PRCC has a better prognosis after surgical treatment when compared to clear cell RCC and most of cases is linked to a lower stage and describe a lower risk of cancer-specific and overall mortality [1, 8–9].
PRCC is characterized by a significant heterogeneity observed in both histologic level and clinical evolution, with the postulation of two morphologically different entities that are linked to cytogenetic diversity [2–3]. Type 1 is constituted by small cells with basophilic cytoplasm, while type 2 by larger cells with eosinophilic cytoplasm. The two histologic subtypes lead to a different rate of recurrence and survival, where stage and lymph node involvement represent an important predictor of relapse.
Several studies identify the correlation between these parameters and both recurrence and survival. Margulis et al. studied 245 patients surgically treated for PRCC describing both tumor stage and lymph node involvement as independent predictors of disease-specific mortality .
Compared to clear cell tumors, PRCC is characterized by predisposition for regional lymph node spread with synchronous metastases at diagnosis . These findings are well linked with tumors larger than 8 cm .
Ledezma et al studied 627 patients with PRCC undergoing surgery and observed that 48 (8%) experienced relapse of which 10 out of 27 patients with papillary type 2 RCC exhibited metastatic disease in the lymph nodes, whereas most patients with type 1 PRCC (11/21) metastasized to the lungs .
According to Dekernion et al, the concomitant presence of local renal fossa recurrence in addition to a metastatic disease leads to a 40% of overall survival at 12 months . On the contrary, the absence of further metastases, showed that surgery was statistically superior for cause specific survival in patients with solitary cancer .
Russell et al identified 50 patients who underwent resection of isolated retroperitoneal lymphadenectomy (RPLN) recurrence of RCC after nephrectomy. They found that those patients with a longer interval from nephrectomy to RPLN recurrence had significantly decreased risks of progression after resection, suggesting that this variable may be used in patient selection .
Open surgical management has been most extensively documented, but the feasibility of laparoscopic management with or without hand assistance has been described only on a limited basis.
We opted to take advantage of robotic instrumentation in relation to the unique nature of these cases with the possibility of dealing with challenging adhesions often encountered in re-operative procedures.
We present the first description of minimally invasive surgical excision for a papillary type I renal cancer nodal recurrence, as well as renal fossa recurrence.
Our present study shows that patients treated with surgical excision for isolated RPLN recurrences may experience durable PFS and CSS. The patient at his least follow-up (24 months) was studied with PET-CT scan that confirmed the absence of local and distant recurrences. The impact of adjuvant therapy for type 1 PRCC (such as tyrosine kinase inhibitors) is still under investigation in literature, and only few reports are on subtype 1 PRCC not allowing to conclude about the role of systemic therapy in this tumour. Furthermore, in our case the therapy was discontinued after only 30 days for the onset of adverse events.
Present data show that surgical resection of isolated RPLN recurrence from PRCC may afford select patients durable cancer control. In particular, those patients with a longer interval from nephrectomy to RPLN recurrence, had significantly decreased risks of progression after resection, suggesting that this variable may be used in patient selection. The extent of resection, as well as the optimal integration of surgery and systemic therapy, remain to be determined in this setting.
Thus, we recommend that, in the setting of isolated RPLN recurrence of RCC (in patients without precluding comorbidities), careful consideration with the patients and medical oncology colleagues be undertaken about the relative and individualized benefits of surgical resection, systemic therapy, and surveillance.