RENAL CARCINOMA AFTER LAPAROSCOPIC CYST DECORTICATION
1
RENAL CARCINOMA AFTER LAPAROSCOPIC CYST DECORTICATION MAXWELL V. MENG, GARY D. GROSSFELD AND MARSHALL L. STOLLER From the Department of Urology, University of California School of Medicine, San Francisco, California KEY WORDS: kidney, cystic; laparoscopy; postoperative complications; renal cell carcinoma Decortication of symptomatic simple renal cysts was one of the earliest applications of laparoscopy in urology. 1, 2 This procedure has been demonstrated to be a feasible, safe and effective means of treating simple cysts causing pain. 2 We report the development of disseminated renal cell carcinoma shortly after laparoscopic decortication of a seemingly simple renal cyst. CASE REPORT A 60-year-old man presented with left flank pain 1 year in duration. Abdominal computerized tomography (CT) and ul- trasonography demonstrated a 10 12.5 20 cm. simple cyst in the left kidney (part A of figure). The patient under- went uncomplicated 4 port transperitoneal cyst decortica- tion. Intraoperative examination of the cyst base did not reveal any suspicious areas prior to fulguration. Final patho- logical evaluation showed the cyst wall was benign. Seven months postoperatively CT for recurrent pain re- vealed a solid contrast enhancing left renal mass, lymphad- enopathy and metastases to the liver and lung (part B of figure). Four subcutaneous nodules were palpable near the port sites. As part of an immunotherapy protocol the left kidney was removed en bloc with the left colon and spleen. Regional lymph nodes and multiple peritoneal lesions were also excised. Pathological examination confirmed chromophil and sarcomatoid renal carcinoma (Fuhrman grade 4) in all specimens, stage pT4N2M1. DISCUSSION Laparoscopic decortication is an option for treating symp- tomatic Bosniak category I renal cysts. To our knowledge there have been no reports of malignancy developing after this procedure. Despite the absence of suspicious features on preoperative imaging and a benign pathological examination, the original lesion in this case was likely a cystic renal cell carcinoma. Our case illustrates a disastrous outcome of laparoscopic management of an apparently simple cyst, and highlights several issues. The growing popularity of laparoscopy will result in increased numbers of laparoscopic cyst decortica- tions because it offers an ideal situation for developing lapa- roscopic skills. We caution, however, that one must recognize the potential for cystic renal carcinoma. Careful review of preoperative imaging, intraoperative examination of the cyst and submission of specimens (cyst wall and fluid) for patho- logical evaluation are necessary aspects of management. In addition, some have used laparoscopy to evaluate indetermi- nate Bosniak category II and III cysts. 3 Santiago et al dis- covered 5 cases (14%) of renal cell carcinoma, but reported no evidence of local recurrence or metastatic disease after ne- phrectomy with a mean followup of 20.2 months. 3 The out- come in this case decreases our enthusiasm for this approach. False-negative frozen section and permanent pathological analyses may delay accurate diagnosis and prompt therapy. More importantly, if an underlying cancer is discovered, the process of laparoscopic decortication may facilitate tumor spread. The initial tumor in our case was likely small and confined to the kidney. However, not only did the cancer recur locally with invasion of adjacent structures, but it also was disseminated to the peritoneal surface and distant or- gans. Laparoscopy may have contributed to the widespread, rapid development of metastases with cyst fluid spillage and insufflation associated dissemination as possible mecha- nisms. This is the first reported case of renal carcinoma following laparoscopic decortication of a simple cyst. Our experience should raise awareness of possible underlying malignancy in “simple” cysts and a potential risk associated with laparos- copy. REFERENCES 1. Stoller, M. L., Irby, P. B., 3rd, Osman, M. et al: Laparoscopic marsupialization of a simple renal cyst. J Urol, 150: 1486, 1993 2. Pearle, M. S. P., Traxer, O. and Cadeddu, J. A.: Renal cystic disease. Laparoscopic management. Urol Clin North Am, 27: 661, 2000 3. Santiago, L., Yamaguchi, R., Kaswick, J. et al: Laparoscopic management of indeterminate renal cysts. Urology, 52: 379, 1998 Accepted for publication October 5, 2001. A, preoperative CT demonstrates simple left renal cyst. B, postoperative CT shows solid left renal mass, hilar lymphadenopathy and likely local invasion. 0022-5347/02/1673-1396/0 THE JOURNAL OF UROLOGY ® Vol. 167, 1396, March 2002 Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION,INC. ® Printed in U.S.A. 1396
-
Upload
marshall-l -
Category
Documents
-
view
218 -
download
3
Transcript of RENAL CARCINOMA AFTER LAPAROSCOPIC CYST DECORTICATION
RENAL CARCINOMA AFTER LAPAROSCOPIC CYST DECORTICATION
MAXWELL V. MENG, GARY D. GROSSFELD AND MARSHALL L. STOLLERFrom the Department of Urology, University of California School of Medicine, San Francisco, California
KEY WORDS: kidney, cystic; laparoscopy; postoperative complications; renal cell carcinoma
Decortication of symptomatic simple renal cysts was one ofthe earliest applications of laparoscopy in urology.1, 2 Thisprocedure has been demonstrated to be a feasible, safe andeffective means of treating simple cysts causing pain.2 Wereport the development of disseminated renal cell carcinomashortly after laparoscopic decortication of a seemingly simplerenal cyst.
