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Concurrent RCC with tuberculous para-aortic lymphadenopathy: a pleasant surprise.

Introduction

The association of tuberculosis and renal cell carcinoma (RCC) is uncommon. (1) While the incidental discovery of RCC in a tuberculous kidney is well-described, (2) the discovery of tuberculous lymph nodes after radical nephrectomy for RCC is exceptional. We describe a rare case of RCC with extensive para-aortic lymphadenopathy of tubercular etiology managed laparoscopically. To the best of our knowledge, this is the first such case report.

Case report

A 44-year-old man, known hypertensive and end-stage renal disease, presented with a history of loss of weight and loss of appetite for the last 2 months. He had an abdominal ultrasound which revealed a left renal mass with large multiple para-aortic lymph nodes. Fine needle aspiration biopsy was done outside and revealed RCC. A magnetic resonance image was done at our centre and showed a left mid polar mass of 4.5 x 3.2 x 2.8 cm with large multiple para-aortic, pre-aortic and inter-aorto caval lymph nodes associated with renal vein thrombus (Fig. 1, Fig. 2, Fig. 3). He underwent single hemodialysis followed by laparoscopic left radical nephrectomy with lymph node dissection extending from renal hilum to the bifurcation of aorta. During lyphadenectomy it was noticed that the lymph nodes were matted together and adhered to great vessels as well as to retroperitoneal tissues. Postoperative recovery was smooth, but the patient had increased drain output and lymphorrhea which settled in 6 days. Histopathological examination revealed Type 1 papillary RCC (Fuhrmans nuclear grade 2), pathologic stage, pT1b, N0, Mx without lymphovascular invasion. There were 22 lymph nodes in the specimen and all lymph nodes showed caseating tubercular lymphadenitis with no evidence of metastasis (Fig. 4).

He was started on anti-tuberculous treatment postoperatively. His follow-up ultrasound at 3 and 6 months did not reveal any recurrence of disease. He is planned for renal transplant once he is disease-free for the next 2 years.

Discussion

RCC comprises 2% to 3 % of malignant neoplasms in adults. About 20% to 30% of patients with RCC present with metastatic disease, (3) but this ranges from 3% in surgical series to 63.6% in autopsy series. (3) Of these patients with metastatic disease, historically 40% have distant metastases only without evidence of lymph node involvement, 50% have both distant metastases and lymph node involvement, and about 3% to 10% present with lymph node involvement only. (4-7)

When lymph node dissection is performed, a number of studies have shown that positive lymph nodes have an independent adverse effect on outcome, irrespective of other variables. (8-10) Patients with node-positive disease have 5-year survival rates ranging from 5% to 35%. (11)

Conclusion

This case highlights the fact that extensive lymphadenopathy associated with RCC on imaging may not necessarily be metastatic in origin. Tuberculosis should be kept in mind especially in developing countries where tuberculosis is widely prevalent.

Competing interests: The authors declare no competing financial or personal interests.

This paper has been peer-reviewed.

References

(1.) Peyromaure M, Sebe P, Darwiche F, et al. Renal tuberculosis and renal adenocarcinoma: A misleading association. Prog Urol 2002;12:89-91.

(2.) El Mejjad A, Fekak H, Debbagh A, at al. Renal cell carcinoma secondary to tuberculous nephritis. Prog Urol 2005;15:309-11.

(3.) Godoy G, O'Malley RL, Taneja SS. Lymph node dissection during the surgical treatment of renal cancer in the modern era. Int Braz J Urol 2008;34:132-42. http://dx.doi.org/10.1590/S167755382008000200002

(4.) Blom JHM, van Poppel H, Marechal JM, et al. Radical nephrectomy with and without lymph-node dissection: Final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881. Eur Urol 2009;55:28-34. http://dx.doi.org/10.1016Aeururo.2008.09.052

(5.) Canfield SE, Kamat AM, Sanchez-Ortiz RF, et al. Renal cell carcinoma with nodal metastases in the absence of distant metastatic disease (clinical stage TxN1-2M0): The impact of aggressive surgical resection on patient outcome. J Urol 2006;175:864-9. http://dx.doi.org/10.1016/S0022-5347(05)00334-4

(6.) Minervini A, Lilas L, Morelli G, et al. Regional lymph node dissection in the treatment of renal cell carcinoma: Is it useful in patients with no suspected adenopathy before or during surgery? BJU Int 2001;88:169-72. http://dx.doi.org/10.1046/j.1464-410x.2001.02315.x

(7.) Vasselli JR, Yang JC, Linehan WM, et al. Lack of retroperitoneal lymphadenopathy predicts survival of patients with metastatic renal cell carcinoma. J Urol 2001;166:68-72. http://dx.doi.org/10.1016/ S0022-5347(05)66078-8

(8.) Frank I, Blute ML, Cheville JC, et al. An outcome prediction model for patients with clear cell renal cell carcinoma treated with radical nephrectomy based on tumor stage, size, grade and necrosis: The SSIGN score. J Urol 2002;168: 2395-400. http://dx.doi.org/10.1016/S0022-5347(05)64153-5

(9.) Leibovich BC, Blute ML, Cheville JC, et al. Prediction of progression after radical nephrectomy for patients with clear cell renal cell carcinoma: A stratification tool for prospective clinical trials. Cancer 2003;97:1663-71. http://dx.doi.org/10.1002/cncr.11234

(10.) Leibovich BC, Cheville JC, Lohse CM, et al. A scoring algorithm to predict survival for patients with metastatic clear cell renal cell carcinoma: A stratification tool for prospective clinical trials. J Urol 2005;174:1759-63. http://dx.doi.org/10.1097/01.ju.0000177487.64651.3a

(11.) Pantuck J, Zisman A, Dorey F, et al. Renal cell carcinoma with retroperitoneal lymph nodes: role of lymph node dissection. J Urol 2003;169:2076-83. http://dx.doi.org/10.1097/01.ju.0000066130.27119.1c

Correspondence: Dr. Praveen Pushkar, Department of Urology, Indraprastha Apollo Hospital, New Delhi, India; praveenpushkar@yahoo.co.in

Praveen Pushkar, MD; * Anshuman Agarwal, MD; * Ashok Sarin, MD;([dagger]) Vikas Kashyap, MD([section])

* Department of Urology, Indraprastha Apollo Hospital, New Delhi, India; ([dagger]) Department of Nephrology, Indraprastha Apollo Hospital, New Delhi, India; ([section]) Department of Pathology, Indraprastha Apollo Hospital, New Delhi, India

http://dx.doi.org/10.5489/cuaj.2439

Published online April 13, 2015.

Caption: Fig. 1. A magnetic resonance image (T2W) showing left renal mass.

Caption: Fig. 2. A magnetic resonance image transverse section showing large left para-aortic lymph nodes.

Caption: Fig. 3. A magnetic resonance image showing left renal mass with extensive lymphadenopathy.

Caption: Fig. 4. Low power (4x) magnification of lymph node showing multiple granulomas with few Langerhan's giant cells. One granuloma is showing central caseation.

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Article Details
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Title Annotation:renal cell carcinoma
Author:Pushkar, Praveen; Agarwal, Anshuman; Sarin, Ashok; Kashyap, Vikas
Publication:Canadian Urological Association Journal (CUAJ)
Article Type:Case study
Date:Apr 1, 2015
Words:1071
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