Papillary renal cell carcinoma (PRCC) is a rare cancer and is the second most frequent histologic type among all renal cell carcinoma, accounting for up to 15%. A 72-year-old man underwent a right radical nephrectomy 7&nbsp;years ago with final histopathology diagnosis of type 1 PRCC with negative surgical margins. Five years after surgery, computed tomography scan imaging showed the presence of multiple masses suspicious for node recurrences disease localized in the renal lodge, in the inter-aorto-caval space, at the iliac vessels bifurcation and right common iliac vessels. Patient underwent a robotic retroperitoneal lymphadenectomy. The histopathological examination confirmed the recurrence of type I papillary renal cancer in all the specimens. No further recurrences have been observed at 24-month follow-up after surgery. This report is the first describing a robot-assisted minimally invasive surgical excision for type I papillary renal cancer nodal and renal fossa recurrences

Al Salhi, Yazan

Aversa, Sara

Capone, Lorenzo

Carbone, Antonio

de Nunzio, Cosimo

Fuschi, Andrea

Pastore, Antonio Luigi

Petrozza, Vincenzo

Porta, Natale

Velotti, Gennaro

English

Archivio della ricerca- Università di Roma La Sapienza

1Journal of Surgical Case Reports, 2020;10, 1–3doi: 10.1093/jscr/rjaa336Case ReportCAS E R E PORTRobot-assisted retroperitoneal lymphadenectomy inpatient with type I papillary renal cancer recurrenceafter 5 years of follow-upYazan Al Salhi1, Andrea Fuschi1, Gennaro Velotti1, Lorenzo Capone1,Sara Aversa2, Cosimo de Nunzio3, Natale Porta2, Vincenzo Petrozza2,Antonio Carbone1 and Antonio Luigi Pastore1,*1Department of Medico-Surgical Sciences and Biotechnologies, “La Sapienza” University of Rome, Urology UnitICOT, Latina, Italy, 2Department of Medico-Surgical Sciences and Biotechnologies, “La Sapienza” University ofRome, Pathology Unit ICOT, Latina, Italy and 3Department of Urology, La Sapienza University of Rome,Sant’Andrea Hospital, Rome, Italy*Correspondence address. Department of Medico-Surgical Sciences and Biotechnologies, “Sapienza” University of Rome, Urology Unit, ICOT, Corso dellaRepubblica, 79, Latina 04100, Italy. Tel: +39-3401138648; Fax: +39-07736513333; E-mail: antopast@hotmail.conAbstractPapillary renal cell carcinoma (PRCC) is a rare cancer and is the second most frequent histologic type among all renal cellcarcinoma, accounting for up to 15%. A 72-year-old man underwent a right radical nephrectomy 7 years ago with finalhistopathology diagnosis of type 1 PRCC with negative surgical margins. Five years after surgery, computed tomographyscan imaging showed the presence of multiple masses suspicious for node recurrences disease localized in the renal lodge,in the inter-aorto-caval space, at the iliac vessels bifurcation and right common iliac vessels. Patient underwent a roboticretroperitoneal lymphadenectomy. The histopathological examination confirmed the recurrence of type I papillary renalcancer in all the specimens. No further recurrences have been observed at 24-month follow-up after surgery. This reportis the first describing a robot-assisted minimally invasive surgical excision for type I papillary renal cancer nodal and renalfossa recurrences.INTRODUCTIONPapillary renal cell carcinoma (PRCC) is the second most fre-quent histology type among all renal cell carcinoma, accountingfor up to 15% [1]. PRCC is classified into two groups, type 1and type 2, depending on nuclear features and growth patterncharacteristics [2].Patients with type 1 PRCC are diagnosed at a lower stageand present lower nuclear grade when compared with type 2 [3].Type 1 reported a higher cancer-specific survival and a reducedassociation with inferior vena cava (IVC) thrombus comparedwith type 2 [4].Received: July 9, 2020. Accepted: July 29, 2020Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2020.This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited.For commercial re-use, please contact journals.permissions@oup.comWe present a case of a papillary type 1 renal cell carcinomalymph nodes recurrence after 5 years of follow-up. To the best ofour knowledge, this is the first report in literature describing apapillary type 1 recurrence after such a long follow-up time.CASE PRESENTATIONA 72-year-old man underwent a right radical nephrectomy7 years ago for a 10 cmmesorenal mass with a final histopathol-ogy diagnosis of type 1 PRCC, stage pT2a with negative