Synchronous Locally Advanced Renal and Colonic Carcinoma—Case Report with Review of Literature

Introduction

Multiple primary tumours pose a clinical challenge in terms of timely diagnosis, proper pre- and intraoperative planning and providing a favourable oncological outcome. The most common tumours reported to occur simultaneously with renal cell carcinoma are prostate, bladder, lung, breast and colon [1]. Synchronous colorectal and renal malignancies have hitherto been known to be diagnosed mostly during radiological investigations, with patients being asymptomatic for the renal malignancy and it being early stage as compared with colorectal component. While upper urothelial malignancy and colorectal malignancy can be a part of spectrum of Lynch syndrome, the genetic association of clear cell carcinoma occurring in a patient with colorectal adenocarcinoma is not yet established. The importance of careful case selection for combining multivisceral radical surgeries cannot be understated. Various studies have stated increased morbidity and poor overall survival in patients with synchronous colorectal and renal malignancies. In the background of multiple previous studies on this phenomenon, we hereby report our modest experience of en bloc excision of synchronous renal cell carcinoma of right kidney with retro-hepatic IVC thrombectomy and right hemicolectomy with a favourable operative outcome.

Case Details

A 65-year-old, hypertensive gentleman presented to us with history of abdominal pain and backache of 4-week duration. He used to consume alcohol occasionally and had no family history of malignancies. On clinical examination, he was pale; there were no palpable supraclavicular nodes, and 8 × 6 cm intraperitoneal lump was palpable in the right lumbar region. A complete hemogram showed haemoglobin level of 6.8 g/dl, normal leucocyte and platelet count. Renal and liver function tests were unremarkable. An ultrasound of abdomen showed a 6 × 6 cm mass in mid pole of the right kidney with increased vascularity. Contrast-enhanced computed tomogram scan of the chest, abdomen and pelvis revealed 7.5 × 7.2 cm heterogeneously enhancing mass in mid pole of the right kidney with breach in perirenal fascia, extending into the right renal vein and inferior vena cava. The tumour thrombus was extending until retro-hepatic IVC (level II), and there were multiple pericolic, aortocaval and para-aortic lymph nodes. Ascending colon thickening with paracolic fat stranding was also noted; however, fat planes were preserved between renal and colonic lesion. There was no evidence of liver or lung metastases. Colonoscopy revealed a circumferential mass in the ascending colon just proximal to the hepatic flexure. Colonic biopsy confirmed well-differentiated adenocarcinoma of the right colon. Serum CEA level was 4.5 ng/ml. Clinico-radiological diagnosis of simultaneous double primary was confirmed, and the case was discussed in multidisciplinary meeting for further course of management. He received two units of packed cell transfusion preoperatively in view of low haemoglobin. Abdomen was entered by Makuuchi (reverse L) incision, and thorough exploration was done to rule out metastatic disease. Right hemicolectomy with complete mesocolic excision was done. Cecum and ileum were mobilized, and ileocolic pedicle was securely ligated at the origin. Ileum was transected, ileal mesentery divided up to middle colic pedicle. Right branch of the middle colic pedicle was dissected and secured. Transverse colon and mesocolon were then divided. Transverse colon and right colon with terminal ileum were reflected towards the right to expose the inferior vena cava (IVC) in retroperitoneum. Anaesthetist was instructed to preload the patient with fluids at this stage. IVC was then exposed in its entire length; proximal control was taken in retro-hepatic portion well above the thrombus level, and distal control was taken below the level of renal veins. Left renal vein was also dissected and looped. Right renal hilum was then dissected. Right renal artery was dissected behind the right renal vein and ligated. Vascular clamps were applied on distal IVC, left renal vein and proximal IVC in a chronological sequence. Clamping time was noted. Cavotomy was then performed at the level of right renal vein insertion and extended proximally. Tumour thrombus was gently separated from caval wall all around, and right renal vein was disconnected from IVC near its insertion. One assistant was continuously irrigating the operating field with heparinised solution during these steps. Cavotomy was then closed with polypropylene 5-0, and vascular clamps were removed. Vascular clamping time was 8 min. The kidney was mobilized all around, and the right ureter was ligated and cut. Specimen was removed en block (right radical nephrectomy and IVC thrombectomy with right radical hemicolectomy, Fig. 1). Operative time was 180 min with 400 ml blood loss. Postoperative recovery was smooth and uneventful. Patient was discharged on 7th postoperative day. Histopathology revealed conventional clear cell carcinoma with renal vein wall invasion (T3bN0M0) and moderately differentiated adenocarcinoma of ascending colon with 1 out of 21 regional nodes showing metastasis (pT2N1M0). On immunohistochemistry, colonic lesion was negative for microsatellite instability. Patient has completed adjuvant chemotherapy and is doing well at 6 months follow-up.

