Case Report
Spontaneous Regression of Primary Renal Neoplasm after Percutaneous Biopsy in a Patient with History of Contralateral Oncocytoma, Case Report and Review
Meghan Brown and Peter Langenstroer*
Department of Urology, Medical College of Wisconsin, USA
*Corresponding author: Peter Langenstroer, Department of Urology, Medical College of Wisconsin, USA
Published: 21 Oct, 2016
Cite this article as: Brown M, Langenstroer P. Spontaneous
Regression of Primary Renal Neoplasm
after Percutaneous Biopsy in a
Patient with History of Contralateral
Oncocytoma, Case Report and Review.
Clin Oncol. 2016; 1: 1125.
Abstract
Background: Increased use of cross-sectional imaging has led to a significant rise in the detection
of solid renal masses, the majority of which represent Renal Cell Carcinoma (RCC). Spontaneous
regression of RCC is a rare, but well-documented phenomenon most often observed in the setting
of metastatic disease. Spontaneous regression of primary RCC is a much more rare occurrence.
Recently it has been reported that spontaneous regression can occur following percutaneous renal
mass biopsy.
Methods: This article describes a case of spontaneous primary tumor regression following
percutaneous biopsy in a patient with a history of contralateral oncocytoma. We also present a
comprehensive review of other published reports describing spontaneous regression of a primary
tumor following percutaneous biopsy.
Results: In addition to our case we identified 4 confirmed cases of spontaneous regression of RCC
following percutaneous biopsy. We also identified 3 cases of spontaneous metastatic lesion regression
following initial remote treatment of the primary lesion, and subsequent biopsy of metastatic lesion.
Conclusion: We present a case and a review of spontaneous regression of a primary and metastatic
RCC after percutaneous biopsy. Though the exact mechanism of spontaneous regression is not
known it is a likely cause/effect relationship with biopsy.
Introduction
Spontaneous regression of renal cell carcinoma metastases is a rare, but well-documented phenomenon. Recently it has been reported that spontaneous regression can occur following percutaneous renal mass biopsy [1]. Only a few such cases have been described [1,2]. The pathophysiologic mechanism for this regression remains unclear. This article describes a case of spontaneous tumor regression following percutaneous renal mass biopsy in a patient with previously resected oncocytoma in the contralateral kidney. We also present a comprehensive review of other published reports demonstrating spontaneous regression of a primary tumor following percutaneous biopsy.
Case Presentation
A 73-year-old male, former-smoker, initially presented to an outside institution in May 2012
for evaluation of chronic cough. A Computed Tomography (CT) study of the chest demonstrated
incidental solid, enhancing mass in the upper pole of the left kidney. Dedicated abdominal
imaging revealed a 6.0cm solid, enhancing mass in the upper pole of the left kidney. The study also
demonstrated a 2.6cm solid, enhancing mass in the anterior lower pole of the right kidney. The
patient underwent attempted left robotic-assisted partial nephrectomy in July 2012. The procedure
was complicated by intra operative bleeding and converted to an open left partial nephrectomy.
Final pathology returned oncocytoma.
The patient subsequently transferred care to our institution. He required evaluation and
management of the right lower-pole lesion. Interval CT performed in April 2013 demonstrated
significant loss of left renal parenchyma from the prior partial nephrectomy and stable appearance of
right lower pole lesion. The radiologic characteristics were very similar in appearance to the resected
left lesion and thought also to represent an oncocytoma. Based on the lesion size, the radiographic
characteristics, and the patient's disappointing experience with his prior partial nephrectomy he
was elected to pursue Active Surveillance (AS). He was offered a
biopsy at that time. Per his preference he was followed at regular sixmonth
intervals with physical examination, imaging and laboratory
evaluation. CT in May 2015 demonstrated interval growth of the right
lesion to 3.4cm (Figure 1a). To establish a diagnosis and stratify the
risk of this lesion he agreed to a percutaneous CT-guided biopsy in
September 2015. Pathology report returned favoring chromophobe
Renal Cell Carcinoma (RCC) eosinophilic variant; versus oncocytoma.
With this relatively favorable histology he declined definitive therapy
and elected to continue AS. CT performed in April 2016at a routine
6-month follow-up, revealed a 6mm focal hypodensity and cortical
irregularity at the site of the previous right renal lesion (Figure 1b).
This was consistent with near-total resolution or involution of the
lesion. Repeat biopsy was not performed. There was no evidence of
metastatic spread or recurrence in resection bed of left kidney. The
patient remains on AS with plan for repeat CT at 6-month intervals.