surgicalmargins.Downloaded from https://academic.oup.com/jscr/article/2020/10/rjaa336/5919871 by guest on 04 November 20202 Y. A. Salhi et al.Figure 1: CT scan and intraoperative image of the: iliac bifurcation lymph node recurrence (A), the interaortocaval space lymph node recurrence (B), the renal fossarecurrence (C) and the peritoneal recurrence (D)Five years after the surgery, computed tomography (CT) scanimaging showed the presence of multiple masses suspicious fornode recurrences disease localized in the renal lodge, in theinter-aorto-caval space, at the iliac vessels bifurcation and rightcommon iliac vessels. Positron emission tomography (PET)-CTscan confirmed the abnormal uptake in the same lesions with amaximal standardized uptake value of 3.2.Patient underwent robot-assisted retroperitoneal lym-phadenectomy. Patient was positioned on the left flank side.A three-arm robotic approach (12 mm camera port located 4 cmlateral to the umbilicus; 8 mm port in the epigastrium for roboticarm #1; 8 mm port in the right lateral mid-abdomen for roboticarm #2; and a 12 mm and 5 mm port inferior and, respectively,lateral andmedial to the camera port for the assistant) with a 30-degree down lens (da Vinci Surgical System Si, Intuitive Surgical,Sunnyvale, CA) was used. Robotic monopolar scissors andMaryland bipolar were primarily used with a robotic prograspfor retraction.The procedure started with the excision of the right com-mon iliac lymph nodes and then moving to the iliac bifurcationlymph nodes. The surgery continued with the access to theinteraortocaval space,with the excision of a 4 cmmasswhere theIVC was carefully defined with meticulous dissection to preventinadvertent violation (Fig. 1). At last, the procedure continuedwith the excision of retroperitoneal fat of the right renal fossaand of a 2 cm peritoneal nodal recurrence.The operative time was 114 min, and estimated blood losswas 200 ml. The abdominal drainage was removed at first post-operative day. The length of hospital stay was 3 days. No compli-cations occurred.At hematoxylin and eosin staining, fibrous connective tissuewith multiple foci of a proliferation consisting of numerouspapillary projections with fibrovascular axis replete with frothymacrophages and delimited by a single layer of small cellularelements, with ovoid nucleus and inconspicuous nucleolus andweakly basophilic cytoplasm (Fig. 2).The removed lesions confirmed on histopathological exam-ination the recurrence of type I papillary renal cancer in all thenodal packages.Three months after surgery, patient was treated with sys-temic immunotherapy (sunitinib), which was stopped 1 monthlater because of severe adverse events (general weakness asso-ciated to nausea and vomiting). Patient is still under follow-upand had no recurrences were observed 24 months after surgery.DISCUSSION AND CONCLUSIONPRCC reports a better prognosis after surgical treatment whencompared with clear cell renal cell carcinoma, and most casesare linked to a lower stage and describe a lower risk of cancer-specific and overall mortality [1, 5, 6].PRCC is characterized by a significant heterogeneity observedin both histology level and clinical evolution, with the postula-tion of two morphologically different entities linked to cytoge-netic diversity [2, 3]. The two histology subtypes lead to differentrates of recurrence and survival, where stage and lymph nodeinvolvement represent the most important predictors of relapse,as reported by several studies [7–10].Margulis et al. [7] studied 245 patients surgically treated forPRCC describing both tumor stage and lymph node involvementas independent prognostic factors of disease-specific mortality.Compared with clear cell renal tumors, PRCC is characterizedby predisposition for regional lymph node spread with syn-chronous metastases at diagnosis [8], and these findings aremore frequently observed in tumors >8 cm [9].Ledezma et al. [10] investigated 627 PRCC patients undergoingsurgery and reported that 48 subjects experienced relapse. Tenout of 27 patients with type 2 PRCC exhibited metastatic lymphnodes, whereas most type 1 PRCC patients (11 of 21) reportedpulmonary metastases.Open surgical management has been most extensively docu-mented, but the feasibility of laparoscopic management with orwithout hand assistance has been described only on a limitedbasis. We present the first description of minimally invasivesurgical