Fig. 1.

a, b and c Axial images of contrast-enhanced CT scan showing heterogeneously enhancing mass in mid pole of the right kidney with tumour thrombus extending into right renal vein and IVC. d Coronal image of a contrast-enhanced CT scan showing tumour thrombus extending into right renal vein and IVC. e Operative bed after removal of specimen. f En bloc specimen of right radical hemicolectomy with radical nephrectomy + IVC thrombectomy

Discussion

Synchronous malignancy of the colon and kidney is a well-documented entity in literature (Table 1). Warren et al. [17] estimated that urogenital and gastrointestinal tumours were the most common pairing of synchronous cancers. However, pathogenetic mechanisms for this association remain unknown. Herein, we report our experience of our case of simultaneous locally advanced renal cell carcinoma with ascending colon carcinoma. This was an interesting case as both primaries were in same area and initial impression was either renal cell carcinoma invading the colon or vice versa. However, a good quality CT scan was able to demonstrate the separate primaries with preserved fat planes between the ascending colon and right kidney. Proper surgical planning was also important as both the organs were in same anatomical quadrant in the peritoneal cavity. En bloc removal of both the tumours was also critical as removing right colon separately might have compromised on the circumferential margin as it was overlying the renal mass. Presence of a tumour thrombus in a renal vein and IVC also increase the magnitude of surgical exercise during the radical nephrectomy with need of special tactics to safely remove the tumour thrombus. Proximal extent of the tumour thrombus dictates the roadmap to the surgical approach in such cases. In our case, as thrombus was extending to retro-hepatic IVC, mobilization of the liver including caudate lobe was necessary to take the proximal control above the level of thrombus. Distal and left renal vein control was taken as described in case details. Careful preoperative planning involving anaesthesia team is of utmost importance in such extended radical surgeries for successful outcomes. After vigilant consideration of all these factors, our case was operated uneventfully, and postoperative course was also uneventful. There have been reports of laparoscopic excision of both tumours, but none have reported a simultaneous IVC thrombectomy with radical colectomy so far. Though the operative risk was increased by combining the resection of tumours with IVC thrombectomy, careful preoperative planning for good oncological and patient outcomes was essential.

Table 1.

