Unpredictable recurrence following partial nephrectomy for chromophobe renal cell carcinoma on an ectopic kidney: Case report and review of literature

Abstract

Introduction

Renal cell carcinoma is one of the 10 most common malignancies. Partial nephrectomy (PN) is the preferred treatment for localized ones. The incidence of local recurrence (LR) after a PN varies between zero and 17% in the literature. Managing a LR following PN is a challenging situation, both ablation therapy and salvage surgery are viable options.

Case presentation

A 38-year-old woman with a history of a right open partial nephrectomy performed on an ectopic kidney four years ago, presented a loco regional recurrence, involving the right ovary and rectus muscle, which we managed by a radical nephrectomy with bilateral oophorectomy et resection of the rectus muscle nodules.

Clinical discussion

LR of RCC after PN presents a clinically challenging scenario. Treatment options include ablative therapy or surgical salvage therapy, which can be either by radical nephrectomy or by repeat partial nephrectomy. Ablative therapy has less complication rate and is preferred for small LR or on a solitary kidney. Repeat PN is also an option for preserving renal function but with high risk of complication. RN is an option if PN is technically challenging, especially in patients with a functional contralateral kidney.

Conclusion

Recurrent renal cell carcinoma (RCC) can manifest differently based on the primary treatment, as well as tumor and patient characteristics. Managing a LR following PN is a challenging situation, both ablation therapy and salvage surgery are viable options.

Highlights

• •The incidence of local recurrence after a partial nephrectomy varies between zero and 17%.
• •Its managing is a challenging situation.
• •Treatment options include ablative therapy or surgical salvage therapy.
• •Ablative therapy has less complication rate and is preferred for small local recurrence or on a solitary kidney.
• •Repeat PN is also an option for preserving renal function but with high risk of complication.

1. Introduction

Renal cell carcinoma (RCC) is one of the 10 most common malignancies, accounting for approximately 3–5% of malignant neoplasms in adults [1]. Partial nephrectomy (PN) is the preferred treatment for localized renal cell carcinoma (RCC), even when confronted with large tumors, delivering comparable oncological outcomes, superior results in renal function and overall survival compared to radical nephrectomy [2]. Contrarily, radical nephrectomy (RN) is recommended for patients facing locally advanced tumors involving vascular or extrarenal involvement [3]. Managing a local recurrence (LR) following partial nephrectomy (PN) is a challenging situation. Completion nephrectomy may represent the optimal therapeutic approach for these lesions, percutaneous ablation (PCA) is also a viable option.

We report an uncommon case of loco regional recurrence following partial nephrectomy for chromophobe renal cell carcinoma on an ectopic kidney. By sharing this case, we aim to improve the understanding of recurrence patterns and to guide the development of more effective management strategies for challenging cases. The work has been reported in line with the SCARE Guidelines 2023 criteria [4].

2. Case presentation

A 38-year-old woman, married with two children, with a history of a right open partial nephrectomy performed, four years ago, for a 5 cm lower pole mass on a pelvic kidney by Pfannenstiel approach, which the pathology indicated a chromophobe cell carcinoma, ISUP 2 and a surgical margin closely met and free from cancer cells, classified as pT1Nx.

As part of the follow-up examination, we discovered a right renal solidocystic mass on the TAP-CT (Fig. 1). Given the cystic nature of the condition, we completed the scan with an MRI, which revealed multiple heterogeneous tissue masses with isosignal T1, hypersignal T2, showing slight enhancement after contrast injection. The largest mass is exophytic and located at the lower pole, measuring 6 cm (Fig. 2a), displacing the right ovary without a clear interface. Additionally, the MRI revealed a left ovarian mass with two nodular muscular lesions of the rectus muscle having similar characteristics to the renal masses (Fig. 2b). Furthermore, the TAP-CT didn't show any distant secondary locations. After informing the patient and obtaining her consent for the surgical procedure and its potential complications, including the risk of bilateral oophorectomy, an indication for an open radical nephrectomy has been established.

Fig. 1.

CT scan image showing the solicystic mass of the right pelvic kidney.

Fig. 2.

Pelvic MRI showing the exophytic renal mass (a) with the left ovarian mass (b).

During the surgical procedure, we discovered that the right ovary was infiltrated by the renal mass and was adhered to the right kidney. A Monobloc surgery was performed, involving a right radical nephrectomy with ipsilateral oophorectomy (Fig. 3). Subsequently, we identified a suspicious left ovarian mass with suspicious characteristics on MRI. A decision was made to perform a left oophorectomy. Finally, both nodules in the right rectus muscle were resected.

Fig. 3.

: Image showing the monobloc specimen including a right radical nephrectomy with ipsilateral oophorectomy.

Histology of the Monobloc piece showed a chromophobe cell carcinoma (Fig. 4), with a tumor thrombus in the renal vein, involving perirenal fat and infiltration of the right ovary (Fig. 5). Additionally, the two nodules in the rectus muscle were infiltrated by tumor proliferation. The left ovary was free from tumor lesions.

Fig. 4.

Image showing the histologic aspect of the chromophobe RCC.

Fig. 5.

Image showing the histological aspect of the ovarian infiltration by the chromophobe RCC.

Following these results, the patient was referred to oncology for potential adjuvant therapy. The follow-up was based on a physical examination and TAP-CT three months post-surgery, revealing no signs of recurrence or secondary locations.

