A 53-year-old patient at the time of diagnosis and personal history of a cesarean section, hypertension and tachycardia treated with Atenolol, who came to the emergency department for a five-month history of progressive left flaccid pain.
An abdominal-pelvic computed tomography (CT) scan was performed and subsequently showed a large solid mass 20x16x13 cm arising from the left renal pole, without associated venous thrombosis.
Para-aortic adenopathies are also observed.
All this was compatible with left renal tumor.
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a Left ventricular outflow tract with an extension study in which microcytic iron deficiency anemia and mild hyperuricemia could be detected, a chest X-ray that is normal, a bone scan with a
With the presumptive diagnosis of renal cell carcinoma with retroperitoneal lymphadenopathies, the patient underwent left radical nephrectomy, removal of all pararenal fat and the common iliac artery to the left iliac lymphadenectomy.
The removal of the mass was dicolonosa due to mesocolon transverse and cola of pancreas released, while the mesocolon was respected.
The anatomopathological result (P.P.) was: Collision renal tumor (Leiomyosarcoma (21 x15 cm) and papillary renal carcinoma type 3 (7 x 3.5 cm)).
The weight of the specimen as a whole was 2539 grams.
The tumor contacted the surgical edge in most areas.
The renal parenchyma was microscopically respected and no tumor was observed.
Ureteral fragment and renal hilium were free of tumor.
The immunophenotypic profile of the tumor was as follows: Actin, Desmin, S-100, Sinaptofusin and CD 56 and c-kit negative; smooth muscle actin positive in the sarcomatous zone.
At the level of the para-aortic chain, 16 lymph nodes were isolated, larger than 2.5 cm, with metastases 14 of them, 13 of carcinoma and 1 with mixed metastasis (sarcoma+carcinoma).
Six adenopathies were isolated in the interaortocaval chain, greater than 1.4 cm, and 3 of them were metastases of carcinoma.
The mesocolic bed was infiltrated by leiomyosarcoma.
Four lymph nodes were isolated in the perisuprarrenal adipose tissue, three of them with metastasis of the carcinoma and another with mixed metastasis (carcinoma+sarcoma).
The left adrenal gland, perirenal fat and gallbladder did not present tumor elements.
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We are therefore faced with a renal collision tumor consisting of a papillary renal cancer stage IV (pT3-4pN2) according to the TNM classification and a renal leiomyosarcoma stage IV (pT2 resected bone metastases gammaJ1)
The postoperative course was uneventful and the patient was referred to the Medical Ongoing Service.
It was decided to propose chemotherapy according to Ifosfamide scheme 5 g/m2 in continuous infusion of 24h x 1day + Adriamycin 60 mg/m2 x 1 day/21 days versus sarcomatous component
Previously, a CAT scan showed a small increase in soft tissue behind the pancreatic tail and renal bed that could be compatible with the present disease.
The patient begins treatment according to the planned scheme 3 weeks after surgery.
It receives a total of 6 cycles with good clinical tolerance.
After the 4th cycle an abdominal CAT scan is performed which is normal, and at the end of the 6th cycle a bone scintigraphy is performed that does not show pathological findings.
The patient undergoes periodic reviews and 3 months later a chest X-ray is performed in which images suggestive of bilateral lung metastases appear, which are confirmed by CT in which multiple bilateral millimetric lung metastases are observed.
In order to establish the origin of these metastases, a consultation was made with Thoracic Surgery and left videothoracoscopy with biopsy.
A.P. diagnosis was poorly differentiated carcinoma metastasis with epithelial (renal) component.
G/21 mg diagnosis 6 days after the end of the chemotherapy regimen, it was decided to initiate a second line of treatment with a chemotherapy regimen with Gemcitabine and Fluorcitamide IV Stage 1000/ 129 which was
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Treatment was initiated with a dose reduction of 20%. The rest of the treatment was maintained due to the patients general condition (ECS 1-2).
After the second cycle the patient suffers as a complication a pulmonary thromboembolism that recovers but causes a delay of 4 weeks in the administration of the third cycle.
After 6 cycles of treatment that receives with acceptable tolerance except grade 4 anemia, a reassessment is performed with body CT in which there is evidence of persistence of lung metastases with appearance of liver metastases, splenicy and local relapse.
IL-2 progression is proposed for 6 weeks (1 week of induction with 18 Miles Units (MU) x 5 days and 5 weeks: 9 MU days 1 and 2 and 18 M.days 3 a) 5
The patient accepts the treatment she receives with moderate toxicity with secondary constitutional status grade 2, anemia grade 3 and emesis grade 1, maintaining the general condition.
At the end of the treatment, a new CT scan was performed, which showed progression of the disease with a large mass in the surgical bed of 19x10x5cm, which had increased compared to the previous CT scan, and persistence of metastases.
The patient shows worsening of the general condition with onset of abdominal and lumbar pain and in physical examination epigastric mass of 5 cm corresponding to the underlying mass.
This new progression is considered that the tumor is resistant to chemotherapy schemes or immunotherapy against renal carcinoma and it is proposed to start palliative treatment with liposomal Adriamycin against the sarcomatous component of the tumor.
The patient accepts the proposal and receives a first cycle.
However, one week later she came to the emergency room for hypovolemic shock with metabolic acidosis and prerenal renal failure secondary to hyperemesis of 4 days duration and grade 4 anemia.
The patient recovers from this episode but a week later begins with fecaloid vomiting of probable obstructive origin due to compression of the retroperitoneal mass, with progressive deterioration of the patient and the patient dies from multiorgan failure at 19 months.