Various studies describing synchronous RCC with CRC

Author (year)	Study detail	Salient features
Beisland C et al. [1] (2006)	Cohort study	Higher risk of other malignancies in RCC patients, 0.28% synchronous colonic cancers
Sato S et al. [2] (2004)	Prospective	1.25% incidence of synchronous colonic and renal malignancy, renal malignancy usually incidental and low stage, synchronous presentation is prognostic factor for survival
Calderwood AH et al. [3] (2008)	Retrospective	Increased risk of colorectal cancer after ureteral/renal pelvis malignancy but not with RCC
Rabbani F et al. [4] (1998)	Retrospective	2.3% incidence of synchronous CRC in patients with RCC
Sijmons RH et al. [5] (1998)	Retrospective	Lynch syndrome is associated with increased risk of TCC of upper urinary tract, no increase in risk of renal parenchymal malignancies
Steinhagen E et al. [6] (2012)	Retrospective	Synchronous RCC and CRC are not likely to be associated Lynch syndrome
Capra F et al. [7] (2003)	Retrospective	0.4% incidence of simultaneous CRC and RCC, RCC usually asymptomatic and incidentally diagnosed
O’Boyle KP et al. [8] (1989)	Case series	Six CRC patients with incidental, small synchronous and metachronous RCC
Bolognesi M et al. [9] (2014)	Case report	CRC with chromophobe RCC, importance of radiological investigations in detecting asymptomatic synchronous primaries
Kozokic A et al. [10] (2011)	Case report	Early stage renal cell carcinoma and sigmoid adenocarcinoma
Papalampros AE et al. [11] (2011)	Case report	Coexistence of a colon carcinoma with a combination of two distinct renal cell carcinomas with different histological subtypes
O’Sullivan M et al. [12] (2015)	Case report	Laparoscopic approach for radical nephrectomy facilitated the CME, decreased hospital stay, less postoperative pain and morbidity, early return to work and better cosmesis
Babu M et al. [13] (2019)	Case report	pT3N0M0 clear cell carcinoma of kidney, no renal vein invasion and adenocarcinoma of rectum
Ferrer MM et al. [14] (2011)	Case report	Signet ring adenocarcinoma of the right colon (pT2N0) with clear cell carcinoma of the left kidney (pT1) in a patient of Lynch syndrome
Fazzin M et al. [15] (2013)	Case report	Multiple colonic tumours with RCC, single stage laparoscopic right radical nephrectomy with sigmoidectomy and right hemicolectomy
Perrin H et al. [16] (2015)	Case report	Totally robotic combined right hemicolectomy and nephrectomy
This Study*	Case report	Locally advanced renal and colonic tumours, single stage en bloc excision with IVC thrombectomy

RCC renal cell carcinoma, CRC colorectal carcinoma, TCC transitional cell carcinoma, IVC inferior vena cava

Multiple primary tumours have been studied and reported since the first paper by Billroth [18] in 1889. Warren et al. [1] has described the criteria for multiple primary tumours, which includes histologically confirmed tumours (each of them) and geographically separate-distinct tumours separated by normal mucosa, and the probability of one being the metastasis of the other is excluded. Multiple cohort studies have been reported in literature demonstrating the association of colonic and renal tumours (Beisland et al. [1], Sato S. et al. [2], Calderwood AH et al. [3], Rabbani et al. [4], O’Boyle KP et al. [8], Asati V et al. [13], Kozokic et al. [10], Onishi et al. [19]). Reported incidence of multiple primaries in RCC (either synchronous or metachronous) is around 20–40%, out of which around 10–15% were synchronous and 2–3% were colonic malignancies. Rabbani et al. [4] reported that 209 patients out of 763 patients (27.4%) with RCC had another primary cancer, of whom 104 cases (13.6%) were synchronous. Fourteen of these patients had concomitant colorectal cancers (1.8%). Other common malignancies in these patients were breast, prostate, urinary bladder and non-Hodgkin’s lymphoma. Although the probability of developing second primary was higher in RCC patients, incidence of colorectal cancers in these patients was not higher than general population. On the contrary, Koumarianou AA et al. [20] observed that patients with urological malignancies are at a higher risk for developing subsequent colonic cancer than the general population and vice versa. They assumed that this two-directional associations might be driven by common environmental risk factors (smoking, diet, carcinogens, etc.), screening bias, a shared genetic predisposition (mismatch repair defect) or by the effect of treatment of one type of cancer on the other. Sato S et al. [2] found that association of other primary malignancies at the time of nephrectomy for renal cell carcinoma was an independent prognostic factor for overall survival after the operation. Also, patients with localized renal cell carcinoma (T1, 2) and coexistent other cancer had poorer overall survival than those with localized renal cell carcinoma alone. Also, at this point, we need to acknowledge the fact that many of the synchronous malignancies are asymptomatic (particularly the renal tumours) and are incidentally detected during imaging for the colonic malignancy [21]. Also, to the best of our knowledge, this is the first case of synchronous locally advanced renal and colonic primaries to be reported from India.

Authors’ Contribution

Synchronous presentation of locally advanced tumours of the kidney and colon is uncommon entity. Decision-making in such scenario is based on thorough understanding of the clinical features and principles of surgical oncology. Perhaps, this is the first case report from India, describing management of synchronous locally advanced colonic and renal tumours.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethics Statement

Written and verbal consent/permission was obtained from patient for publishing the case details.