Figure 1
Discussion
Increased use of cross-sectional imaging for the evaluation of a
multitude of disease processes has led to a significant, yet serendipitous
rise in the detection of solid renal masses. The majority of these masses
are considered small (<4cm) [3]. However up to 85% of solid renal
masses confined to the kidney may represent malignancy, primarily
renal cell carcinoma (RCC) [4]. Given the increased detection of
solid renal masses the role of biopsy for these lesions has been an
area of increased interest and investigation. While not indicated for
all patients, biopsy can be a safe and effective diagnostic tool in the
evaluation of small renal masses [5]. There are several management
options for kidney-confined solid renal masses, particularly in the
setting of stage T1a disease (tumor <4cm). These include AS, surgical
treatment in the form of partial or radical nephrectomy, and local
thermal ablation. Cancer-specific survival (CSS) for patients with
cT1a disease is greater than 90% [6].
Spontaneous regression is defined as “the partial or complete
disappearance of a malignant tumor in the absence of all treatment
or in the presence of therapy which is considered inadequate” [7].
Spontaneous regression of RCC is a rare, but a well-described
phenomenon, observed in <1% of cases [1-2,9-11]. It has typically been
observed in the setting of metastatic disease after extirpative treatment
of the primary tumor with subsequent regression of metastatic lesions
[8]. There are greater than 100 cases of spontaneous regression of
metastatic RCC reported in the literature [1]. Spontaneous regression
of primary RCC following percutaneous biopsy is a much more rare
phenomenon, with only 4 identified cases reported in the literature
[1,2]. An additional case describing regression of primary renal tumor
with caval thrombus after biopsy has also been described, though not
histologically proven to be RCC [12]. Similar to regression of primary
lesion, three cases of regression of a metastatic lesion following initial
remote treatment of the primary lesion and subsequent biopsy, in
the absence of other therapeutic interventions, have been described
[9-11]. All 8 of these cases, including the case reported here, are
summarized in Table 1. The largest series of spontaneous regression
of primary RCC reported by Dickerson includes three patients.
In this series regression was observed after percutaneous biopsy in
patients on AS. Time to regression after biopsy ranged from 6-12
months. Biopsy demonstrated papillary RCC in 2 patients and
chromophobe in the 3rd patient. Another report by Jawanda describes
gradual regression of a primary papillary type I RCC over a 2-year
surveillance period after biopsy.
A case report by Edwards describes a patient with likely regression
of primary and metastatic disease following renal mass biopsy. Their
patient presented with left-side renal mass, multiple pulmonary
nodules and enlarged periaortic lymph nodes. Biopsy of the renal
lesion confirmed RCC for which the patient initially refused therapy.
In the absence of intervention the pulmonary nodules were noted to
completely regress at a period of 1 year and significant size reduction
of primary tumor was also observed. At this time the patient agreed
to undergo radical nephrectomy which revealed residual renal
cell carcinoma with marked fibrosis and calcification. The tumor
extended into the left renal vein, where marked necrosis was again
found. The periaortic nodes were negative for malignancy, revealing
only fibrosis and calcification. A case by Lim describes a patient
with a history of type II papillary RCC for which he had undergone
radical nephrectomy. Metastatic work-up, including CT of the chest
was negative at the time of surgery. However at 6 year follow-up the
patient was noted to have a solitary pulmonary nodule. Percutaneous
biopsy yielded RCC and the patient refused definitive wedge resection.
In the absence of other therapy complete spontaneous resolution of
the nodule was observed at 12 months. A final case of spontaneous
resolution after percutaneous biopsy for RCC, described by Nakajima
was observed in a patient with a history of pT1aN0M0 RCC who had
undergone a radical nephrectomy. The patient presented 2 years later
with anterior chest pain and was found to have an 8cm sternal lesion;
which was biopsied and discovered to be metastatic RCC. The patient
subsequently underwent resection of this mass and final pathology
revealed granulation tissue and tissue necrosis with extensive
infiltration of inflammatory cells and fibroblasts, leading the others
to conclude that spontaneous regression of the tumor had occurred.
There are several mechanisms that are hypothesized to play a
role in spontaneous regression. These include disruption of local
blood supply in the setting of percutaneous biopsy, leading to
tumor ischemia. The series by Dickerson et al. [1] hypothesized that
thrombotic agents injected at the time of biopsy, as prophylaxis for
post-procedure hemorrhage, may enhance this mechanism. Another
theory proposes immune system response to new exposure to tumor
antigens in the setting of trauma such as biopsy or tumor resection
[13]. While the exact mechanism is unknown it is possible that
either of these mechanisms may play a role in spontaneous tumor
regression. Thought exceptionally rare, spontaneous resolution of
primary RCC is most often described after percutaneous biopsy. As
illustrated in the literature, metastatic lesions can demonstrate the
same phenomenon following biopsy.
Table 1
Conclusion
In the era of increased detection of small renal masses it is likely the role of biopsy will continue to evolve. We present a case and a review of spontaneous regression of a primary and metastatic RCC after percutaneous biopsy. Though the exact mechanism of spontaneous regression is not known it is a likely cause/effect relationship with biopsy. Further investigation into this mechanism could lead to development of more targeted and effective therapies.
References
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