Gynecologic bleeding revealing vaginal metastasis of renal cell carcinoma

Gynecologic bleeding revealing vaginal metastasis of renal cell carcinoma

 

Zineb Benbrahim^1,2,&, Ali Chouaib³, Renaud Mazeron¹, Marie Bénédicte Leger-Ravet⁴, Catherine Lefort⁴, Catherine Lhommé¹, Omar El Mesbahi², Bernard Escudier¹

 

¹Department of medecine, Gustave Roussy Institute, France, ²Department of Medical Oncology, Hassan II University Hospital, Morocco , ³Department of urology, Tenon Hospital, France, ³Department of Pathology, Long Jumeau Hospital, France

 

 

^&Corresponding author
Zineb Benbrahim, Department of medecine, Gustave Roussy Institute, France; Department of Medical Oncology, Hassan II University Hospital, Morocco

 

 

 

 

The vaginal metastases of the renal cancer are rare. Eighty five cases were reported in the literature. These secondary locations deserve a particular attention because their diagnosis often precedes that of the Renal Cell Carcinoma. We report the case of a woman who presented vaginal metastasis two years after nephrectomy for a Renal Cell carcinoma and we discuss the modes of dissemination of these metastases.

 

 

A 75-year-old white woman, had history of fullness in the right upper quadrant, and a weight loss. On physical examination there was a large palpable mass in the right upper quadrant. Radiologic examination revealed tumor of right kidney measuring 14 x 8cm. A right nephrectomy was done through a long midline incision. The excised organ measured 15 x 9 x 6.5cm and weighed 660 g. The microscopic appearance was typical of renal cell carcinoma. The tumor was classified grade III of Furhman grading system and pT3b N0 M0 of the Union of International Cancer Control classification. Evolution has been marked by the occurrence of mediastinal and lombo-aortic lymph nodes. She received two months of targeted therapy (bevacizumab associated with interferon) that was stopped because of intolerance. At that time, disease was stable on CT scan and remained stable for almost one year. She was readmitted because of vaginal bleeding. On examination a 4 x 5 cm mass was found arising from the lower one-third of the vagina. A biopsy revealed uniform population of neoplastic cells with clear cytoplasm, atypical nuclei (Figure 1 and Figure 2) and positive staining with KL1 and CD10 (Figure 3). Anatomopathologists concluded to a metastasis of renal cell carcinoma. External hemostatic radiotherapy was started delivering a tumor dose of 20 Gy in 6 cycles. Patient is still alive 6 months later with local control.

 

 

Primary adenocarcinoma of the vagina comprises 9% of all vaginal neoplasms [1]. Therefore, adenocarcinoma of vagina must be considered as metastatic until the opposite is demonstrated [2]. This metastasis may develop from the cervix, endometrium, ovary, or colon in approximately 65% of cases [3]. Secondary localisations from the pancreas, stomach, and kidney are even less common [4]. The first description of vaginal metastasis from renal cell carcinoma was reported in 1906 [5]. In 2003, Mendese had reviewed 85 cases of theses tumors. Median age at diagnosis was 57 years (average 14-88). Clinical presentation in 65% of cases was vaginal leaking, haemorrhage, or mass effect. The vaginal lesion size ranged from 0,5 to 8 cm. Renal cell carcinoma vaginal metastasis usually preceded and rarely came after the diagnosis of renal tumor. In 63 % of cases, primary location of tumor was left kidney. Usuallly metastasis is solitary. It appears at the same side of primary tumor and is usually located in the lower third of the anterior wall of the vagina [6]. The most important prognostic factor in patients with vaginal metastasis is the presence or absence of other secondary localisations. Moreover, patients with metachronous metastasis present longer survival than those with synchronous metastasis. Median survival of all types confounded is 19 months (range 1- 96) [4,6,7].

 

Several pathways (urinary, lymphatic and systemic) were evoked at the origin of vaginal implantation of renal carcinoma. However, the only one having been demonstrated is the venous retrograde way. Movedlcahy and Furlow objectified radiologically flux between the renal vein and the genital vein at several patients with renal cancer and vaginal metastasis [8].

 

 

This observation suggests the interest of early ligature of genital vein during nephrectomy to limit migration of neoplasmic cell and prevent gynaecologic metastasis.

 

 

The authors declare no competing ineterests.

 

 

All the authors have contributed to this case report in ways that comply to ICMJE authorship criteria. All the authors have read and approved the final version of the manuscript.

 

 

Figure 1: neoplastic cells in deep chorion (HE x25)

Figure 2: neoplastic clear cells (HE x 250)

Figure 3: immunoreactivity of neoplastic cells for CD10 (x250)

 

 

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