCC was done.

Case report
In March 2015. a 84-years old male was reffered to nephrologist. During his annual routine general-practitioner check-up elevated levels of creatinine were established. His previous medical history was not contributary. Nephrologist diagnosed him with chronic kidney insuficiency ( CKI ) grade II, but also established 1st degree hydronephrotic changes of left kidney on ultrasound so he was sent to urologist. Subsequential diagnostic procedure included CT scan and left-side retrograde ureteropyelography ( RUP ). In regard to his CKI CT was done without contrast and it was described as non remarkable. Left-side RUP showed filling defect in proximal part of ureter. Subsequently on March 3rd 2015. left side semirigid ureterorenoscopy ( URS ) was done. Semirigid ureteroscopy demonstrated a smooth surfaced vascular pale pedunculated lesion on a narrow stalk extending into the lumen of the ureter. Dormia basket ( 1.9 French ZeroTip Nitinol basket ) was placed proximal to tumor and stalk was dissected with electricfibre ( cut 100 W ). Tumor lesion was „en bloc“ remowed. The pedicle base was fulgurated ( coagulation 60 W ). The ureter was secured with a 4.7 French 28 cm JJ stent. Pathologist report showed that it was a tumor lesion which could correspond, morphologicaly and immunohistochemically ( CD10 positive, vimentinpositive, CK 7positive, p63negative, CD 34 negative, TTF negative, napsin negative), to infiltration of clear-cell kidney cancer. Therefore further diagnostic procedure was initiated. MRI of abdomen and pelvis was done and it showed right-side kidney parenchymal tumor 4 cm in diameter located in close proximity to renal sinus and hilum. The size and position of the renal mass meant that, according to RENAL nephrometry score, it had high-grade of complexity to nephron sparing surgery. After consultation with the patient it was decided to do a nephrectomy which was subsequently performed. Patohistological finding showed clear-cell kidney cancer, pT3a, Furhman grade II, R0. Since there were no signs of disseminated disease on radiological work-up patient was scheduled for regular oncological check-up and an appointment to nephrologist was made. He was confirmed with CKI grade II. On the check-up in February 2016. MRI did not show any signs of recurrent or progression of the disease. There are no changes in the left ureter so we conclude that the patient did not develope localised strictures and therefore does not need long-term stenting.

Discussion
The robust clinical responses of targeted therapy have revitalized the treatment of metastatic renal cell carcinoma. Targeted drugs, such as sunitinib, sorafenib, everolimus, and bevacizumab, have improved the tumor response rate and changed the treatment algorithms of mRCC in recent years. Each of these molecular targeted therapies offers some new perspectives, each with their own efficacy and side effects. However, the complete response rate is rather low, and none of the drugs are curative. The role of metastasectomy in an era of targeted therapy is an actively researched field.

Conclusion
We presented a case of a mRCC patient whose complete treatment was surgical. Clinical guidelines for the medical treatment exist, but the real question lies in the individual treatment of each patient. Surgery as part of a multimodal treatment of mRCC is a potential way to improve the long term survival.