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Abstract
Renal cell carcinoma (RCC) frequently presents with osseous metastasis, predominantly lytic and prone to pathological fracture. The metastatic lesion in the extremity presents with local swelling, pain and immobility due to pathological fracture. The solitary or oligometastatic lesions should be treated with curative intent, which can help the patient to lead a more prolonged and disability-free life. The RCCs and their metastases are hypervascular with an exuberant arterial supply. Surgery can lead to uncontrolled life-threatening haemorrhage. Preoperative transarterial embolisation reduces tumour vascularity significantly and reduces intraoperative blood loss. We present a 46-year-old male patient with solitary hypervascular metastatic recurrence of RCC with a pathological femoral fracture with an infeasible initial surgery due to profuse haemorrhage. He was successfully treated by preoperative transarterial embolisation, followed by surgical resection and implantation of a megaprosthesis. Multidisciplinary management reduces patient morbidity and mortality with successful treatment in solitary hypervascular metastasis from RCC.
- interventional radiology
- orthopaedics
- oncology
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Background
Solitary metastasis to the proximal part of an extremity causing pathological fracture presents with pain, swelling and limb immobility. The treatment is resection with reconstruction by implanting a prosthesis which helps the patient lead a more prolonged and disability-free life. As the metastatic deposits from renal cell carcinoma (RCC) are also hypervascular with an exuberant arterial supply, there is a risk of severe intraoperative haemorrhage and reduces surgery feasibility. So preoperative devascularisation by transarterial catheter embolisation of the hypervascular mass should be considered to reduce the risk of intraoperative haemorrhage.1 Multidisciplinary management reduces patient morbidity and mortality with successful treatment.2
Case presentation
A 46-year-old male patient who was a known case of RCC, stage I (pT1bN0M0), postright nephrectomy status, presented to an outside medical centre with pain and swelling of the left upper thigh for the last 6 months which had started 2 months after the surgery. X-ray hip joint showed right subtrochanteric pathological fracture with a huge lytic lesion having soft-tissue component (figure 1) and was diagnosed with femoral metastasis with subtrochanteric fracture. A team of surgeons attempted to resect it but abandoned the procedure due to profuse bleeding and subsequently referred it to us. On examination, there was limb swelling and shortening. The hip joint was externally rotated and abducted with restricted movements. The rest of the organ systems were within normal limits. There was no history of diabetes mellitus or hypertension. There was no significant family history.
The frontal radiograph of the pelvis shows a large expansile lytic lesion involving the proximal right femoral meta-diaphysis with an associated soft tissue swelling and subtrochanteric pathological fracture.
Investigations
The preoperative haemoglobin (Hb) level was 137 g/L, and the haematocrit was 44.8. The renal function test was normal. Serum alkaline phosphatase levels were raised. The rest of the laboratory parameters were within the normal limit. A positron-emission CT (PET-CT) scan did not reveal abnormal activity anywhere else in the body, suggesting a solitary metastasis. MRI revealed a mass of heterogeneous signal intensity in the intertrochanteric region of the right femur. CECT with angiography revealed a destructive heterogeneous grossly enhancing hypervascular mass of size 9.0×7.7×6.7 cm involving the intertrochanteric region of the right femur with a pathological fracture (figure 2A). There was exuberant arterial supply from the profunda femoris and superficial femoral arteries (figure 2B,C) on CT angiography with prominent venous drainage into femoral veins.
(A) The coronal section image of the CECT of the pelvis shows heterogeneous grossly enhancing mass involving the intertrochanteric region of the right femur with a pathological fracture. (B) The CT angiography maximum intensity projection image showing the hypervascular nature of the renal cell carcinoma metastasis. (C) The CT angiography 3 dimensional volume-rendered image showing the rich arterial supply to the renal cell carcinoma metastasis from the branches of the superficial femoral and deep femoral arteries.
Treatment
The treatment plan was excision of the lesion with a megaprosthesis implantation after preoperative transarterial embolisation to reduce tumour vascularity and intraoperative blood loss.
The left common femoral arterial puncture was done to gain intravascular access, and then the 5-French C2 catheter (Cobra 2; AngioDynamics, Queensbury, New York, USA) was negotiated over a 0.035-inch guidewire (Radifocus, Terumo, Tokyo, Japan) into the right common iliac artery, followed by external iliac and common femoral arteries. Angiography of the common femoral artery revealed feeders predominantly from the deep femoral artery and the superficial femoral artery (figure 3A,B). The Feeders from the deep and superficial femoral arteries were super selectively catheterised by a coaxial 2.7-French microcatheter (Progreat Terumo, Tokyo, Japan), and the tumour feeders were embolised using polyvinyl alcohol particles (100–500 µm) (Cook Medical, Bloomington, Indiana, USA), gelfoam, and 0.018-inch platinum microcoil with extended embolus length 3 cm and coiled embolus diameter 3 mm (Nester Embolisation coil, Cook Medical, Bloomington, Indiana, USA) under conscious sedation. Postembolisation check angiogram revealed complete disappearance of the tumour blush (figure 4A,B). The patient was taken up for surgery the following day under general anaesthesia. Wide resection (figure 5) with proximal femur replacement (DePuy LPS system) was done. As it was a redo surgery, multiple adhesions were present, posing difficulty in surgery. During surgery, around 500 mL of blood loss from the fracture site. The tumour was avascular, and some bleeding occurred distally with a total blood loss of about 1 L. Two units of intraoperative blood transfusion (BT) were done. Two postoperative drains were placed. The patient was extubated on the table Andrew kept in the intensive care unit for 1 day. On the first postoperative day, the Hb was 130 g/L, and haematocrit was 40.8.