3. Discussion

Renal cell carcinoma (RCC) is the most common primary malignancy of the kidney, accounting for 2% of all cancers [3]. In recent decades, there has been an observed increase in the detection of localized RCC at stage T1a and rarely as a locally advanced or primary metastatic renal tumor [5]. That could be partially attributed to the extensive use of sectional imaging for unrelated symptoms.

Partial nephrectomy (PN) has become the preferred treatment for localized RCC at stage T1a–b. It can also be used for large tumors if technically feasible. Compared to open partial nephrectomy (OPN), minimally invasive partial nephrectomy (MIPN) showed significantly shorter hospital stays, reduced blood loss, lower transfusion rates, and fewer complications [6]. Moreover, MIPN has comparable oncologic outcomes to OPN and no difference was found in terms of operative time, warm ischemia time, estimated glomerular filtration rate decline, intraoperative complications, positive surgical margins, local recurrence, overall survival, and recurrence-free survival [7]. Alternatively, radical nephrectomy (RN) is recommended for patients with locally advanced tumors involving vascular or extrarenal involvement. Nonsurgical curative treatment options, such as ablative therapy (AT) and stereotactic ablative radiotherapy, may be proposed to some specific patients [8].

Recent years have seen an increase in the utilization of partial nephrectomy (PN) for more challenging, larger, and complex renal masses [9]. This has led to a general rise in the identification of tumors having adverse pathological features, including higher tumor grade, advanced tumor stage, unfavorable histological subtypes, and positive surgical margins [10], consequently, an increased incidence of oncological failures, particularly local recurrence (LR).

Local recurrence of RCC after PN presents a clinically challenging scenario. The incidence of local recurrence after a PN varies between zero and 17% depending on the series [11]. In addition to ensuring satisfactory cancer control, preserving sufficient renal function is crucial to avoid end-stage renal disease which is linked to increased rates of cardiovascular events, hospitalization, and mortality [12]. Several studies have assessed the oncological outcomes following PN and concluded that that a high pT stage, high grade, complex tumors and positive surgical margin was linked to an elevated risk of tumor recurrence [13].

Treatment options for patients experiencing a local recurrence after PN include ablative therapy or surgical salvage therapy, which can be either by RN or by repeat PN [3].

In the literature, ablative therapy following PN is considered the preferred approach when the primary goal is to achieve the lowest complication rates [3]. Several studies have reported few to no complications after AT, these recurrences following PN that were treated with ablation were small in general (median size 2 cm), and the success rate, defined as negative post-interventional imaging, was 100% in these studies [[14], [15], [16]]. Also, ablative therapy offers comparable oncological outcomes to salvage surgery in the short term, with improved preservation of renal function [17].

Salvage surgery stands as a viable option for recurrent RCC after PN, particularly when the tumor size or location is not conducive to thermal ablation. Both RN and repeat PN following an initial failed PN have been described as alternative approaches [3]. Repeat open PN has been demonstrated to be associated with favorable functional and oncological outcomes [18]. Repeat PN is preferable over RN in patients with a solitary kidney or in individuals with hereditary RCC [3]. However, the procedure can be technically challenging due to the increased risk of complications attributed to fibrosis [3]. Although radical nephrectomy has traditionally been deemed acceptable in this challenging scenario, as was the case with our patient, who additionally presented with multifocality and involvement of neighbor organs. However, RN is considered the least favorable due to its potential adverse effect on renal function [18].

However, no randomized studies have been published comparing the efficacy of surgical procedures versus systemic therapy alone. Furthermore, local treatment may play a role in delaying the need for systemic treatment and its associated toxicity [19]. Management of RCC recurrence should involve a multidisciplinary evaluation to consider a possible local treatment. Therefore, even in cases of slow growth RCC metastases, such as pancreatic metastases, surgical resection should be considered when an R0 resection is achievable, particularly in high-volume surgical centers, as surgical resection has been demonstrated to positively impact long-term oncological outcomes [20]. It is likely that combination therapy including newly available targeted therapies and immunotherapy used alongside surgical excision will be crucial for managing these patients in the future.

Several limitations affect the interpretation of this case report. It is based on a single patient, which may limit the generalizability of the results. The lack of long-term follow-up data limits assessment of the enduring efficacy and potential complications of the management strategy. Additionally, the unique presence of a pelvic kidney in this case may affect the applicability of the findings to patients with more common kidney locations.

4. Conclusion

Recurrent renal cell carcinoma (RCC) can manifest differently based on the primary treatment, as well as tumor and patient characteristics. For local recurrence after PN, both ablation and salvage surgery are viable options. Radical nephrectomy might be considered as an option in cases of recurrence when partial nephrectomy is technically challenging, especially in patients with a functional contralateral kidney.

Consent

A written consent was obtained from the patient to publish this case report and accompanying images.

Ethical approval

Ethical approval is not required as the case report does not contain any personal data. This decision was made in accordance with the guidelines of the Ibn Sina Hospital and University Mohammed V of Rabat Institutional Review Board.

Funding

No financial support or grant funding was received.

Author contribution

Adam El Aboudi, Jihad Lakssir, Imad Boualaoui: performed surgery, paper writing and editing.

Ahmed IBRAHIMI, Hachem El-SAYEGH, Yassine NOUINI: literature review, Supervision.

Adam El Aboudi, Jihad Lakssir: Manuscript editing, picture editing.

Guarantor

Adam El Aboudi M.D., Urology A Department, Ibn Sina University Hospital Center, Morocco.

Email: elaboudiadam2@gmail.com

Research registration number

Not applicable.

Conflict of interest statement

The authors assert that they do not have any competing interests pertaining to the subject matter discussed in this article.