Patient aged 53 years at the time of diagnosis with a personal history of a caesarean section, arterial hypertension and tachycardia treated with Atenolol, who came to the Emergency Department with a 5-month history of progressive dull pain in the left flank and microhaematuria. Ultrasound and then abdominal-pelvic computerised axial tomography (CAT) scans revealed a large solid mass measuring 20x16x13 cm arising from the left renal pole, without associated venous thrombosis. Para-aortic adenopathies were also observed. All this was compatible with a left renal tumour.
In view of this finding, an extension study was carried out with a general analysis showing mild iron-deficiency microcytic anaemia and hyperuricaemia, a normal chest X-ray, a bone scan showing an image with a slight increase in tracer uptake corresponding to soft tissue, with a rounded morphology, located in the hypochondrium and in the hypochondrium, located in the left hypochondrium and void, exceeding the midline, and 3 foci of tracer uptake, one in the left iliac blade, the second in the left hemivertebrae L4 and L5 and the third at the level of the right hemivertebra L2, which could correspond to bone involvement due to contiguity or be metastatic, and an abdominal MRI scan which confirms the findings of the CT scan.
With the presumptive diagnosis of renal cell carcinoma with retroperitoneal adenopathy, the patient underwent radical left nephrectomy, removal of all the pararenal fat and the left adrenal gland and para-aortic and interaortocaval lymphadenectomy from the renal artery to 3 cm from the common iliac artery. Removal of the mass was difficult due to infiltration of the transverse mesocolon and tail of the pancreas, which were released, leaving the mesocolon untouched. The anatomo-pathological (A.P.) result was as follows: Collision renal tumour (Leiomyosarcoma (21 x 15 cm) and renal carcinoma papillary type nuclear grade 3 (7 x 3.5 cm)). The weight of the whole specimen was 2539 grams. The tumour was in contact with the surgical edge in most areas. The renal parenchyma was microscopically respected and no tumour infiltration was observed. The ureteral fragment and renal hilum were free of tumour infiltration. The immunophenotypic profile of the tumour was as follows: Actin, Desmin, S-100, Synaptofusin and CD 56 and c-kit negative; Smooth muscle actin positive in the sarcomatous zone and keratin cocktail (E1, E3) positive in the carcinomatous zone. At the level of the para-aortic chain, 16 adenopathies were isolated, the largest measuring 2.5 cm, with metastases in 14 of them, 13 from the carcinoma and 1 with mixed metastases (sarcoma+carcinoma). Six adenopathies were isolated in the interaortocaval chain, the largest measuring 1.4 cm, three of which were carcinoma metastases. The mesocolic bed was infiltrated by leiomyosarcoma. In the perisuprarenal adipose tissue 4 adenopathies were isolated, 3 of them with metastasis of the carcinoma and another with mixed metastasis (carcinoma+sarcoma). The left adrenal gland, the perirenal fat and the gall bladder showed no tumour elements.
We were therefore faced with a renal collision tumour consisting of a stage IV papillary type renal cancer (pT3-4pN2) according to the TNM classification and a stage IV renal leiomyosarcoma (pT2bpN1) according to the AJCC classification, not radically resected and with possible bone metastases according to bone scintigraphy.
The postoperative period was uneventful and the patient was referred to the Medical Oncology Department. It was decided to propose complementary chemotherapy treatment with Ifosfamide 5 g/m2 in a continuous infusion of 24h x 1 day + Adriamycin 60 mg/m2 x 1 day/21 days against the sarcomatous component of the tumour. A CT scan was previously requested in which a small soft tissue enlargement was observed behind the pancreatic tail and renal bed, which could be compatible with present disease.
The patient started treatment according to the planned schedule 3 weeks after surgery. She received a total of 6 cycles with good clinical tolerance. After the 4th cycle, an abdominal CAT scan was performed, which was normal, and at the end of the 6th cycle, a bone scan was performed, which showed no pathological findings. The patient underwent regular check-ups and 3 months later a chest X-ray was performed showing images suggestive of bilateral pulmonary metastases, which were confirmed by a CT scan showing multiple bilateral millimetric pulmonary metastases. In order to identify the origin of these metastases, Thoracic Surgery was consulted and it was decided to perform a left videothoracoscopy with biopsies. The P.A. diagnosis was metastasis of poorly differentiated carcinoma with an epithelial component (renal). In view of this diagnosis, 6 months after finishing the first chemotherapy regimen, it was decided to start a second line of treatment with a chemotherapy regimen with Gemzitabine and Fluoropyrimidines9 that had proved useful in stage IV renal carcinoma: Gemcitabine 1000 mg/m2 days 1 and 8 + Capecitabine 1000 mg/m2/12h days 1-14/21 days, which the patient accepted.
Treatment was started with a 20% dose reduction which was maintained for the rest of the treatment given the patient's general condition (ECOG: 1-2). After the second cycle, the patient suffered a complication of pulmonary thromboembolism from which she recovered but which caused a delay of 4 weeks in the administration of the third cycle. After 6 cycles of treatment, which she received with acceptable tolerance except for grade 4 anaemia, she was re-evaluated with a body CT scan which showed persistent pulmonary metastases with the appearance of liver and spleen metastases and local relapse.
In view of this progression, treatment with IL-2 was proposed for 6 weeks (1 week of induction with 18 Million Units (MU) x 5 days and 5 weeks: 9 MU days 1 and 2 and 18 MU days 3 to 5)10. The patient accepted the treatment with moderate toxicity with secondary constitutional symptoms grade 2, anaemia grade 3 and emesis grade 1, maintaining her general condition.
At the end of treatment, a new re-evaluation was performed with a CT scan showing progression of the disease with a large mass in the surgical site measuring 19x10x5cm, which had grown with respect to the previous CT scan, and persistent metastases in the rest of the previous sites. The patient's general condition worsened, with the appearance of abdominal and lumbar pain, and on physical examination a 5cm epigastric mass was palpated, corresponding to the underlying mass.
Given this new progression, it is considered that the tumour is resistant to chemotherapy or immunotherapy schemes against renal carcinoma and it is proposed to start palliative treatment with liposomal Adriamycin against the sarcomatous component of the tumour. The patient accepted the proposal and received a first cycle. However, a week later she went to the emergency department for hypovolemic shock with metabolic acidosis and pre-renal renal failure secondary to hyperemesis of 4 days' evolution and grade 4 anaemia. The patient recovered from this episode but a week later she began with faecal vomiting of probable obstructive origin due to compression of the retroperitoneal mass, causing progressive deterioration of the patient and the patient died of multi-organ failure 19 months after diagnosis.