(A) The digital subtraction angiography (DSA) image obtained by selective catheterisation of the superficial femoral artery through transfemoral route showing tumour blush. (B) The selective catheter angiography of the deep femoral artery under DSA showing tumour blush and the endovascular coil deployed in the branch of the superficial femoral artery supplying the tumour.
(A) The postembolisation check angiogram of the superficial femoral artery showing almost complete disappearance of the tumour blush with patent artery. (B) The postembolisation check angiogram of the deep femoral artery showing no residual tumour blush.
The resected specimen of the proximal end of the right femur containing the metastatic tumour after wide resection.
The postoperative X-ray showed the megaprosthesis in situ (figure 6). Postoperatively, the patient was doing well and discharged on the 7th postoperative day.
The frontal radiograph of the pelvis after surgical resection and prosthesis implantation showing the megaprosthesis in situ.
Outcome and follow-up
At 6 months follow-up, the patient had excellent outcome (Musculoskeletal Tumour Society score of 27/30). He was walking independently without pain. There was no evidence of local recurrence.
Discussion
RCC metastasise most commonly to lungs followed by bones.2 Santini et al found in their study of more than 1800 patients that 31% of patients had bone metastases at the time of RCC diagnosis, whereas 68% developed bone metastasis at a median period of 25 months throughout their disease course.3 The commonly involved bones are the pelvis, sacrum, spine and proximal part of the extremities.3 Usually, the bony metastases are osteolytic (80%) in nature, and thus, they are more prone to pathological fracture.3 Osteoblastic lesions account for 7% and 13% mixed lytic and blastic lesions. Seventy-one per cent of patients present with multiple skeletal metastases.
Bony metastases from RCC present clinically with pathological fracture, intractable pain, palpable swelling, spinal instability, spinal cord compression with quadriparesis, paraparesis or cauda equina syndrome, restricted limb motion according to the site of metastasis and hypercalcaemia.4
X-ray of the affected part is the initial radiological imaging modality to detect a metastatic lesion and associated fracture. CT scan or MRI can also detect metastatic lesions. CT angiography detects the source of arterial supply and intratumoural arteriovenous malformations and in preembolisation planning. PET-CT and bone scintigraphy are highly sensitive in diagnosing bony metastases.2
In multiple metastases, palliative treatment such as local radiotherapy, palliative surgery like osteoplasty, chemotherapy is required. Palliative transarterial tumour embolisation can be done. Forauer et al reported that selective embolisation of osseous RCC metastases is an effective technique that can provide palliative relief to patients with limited therapeutic options.5
A solitary bone metastasis with no other extraosseous lesion and a long interval (≥24 months) between RCC diagnosis and the onset of bone metastases are associated with prolonged survival. Long-term survival can be achieved in patients with solitary bone metastasis by complete tumour resection.2 Thus, the solitary metastasis should be aggressively treated surgically with curative intent.6 Surgical procedures include wide resections with or without reconstruction, internal fixation and neural decompression (in the case of spinal cord compression).2 6 Surgical resection of such lesions can improve the prognosis, local tumour control, pain relief and preservation or reconstitution of function. Limb reconstruction can be done by a prosthetic replacement of the femoral or humeral head, which helps preserve the function.7 Transarterial embolisation is generally used in metastatic bone tumours to reduce operative haemorrhagic risks or enabling more definitive surgery.2 Pazionis et al revealed that preoperative embolisation probably reduces estimated blood loss (EBL), particularly for large tumours and during open femoral procedures.1 Barton et al reported a mean EBL of 0.5–2.8 L with embolisation vs 6.8 L without embolisation.8 More than 75% reduction of tumour blush was associated with reduced EBL without the requirement of BT. In such cases, BT was required due to associated sideropenic anaemia or increased intraoperative EBL.7 Less than 50% to 50%–75% reduction in tumour blush had greater intraoperative EBL requiring BT.7 More than 70% reduction of tumour stain reduced intraoperative blood loss as per Sun and Lang.9 In our case, although postembolisation check angiogram revealed no tumour blush, still patient had 1 L of blood loss requiring two units of BT because of the presence of multiple adhesions and bleeding occurred from the distal site and not from the tumour. Thus, transarterial embolisation should always be considered before resection of hypervascular bone metastases in case of the solitary metastatic lesion from RCC.
Learning points
Solitary osseous metastasis from renal cell carcinoma (RCC) can be cured by surgery with prolongation of patient survival.
The treatment of solitary osseous metastasis from RCC to the proximal part of a limb is wide resection with a prosthetic replacement of the femoral or humeral head for functional restoration.
Contrast-enhanced CT with angiography is the best modality to detect the vascular supply to the tumour.
Hypervascular metastasis bears a high risk of severe intraoperative haemorrhage, leading to patient morbidity and mortality and reduced surgery feasibility.
Preoperative tumour devascularization by transarterial embolization reduces intraoperative blood loss and should always be considered before resection of hypervascular solitary bone metastases from RCC.
Ethics statements
Patient consent for publication
Footnotes
Contributors SM: manuscript drafting, editing and reviewing, transarterial embolisation of tumour. ST: manuscript editing and reviewing. Clinical evaluation of the patient. Did surgery and prosthesis implantation. Follow-up of patient. NDB: editing and reviewing of manuscript, interpretation of images. NM: editing and reviewing, handled the anaesthesia during surgery, intraoperative and postoperative patient management
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.