excision for type I PRCC nodal recurrence, as well asrenal fossa recurrence.Our present study shows that patients treated with surgicalexcision for isolated retroperitonial lymph nodes (RPLN)recurrences may experience durable progression free survivaland cancer free survival. The patient at his last follow-up(24 months) was studied with PET-CT scan that confirmed theDownloaded from https://academic.oup.com/jscr/article/2020/10/rjaa336/5919871 by guest on 04 November 2020Robot-assisted retroperitoneal lymphadenectomy 3Figure 2: (A) Low-power photomicrograph showing primary papillary renal cell carcinoma (original magnification ×4). (B) Medium-power photomicrograph showingthe detailed structure of primary papillary renal cell carcinoma: papillae formed by delicate fibrovascular cores that contain foamymacrophages (original magnification×20). (C) Low-power photomicrograph showing metastatic papillary renal cell carcinoma (original magnification ×4)absence of local and distant recurrences. The impact of adjuvanttherapy for type 1 PRCC (such as tyrosine kinase inhibitors) isstill under investigation in literature, and only few reports areon subtype 1 PRCC not allowing to conclude about the role ofsystemic therapy in this tumor. Furthermore, in our case, thetherapy was discontinued after only 30 days for the onset ofadverse events.Present data show that surgical resection of isolated RPLNrecurrence from PRCC may afford select patients durable cancercontrol.ETHICS APPROVALAll procedures in this study were approved by the EthicalCommittee of the Sapienza University of Rome, Departmentof Medico-Surgical Sciences and Biotechnologies.CONSENT FOR PUBLICATIONWritten informed consent was obtained from the patient for thepublication of this case report and any accompanying images. Acopy of the written consent is available for review by the editor-in-chief of this journal.CONFLICT OF INTEREST STATEMENTNone declared.FUNDINGNone.REFERENCES1. Steffens S, Janssen M, Roos FC, Becker F, Schumacher S, Sei-del C, et al. Incidence and long-term prognosis of papillarycompared to clear cell renal cell carcinoma—a multicentrestudy. Eur J Cancer 2012;48:2347–52.2. Shuch B, Amin A, Armstrong AJ, Eble JN, FicarraV, Lopez-Beltran A, et al. Understanding pathologicvariants of renal cell carcinoma: distilling therapeuticopportunities from biologic complexity. Eur Urol 2015;67:85–97.3. Klatte T, PantuckAJ, Said JW,SeligsonDB,RaoNP, LaRochelleJC, et al. Cytogenetic and molecular tumor profiling for type1 and type 2 papillary renal cell carcinoma. Clin Cancer Res2009;15:1162–9.4. Pignot G, Elie C, Conquy S, Viellefond A, Flam T, ZerbibM, et al. Survival analysis of 130 patients with papillaryrenal cell carcinoma: prognostic utility of type 1 and type2 subclassification. Urology 2007;69:230–5.5. Keegan KA, Schupp CW, Chamie K, Hellenthal NJ, Evans CP,Koppie TM. Histopathology of surgically treated renal cellcarcinoma: survival differences by subtype and stage. J Urol2012;188:391–7.6. Pal SK, Nelson RA, Vogelzang N. Disease-specific survival inde novo metastatic renal cell carcinoma in the cytokine andtargeted therapy era. PLoS One 2013;8:e63341.7. Margulis V, Tamboli P, Matin SF, Swanson DA, Wood CG.Analysis of clinicopathologic predictors of oncologic out-come provides insight into the natural history of sur-gically managed papillary renal cell carcinoma. Cancer2008;112:1480–8.8. Renshaw AA, Richie JP. Subtypes of renal cell carcinoma.Different onset and sites of metastatic disease. Am J ClinPathol 1999;111:539–43.9. Mai KT, Landry DC, Robertson SJ, Commons AS, Burns BF,Thijssen A. A comparative study of metastatic renal cellcarcinoma with correlation to subtype and primary tumor.Pathol Res Pract 2001;197:671–5.10. Ledezma RA,Negron E, Paner GP, Rjepaj C, Lascano D,Hasee-buddin M, et al. Clinically localized type 1 and 2 papillaryrenal cell carcinomas have similar survival outcomes follow-ing surgery.World J Urol 2016;34:687–93.Downloaded from https://academic.oup.com/jscr/article/2020/10/rjaa336/5919871 by guest on 04 November 2020

Robot-assisted retroperitoneal lymphadenectomy in patient with type I papillary renal cancer recurrence after 5 years of follow-up

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Robot-assisted retroperitoneal lymphadenectomy in patient with type I papillary renal cancer recurrence after 5 years of follow-up

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