Case 1 was a 49 year-old male presenting with gross hematuria. He had a past medical history of coronary artery disease requiring stenting twice. His creatinine was 1.01 with a glomerular filtration rate (GFR) of 100. On computed tomography (CT) imaging, there was a 6.5 cm mass in the lower pole. He subsequently underwent right robotic-assisted laparoscopic partial nephrectomy (RPN) with pathology showing T3a clear cell renal cell carcinoma (RCC), Fuhrman grade 3. Two years after surgery, an isolated 5 mm pulmonary nodule was discovered on CT imaging. The following year, an additional 11 mm pulmonary nodule was discovered. He underwent video-assisted thoracic surgery with wedge resection with pathology revealing metastatic RCC.
Case 2 was a 72 year-old man with an incidentally found right renal mass on restaging for his multiple myeloma. He had a past medical history of (very) low-risk prostate cancer, multiple myeloma (with excellent prognosis), hypertension, benign prostatic hyperplasia, and obstructive sleep apnea. His creatinine was 1.51 with a GFR of 45. CT imaging showed a 2.8 cm posterior lower pole renal mass. Management options discussed included active surveillance, surgery, and ablation. He underwent right RPN with pathology showing T1a clear cell RCC, Fuhrman grade 2.
Case 3 was a 53 year-old man found to have bilateral renal masses. He had a past medical history of hypertension, hyperlipidemia, and obstructive sleep apnea. He had no family history of kidney cancer. His creatinine was 1.02 with a GFR of 78. CT imaging showed 5.8 cm renal mass on the left and a 3.6 cm renal mass on the right. The panelists discussed the options of a staged partial nephrectomy (left side first vs. right side first) or a bilateral partial nephrectomy. The patient underwent a staged RPN, right side first. Pathology of the right renal mass revealed a T1b papillary type 1 RCC; pathology of the left renal mass revealed a T1a papillary type 1 RCC. Annual imaging for five years showed no evidence of disease. At his ten year follow up, CT imaging showed multiple left-sided nodal masses of sizes 2.4 cm, 3.4 cm, and 5.3 cm. Biopsy of the nodal masses revealed metastatic papillary type 1 RCC. He underwent robotic-assisted laparoscopic retroperitoneal (para-aortic) lymph node dissection (RPLND) and pathology showed 5/20 lymph nodes positive for metastatic papillary type I RCC.
Case 4 was a 43 year-old woman with metastatic RCC presenting with gross hematuria and back pain. Her creatinine was 0.76 with a GFR of 96. CT imaging showed a 7 cm right-side renal mass and a 2 cm para-aortic nodal mass. Biopsy revealed papillary type II RCC. She underwent left robotic-assisted laparoscopic radical nephrectomy with RPLND. Pathology showed a poorly differentiated T3a papillary type II RCC and 8/31 positive lymph nodes. She was enrolled in a phase II clinical trial of bevacizumab and erlotinib and is currently showing partial response to therapy at three years following her surgery; her only site of metastasis is the left iliac bone.
Moderator(s): Mark Ball
Panelist(s): Georges Pascal Haber, Robert Uzzo, Sandy Srinivas, Sumanta Pal, and Louis Kavoussi
Written by: Michael Owyong, MD, Twitter: @ohyoungmike, Department of Urology, University of California-Irvine at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA