Case Report
Displacement of the Spleen Mimicking Renal Cell Cancer Recurrence Post-Nephrectomy: A Case Report
Carolina S. Emanuels*1, Krista D. Timmerman*2, Tabish Aijaz1, Thu-Cuc Nguyen1, Nathaniel Jest1, Walter E. Drane2, Scott M. Gilbert3, Paul L. Crispen3, Li-Ming Su3, Lori A. Deitte2, Long H. Dang1
1Division of Hematology/Oncology, Department of Internal Medicine, University of Florida Shands Cancer Center; 2Department of Radiology; 3Department of Urology, University of Florida, Gainesville, Florida, USA.
Abstract
Local
regional recurrence of renal cell cancer post-nephrectomy most often occurs
within three years after surgery.
Post-nephrectomy, many processes may mimic RCC recurrence. We present the case of a 75 year-old
Caucasian male patient with a mass in his renal fossa post-nephrectomy for
renal cell cancer, suggesting local recurrence.
Use of the technetium-99m sulfur colloid scan showed that the mass was
his spleen which had been displaced into the renal fossa. With high index of suspicion, characterization
of these processes as splenic in origin would prevent subjecting patients to
risks of biopsy or even surgery.
Received: 27 April 2015; Accepted after revision: 14 June June 2015;
Published: 20 June
2015.
Authors
for correspondence: Long H. Dang MD PhD, Department of Internal Medicine,
University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA. Email: [email protected]; Lori A. Deitte MD,
Department of Radiology; University of Florida, Gainesville, Florida, USA.
Email: [email protected]. *These
authors contributed equally.
How
to cite: Emanuels CS, Timmerman KD, Aijaz T,
Nguyen T-C, Jest N, Drane WE, Gilbert SM, Crispen PL, Su L-M, Deitte LA, Dang
LH. Displacement of the Spleen Mimicking
Renal Cell Cancer Recurrence Post-Nephrectomy: A Case Report. Journal of Kidney
Cancer and VHL 2015;2(3):130-133. Doi: http://dx.doi.org/10.15586/jkcvhl.2015.36
IntroductionIt is estimated that 63,920 new cases
of kidney and renal pelvis cancer were diagnosed in the United States in 2014,
and 13,860 patients succumbed to the disease (1). The incidence of renal cancer has risen by
2-3% every year since the early 1990s, many discovered serendipitously due to
the increased use of computed tomography (CT) scans. Of the renal malignancies, 92% are renal cell
carcinoma (RCC) (2). RCC, which are
adenocarcinomas of the renal tubular epithelium, can be further distinguished
into clear cell, (accounting for 70-80% of all RCC), papillary (10-15%),
chromophobe and collecting duct carcinoma (6% or less, collectively) (2). Surgery (radical or partial nephrectomy)
remains the mainstay of treatment for RCC.
Unfortunately, about one third of
patients who undergo surgical resection for localized disease have recurrence,
either locally or with distant metastatic disease (1). Therefore active
surveillance with regular CT scan is recommended in the first five years after
resection (3). Here, we present a unique case of spleen appearing as recurrent
tumor after migrating in the surgical defect created by total nephrectomy. To our knowledge, no
similar case of complete displacement of spleen in the renal fossa has been
reported previously.
Consent
Written informed consent was obtained
from the patient for publication of this case report and accompanying
images. A copy of the written consent is
available for review.
Case presentation
We present the case of a 75 year-old
Caucasian male patient who presented to our institution for evaluation of a
rapidly growing left renal mass. His
initial abdominal CT, performed for flank pain, showed an approximately 2 cm
cortically based mass in the left kidney (Figure
1A). He presented again after 13
months, at which time he had an abdominal MRI.
This again showed the left renal mass, which had grown to 4.5 cm and had
an infiltrative appearance (Figure 1B). He was referred to our Urology department for
further evaluation. CT urography, performed approximately 1 month after the
MRI, showed further growth of the infiltrative left renal mass to 5.2 cm along
with thrombus of the left renal vein (Figure
1C). The thrombus did not extend
into the IVC. Extent of disease work up
including chest radiograph and serum chemistry revealed no evidence of
metastasis. Serum creatinine was 1.4 mg/dL
with normal liver function tests and alkaline phosphatase. Comorbidities included hypertension, type 2
diabetes and hyperlipidemia. On physical
examination, there was no suspicious distant lymphadenopathy.
Figure 1. A.
