Urology Department, The Pennine Acute Hospitals NHS Trust, Manchester, UK.
Radiology Department, Barts and The London NHS Trust, London, UK.
Urologia. 2022 May;89(2):307-310. doi: 10.1177/03915603211007059. Epub 2021 Mar 29.
Renal Cell Carcinomas are notorious for asynchronous metastases, atypical metastatic sites and late relapses even decades after nephrectomy. It is quite rare though for RCCs to present as metastatic, solitary and symptomatic bone lesions. Even more uncommon is a solitary bone metastasis much larger that the primary tumour caused by a low risk primary T1a RCC which would have otherwise been eligible for active surveillance.
An otherwise healthy 68-year-old female was seen by the orthopaedics for right shoulder and upper arm worsening pain. Imaging showed a pathological fracture caused by a 5.5 cm lytic lesion involving the coracoid process and proximal humerus. She underwent proximal humeral replacement and histology of the lesion showed metastatic RCC. Whole body CT scan revealed a primary tumour of the left kidney less than 4cm in diameter. The patient underwent laparoscopic radical nephrectomy and diagnosis of a T1a, clear cell RCC without adverse pathological features was confirmed. She has been on systematic therapy with oral TKIs since and is free from recurrence at 12-months follow up.
Even T1a RCCs without adverse pathological features can give rise to distant metastases following unpredictable patterns of spread thereby questioning the safety of active surveillance in healthy and fit patients.
肾细胞癌以转移性、非典型转移部位和肾切除后甚至几十年后复发而闻名。然而，肾细胞癌以转移性、孤立性和症状性骨病变表现则相当罕见。更罕见的是，由低风险 T1a 肾细胞癌引起的孤立性骨转移灶比原发肿瘤大得多，否则这些患者将有资格接受主动监测。
一位健康的 68 岁女性因右肩部和上臂疼痛加剧而到骨科就诊。影像学检查显示，由于 5.5cm 的溶骨性病变累及喙突和肱骨近端，导致病理性骨折。她接受了肱骨近端置换术，病变的组织学检查显示为转移性肾细胞癌。全身 CT 扫描显示左肾直径小于 4cm 的原发肿瘤。患者接受了腹腔镜根治性肾切除术，诊断为 T1a、透明细胞肾细胞癌，无不良病理特征。自那以后，她一直在接受口服 TKI 系统治疗，在 12 个月的随访中无复发。
即使是无不良病理特征的 T1a 肾细胞癌也可能以不可预测的扩散模式导致远处转移，从而质疑健康和合适患者接受主动监测的安全性。
