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BMJ Case Rep. 2010; 2010: bcr1020092340.
Published online 2010 October 28. doi:  10.1136/bcr.10.2009.2340
PMCID: PMC3029602
Reminder of important clinical lesson

Partial nephrectomy and enbloc liver resection using a bipolar radiofrequency device for renal cell carcinoma invading the liver

Abstract

A 66-year-old man presented with right- sided abdominal pain. Ultrasound, CT and MRI scans showed a right renal mass arising from the upper pole with direct involvement of the right lobe of the liver. Biopsy confirmed renal cell carcinoma. After Multi Disciplinary Team (MDT) discussion, right partial nephrectomy with enbloc resection of segments VI and VII of the liver was performed with the help of intraoperative ultrasound scan and the Habib 4X bipolar radiofrequency device. Apart from symptomatic collection, which was drained radiologically, the patient made a good recovery. The patient developed recurrence at the resection margin but is in remission following chemotherapy at 12 months.

Background

Direct liver involvement in renal cell carcinoma (RCC), although uncommon, is a dismal prognostic sign. However, aggressive surgical treatment improves survival. In this case we achieved enbloc resection without sacrificing the right kidney by using the bipolar radiofrequency device and performed nephron sparing surgery.

Case presentation

The patient presented to his general practitioner with right upper quadrant pain. There was no significant past medical or family history.

Investigations

The patient had an ultrasound scan, which showed a mass arising from the upper pole of the right kidney. A subsequent CT scan (figure 1A) showed a mass arising from the upper pole of the kidney with direct involvement of liver segments VI and VII. CT-guided biopsy confirmed RCC. MRI scan (figure 1B) showed no other organ involvement. A Dimercapto Succinic Acid (DMSA) scan showed a normally functioning left kidney.

Figure 1Figure 1
(A) MRI and (B) CT scans showing renal mass invading the liver.

Differential diagnosis

The case was discussed at MDT and enbloc resection was planned.

Treatment

Using a standard liver resection incision the liver was mobilised. After opening the Gerota's fascia the right kidney was mobilised. Intraoperative ultrasound scan was performed. As the tumour was confined to the upper pole of the right kidney, a partial nephrectomy was performed enbloc with the segments VI and VII of the liver using the Habib 4X radiofrequency device (AngioDynamics Inc, New York, USA) (figures 2A, B). The patient made an uneventful recovery and was discharged home on day 5. On day 12 the patient was readmitted with a symptomatic collection, which was drained radiologically.

Figure 2Figure 2
Intraoperative picture showing (A) Habib 4X bipolar resection device in use during partial nephrectomy and (B) bloodless resection margin post partial nephrectomy.

Outcome and follow-up

A recurrence at the resection margin developed within 7 months of surgery. The patient was referred to the oncologist and with chemotherapy the tumour regressed. The most recent CT scan showed no evidence of recurrence at 1-year follow-up. The patient remains well.

Discussion

RCC involves adjacent organs in 10% of cases. Five-year survival rate is less than 5% with a high risk of disease recurrence with rates ranging from 50–85% depending on tumour state and lymph node involvement.1 Despite advances in adjuvant systemic treatments for RCC, surgical resection continues to be the best option for improved long-term survival in selected patients with RCC and liver involvement by contiguity.2 3 Johnin K et al reported two patients with renal tumour invading the liver who had radical nephrectomy and liver resection and showed no evidence of disease at 100 and 57 months after resection.4 One patient with locally invasive RCC required resection of the kidney, adrenal glands, liver, diaphragm and lung, with diaphragmatic reconstruction. The patient was alive and well at 5 years.3 Karellas et al reported improved survival with extended resection.5 Applying bipolar radiofrequency energy to an electrode array can enable transmural excision of renal parenchyma in a bloodless way (figure 2B) without incurring system injury6 and without renal pedicle clamping.7 Ablation results in complete cell destruction.8 Neoadjuvant strategies that integrate aggressive surgical intervention with systemic treatment may be a promising treatment paradigm.9

Learning points

[triangle]
Aggressive surgical treatment improves survival in cases of RCC with direct liver invasion.
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Radiofrequency assisted resection technique helps to achieve nephron sparing renal surgery.

Footnotes

Competing interests None.

Patient consent Obtained.

References

1. Atzpodien J, Schmitt E, Gertenbach U, et al. ; German Cooperative Renal Carcinoma Chemo-Immunotherapy Trials Group (DGCIN) Adjuvant treatment with interleukin-2- and interferon-alpha2a-based chemoimmunotherapy in renal cell carcinoma post tumour nephrectomy: results of a prospectively randomised trial of the German Cooperative Renal Carcinoma Chemoimmunotherapy Group (DGCIN). Br J Cancer 2005;92:843–6. [PMC free article] [PubMed]
2. Quicios Dorado C, Mayayo Dehesa T, Nuño Vázquez-Gaza J, et al. [Renal cell carcinoma with liver extension: a report of a new case and literature review]. Actas Urol Esp 2007;31:541–7. [PubMed]
3. Bennett BC, Selby R, Bahnson RR. Surgical resection for management of renal cancer with hepatic involvement. J Urol 1995;154:972–4. [PubMed]
4. Johnin K, Nakai O, Kataoka A, et al. Surgical management of renal cell carcinoma invading into the liver: radical nephrectomy en bloc with right hepatic lateral sector. Urology 2001;57:975. [PubMed]
5. Karellas ME, Jang TL, Kagiwada MA, et al. Advanced-stage renal cell carcinoma treated by radical nephrectomy and adjacent organ or structure resection. BJU Int 2009;103:160–4. [PMC free article] [PubMed]
6. Pareek G, Wilkinson ER, Schutt D, et al. Haemostatic partial nephrectomy using bipolar radiofrequency ablation. BJU Int 2005;96:1101–4. [PubMed]
7. Klingler HC, Marberger M, Mauermann J, et al. ‘Skipping’ is still a problem with radiofrequency ablation of small renal tumours. BJU Int 2007;99:998–1001. [PubMed]
8. Wagner AA, Solomon SB, Su LM. Treatment of renal tumors with radiofrequency ablation. J Endourol 2005;19:643–52; discussion 652–3. [PubMed]
9. Wood CG. Multimodal approaches in the management of locally advanced and metastatic renal cell carcinoma: combining surgery and systemic therapies to improve patient outcome. Clin Cancer Res 2007;13:697s–702s. [PubMed]

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