Axial postcontrast CT image demonstrating the 2 cm cortical based mass in the
inferior left kidney (red arrow). B. Coronal postcontrast fat-suppressed
T1-weighted MR image demonstrating the 4.5 cm infiltrative mass in the inferior
left kidney. C. Demonstrates a filling defect in the left renal vein (yellow
arrow), representing tumor thrombus, approaching but not quite extending into
the IVC.
The patient subsequently underwent left
radical nephrectomy through an open subcostal incision. A limited regional para-aortic
lymphadenectomy was also performed due to small palpable lymph nodes noted at
the time of surgery. Pathology showed a
7.8 cm papillary type 2, grade 3 RCC with invasion into the renal vein and
negative surgical margins. The adrenal
gland and a left perihilar lymph node were negative for carcinoma. Pathologic stage was pT3aN0. The patient’s postoperative course was
unremarkable with a three day hospital stay.
He was discharged in stable condition.
Follow-up
fluorine-18-fluorodeoxyglucose (FDG) PET/CT approximately 3 months following
surgery demonstrated an 8.5 x 6.5 cm soft tissue mass in the left renal fossa
with mild F-18-FDG uptake (SUV max of 2, with a background of 1.5) (Figure 2A). Differential diagnoses included
recurrent/residual disease versus post-surgical change. There was no other areas concerning for metastatic
disease. The corresponding clinical
presentation at this time was unremarkable; the patient had no hematuria, flank
pain or any major complaints. The patient was also regaining his appetite. On examination, his lungs were clear to
auscultation, abdomen was soft, non-tender and non-distended; no masses were appreciated. There were no signs of lymphadenopathy.
A review of the patient’s prior imaging
and surgical history revealed the presence of a spleen on the pre-operative
imaging studies and no splenectomy at the time of left nephrectomy. This raised the possibility that the soft
tissue mass in question may represent the spleen that had fallen into the renal
fossa. As CT and MRI scans were
equivocal in this case, we decided to use radio-nucleotide imaging to further
identify the mass before proceeding with any interventional procedure. A technetium-99m sulfur colloid scan was then
performed, confirming the location of the spleen in the left renal fossa (Figure 2B).
Figure 2. A.
Axial fused PET/CT image demonstrating an 8.5 x 6.5 cm soft tissue mass in the
left renal fossa (red arrow) with mild FDG uptake. There is physiologic FDG
uptake in the liver, bowel, and right kidney.
B. Transverse Tc-99m sulfur
colloid scintigram showing uptake by the liver and spleen (red arrow), with the
latter located in the left renal fossa.
Discussion
Local regional recurrence of RCC
post-nephrectomy most often occurs within three years after surgery. Metastatic disease to the adrenal gland,
perilymphatics and perinephric fat may be the sources of recurrence in the
renal fossa. Isolated local recurrence
following nephrectomy is uncommon, occurring in less than 2% at 5 years (4). Post-nephrectomy,
many processes mimicking RCC recurrence have been previously described in adult
patients (5-9). Page et al. reported a
case of mass detected after nephrectomy and total splenectomy, which was
removed due to suspicion of tumor (6).
It later turned out to be accessory spleen on histological
examination. Although uncommon,
post-operative changes can also look like tumor. Tolhurst et al. reported a
case of benign organizing hematoma mimicking recurrence of RCC (8). Besides these, there are few other reports of
accessory spleen mimicking a renal tumor, where CT scans used for oncologic
follow-up were unable to definitively differentiate between recurrence and
other mass-occupying processes (5-9).
Our case report is unique from
previously published literature, as displacement of the entire spleen into the
renal fossa post-nephrectomy has not been reported in adult patients. It is evident that previous surgery, atypical
location and abnormal shape make it difficult to differentiate between spleen
and tumor recurrence using CT scan or MRI.
Technetium-99m sulfur colloid scan is more sensitive in detecting
spleen, making it useful in cases where other imaging modalities show equivocal
results.
Summary
We suggest that with a high index of
suspicion, the use of the technetium-99m sulfur colloid scan would allow the
characterization of these lesions as splenic in origin and prevent subjecting
patients to risks of biopsy or even surgery.
Competing interests
The authors declare that they have no
competing interests.
Authors’ contribution
CSE, KDT, TA, TCN, NJ, WED, SMG, PLC,
LMS, LAD, and LHD contributed to the care of the patient and analyzed the
data. LAD raised the suspicion and
diagnosed the mass as the patient’s spleen.
CSE, KDT, TA, and LHD drafted the manuscript. All authors read and approved the final
manuscript.
Acknowledgement
This work was supported by the Gatorade
Trust through funds distributed by the University of Florida, Department of
Medicine.
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