CASE REPORT
A 60-year-old man presented with left flank pain 1 year induration. Abdominal computerized tomography (CT) and ul-trasonography demonstrated a 10 � 12.5 � 20 cm. simplecyst in the left kidney (part A of figure). The patient under-went uncomplicated 4 port transperitoneal cyst decortica-tion. Intraoperative examination of the cyst base did notreveal any suspicious areas prior to fulguration. Final patho-logical evaluation showed the cyst wall was benign.
Seven months postoperatively CT for recurrent pain re-vealed a solid contrast enhancing left renal mass, lymphad-enopathy and metastases to the liver and lung (part B offigure). Four subcutaneous nodules were palpable near theport sites. As part of an immunotherapy protocol the leftkidney was removed en bloc with the left colon and spleen.Regional lymph nodes and multiple peritoneal lesions werealso excised. Pathological examination confirmed chromophiland sarcomatoid renal carcinoma (Fuhrman grade 4) in allspecimens, stage pT4N2M1.
DISCUSSION
Laparoscopic decortication is an option for treating symp-tomatic Bosniak category I renal cysts. To our knowledgethere have been no reports of malignancy developing afterthis procedure. Despite the absence of suspicious features onpreoperative imaging and a benign pathological examination,the original lesion in this case was likely a cystic renal cellcarcinoma.
Our case illustrates a disastrous outcome of laparoscopicmanagement of an apparently simple cyst, and highlightsseveral issues. The growing popularity of laparoscopy will
result in increased numbers of laparoscopic cyst decortica-tions because it offers an ideal situation for developing lapa-roscopic skills. We caution, however, that one must recognizethe potential for cystic renal carcinoma. Careful review ofpreoperative imaging, intraoperative examination of the cystand submission of specimens (cyst wall and fluid) for patho-logical evaluation are necessary aspects of management. Inaddition, some have used laparoscopy to evaluate indetermi-nate Bosniak category II and III cysts.3 Santiago et al dis-covered 5 cases (14%) of renal cell carcinoma, but reported noevidence of local recurrence or metastatic disease after ne-phrectomy with a mean followup of 20.2 months.3 The out-come in this case decreases our enthusiasm for this approach.False-negative frozen section and permanent pathologicalanalyses may delay accurate diagnosis and prompt therapy.More importantly, if an underlying cancer is discovered, theprocess of laparoscopic decortication may facilitate tumorspread. The initial tumor in our case was likely small andconfined to the kidney. However, not only did the cancerrecur locally with invasion of adjacent structures, but it alsowas disseminated to the peritoneal surface and distant or-gans. Laparoscopy may have contributed to the widespread,rapid development of metastases with cyst fluid spillage andinsufflation associated dissemination as possible mecha-nisms.
This is the first reported case of renal carcinoma followinglaparoscopic decortication of a simple cyst. Our experienceshould raise awareness of possible underlying malignancy in“simple” cysts and a potential risk associated with laparos-copy.
REFERENCES
1. Stoller, M. L., Irby, P. B., 3rd, Osman, M. et al: Laparoscopicmarsupialization of a simple renal cyst. J Urol, 150: 1486,1993
2. Pearle, M. S. P., Traxer, O. and Cadeddu, J. A.: Renal cysticdisease. Laparoscopic management. Urol Clin North Am, 27:661, 2000
3. Santiago, L., Yamaguchi, R., Kaswick, J. et al: Laparoscopicmanagement of indeterminate renal cysts. Urology, 52: 379,1998Accepted for publication October 5, 2001.
A, preoperative CT demonstrates simple left renal cyst. B, postoperative CT shows solid left renal mass, hilar lymphadenopathy and likelylocal invasion.
0022-5347/02/1673-1396/0THE JOURNAL OF UROLOGY® Vol. 167, 1396, March 2002Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.® Printed in U.S.A.
1396
