DOI: https://doi.org/10.21203/rs.3.rs-1163227/v1
Lung carcinoma is the most common cause of cancer-related death worldwide. Despite the use of effective treatments in Non-Small Cell Lung Carcinoma (NSCLC), survival is still unsatisfactory. In this article, I will present a patient who was diagnosed with squamous cell lung cancer (SCC) after an incidentally detected kidney mass was operated with a preliminary diagnosis of Renal Cell Cancer (RCC).
Lung cancer is divided into two main groups as small cell lung cancer (SCLC) and NSCLC. NSCLC is the main subtype of lung cancer. Squamous cell carcinoma, a subtype of NSCLC, accounts for approximately 40% of all NSCLC. [1] In these patients, metastases may be present at the time of diagnosis, and metastases that develop after definitive treatments are also common. Most metastasis sites of NSCLC; brain, liver, surrenal and bone. [2] However, it rarely metastasizes to the kidney and is usually detected in autopsy series. [3] In the literature review, NSCLC articles with kidney metastases were generally presented as case reports. This case is interesting because the patient who presented with a mass in the kidney was diagnosed with squamous cell cancer metastasis after the operation. Nephrectomy was performed with a radiological diagnosis of RCC. However, as a result of post-operative pathological evaluation, it was determined that the renal mass was lung carcinoma metastasis.
A 66-year-old male patient was referred to our center because of abdominal pain and a mass in the kidney on ultrasound (USG). Abdominal computed tomography (CT) was performed on the patient who applied to the urology outpatient clinic. In the abdominal CT imaging, a 3x4 cm (cm) mass was detected in the lower pole of the left kidney. At the same time, the lesion was evaluated by performing abdominal Magnetic Resonance Image (MRI). The patient's abdominal CT and abdominal MR images are shown in Figure-1. As a result of the examinations, the preliminary diagnosis was evaluated as RCC by the radiologist. In addition, it was observed that the patient had 1 mass that was evaluated as metastasis in thorax CT. Laparoscopic nephrectomy and left perirenal lymph node dissection were planned for the patient's kidney mass. In the pathological evaluation after nephrectomy, squamous cell carcinoma was detected. It was determined that the largest tumor diameter was 4.5X3X4 cm, in 6 foci. In addition, the tumor was positive in the lymph nodes, and the surgical margin was positive in the perirenal fatty tissue and sinus fatty tissue. In the post-operative positron emission tomography (PET), no tumor focus other than the primary lung cancer was detected. PET/CT image of the patient is shown in Figure-2. At this stage, the patient applied to our oncology outpatient clinic. The result of bronchoscopic biopsy performed from the mass in the lung was also reported as p40 positive and TTF-1 negative staining, which was consistent with SCC. For the treatment of the patient; If surgery as a lobectomy is possible, it was decided to operate on the primary mass in the lung, followed by adjuvant chemotherapy and radiotherapy to the renal surgical border area. However, if medically inoperable or pneumonectomy would be required, it was decided to offer the patient the option of definitive chemoradiotherapy. After this stage, the patient's treatment was evaluated in the oncological tumor board.
Although the kidney is an organ with high blood supply, it is rarely the site of metastasis of solid organ tumors. Despite this, tumors that metastasize to the kidney frequently; lung, colorectal, breast, soft tissue tumors and thyroid cancer. [4] Renal metastases are usually asymptomatic and detected on radiological scans. There are no studies with large number of patients on tumors that have metastasized to the kidney. Ademy et al. In a study of 15 patients that he published, gross hematuria was observed in 15% of [5] patients, and most of the patients were diagnosed with renal metastasis as a result of radiological examinations. In the same study, it was stated that surgical resection and metastasectomy in patients with solitary renal metastases was an aggressive approach and stereotactic body radiotherapy (SBRT) could be used as an alternative. Of course, in the vast majority of patients, there is no isolated renal metastasis, but it is usually part of disseminated disease or bilateral renal metastases. 6, 7 In addition, there are no prospective randomized controlled studies in the literature due to the low number of patients with lung cancer and isolated renal metastases. Therefore, the treatment of these patients should be decided individually.
I think that this case will contribute to the literature. Almost all of the cases reported in the literature are patients with lung carcinoma diagnosed at an early stage and relapsed with isolated renal metastasis after definitive treatment. The uniqueness of our patient is that he had isolated metastasis at the time of diagnosis and was operated on because this metastasis was radiologically in RCC morphology. The missing part in the treatment of this patient is that he was not presented to the oncological tumor board before surgery. The solid lesion in the lung is more similar to primary lung carcinoma than metastasis. Every patient diagnosed with cancer should be evaluated in the tumor board, and the patient's treatment plan should be made as a result of the consensus of each branch participating in the board. Physicians with different perspectives should decide together on the treatment of each oncological case. This case clearly demonstrated the importance of oncological tumor board.
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