李宗叡、張兆祥

中國醫藥大學附設醫院 泌尿部

Tzung-Ruei Li, Chao-Hsiang Chang

Department of Urology, China Medical University Hospital, Taichung, Taiwan

Carcinoembryonic antigen (CEA) is an oncofetal glycoprotein that is normally expressed by mucosal cells. It is overexpressed by a variety of malignancies. Several studies had shown its relation to colorectal cancer, and others such as breast, liver, stomach, and pancreas. Here we present a case of CEA elevation as a presentation of renal cell carcinoma metastasis after radical nephrectomy.

 

This 37 year-old female was generally healthy before. She had accidentally found a 6.5*4.5cm right renal mass over the lower pole in May, 2011 through the CT scan. There was no other lesion in lymph nodes or site. Due to the asymptomatic mass, which was suspect malignancy, she then further received laparoscopic radical nephrectomy on 2011/5/31 smoothly, and pathology showed clear cell renal cell carcinoma, Fuhrman 2 pT3aNXM0, with intra-Gerota fascia renal vein thrombus. Further bone scan, chest and abdomen CT showed no other lesion in 2011. She then followed up on our out-patient clinic. She initially had CT image every 3 months in first year, then half year for another year, then annual image survey since 2013. She was generally physically fine until June, 2018, which CEA showed 201.45 during the health examination. The other tumor markers like AFP, CA-125, BCG, LDH and CA19-9 were in normal limit. She then referred to colorectal and gynecology department. Further CT in April, 2018 showed only adnexal cyst and small diverticulosis over the ascending colon, also certified by colonoscope. Pandoscope also showed no lesion. Her CEA level gradually increase from 206.32 in June, 2018 to 548 .35, in Sep.2019. She then received PET-CT, and one osteolytic lesion over the left femoral head was noted in November, 2018. Further bone scan also showed left femoral head increase uptake. However, MRI in March, 2019 showed a sclerotic rim with homogenous pattern, which favored benign lesion. She denied any bone pain or other discomfort. She chose observation first but the CEA showed elevation and reached the peak of 674.33 in Jan, 2020. The malignant change of bone lesion was highly suspect even with benign-like image. She then received bone curettage in Jan, 2020. Further pathology showed metastatic RCC. There was no other recurrence from chest-pelvis CT, and PET. Further wide excision of femoral head was recommended but she refused. She started sunitinib 12.5mg 4 pills per day since Feb, 2020. The CEA level decreased from 674.33 to 597.06 after surgery, then decreased to 321.49 in March, 2020 after sunitinib as Tyrosine-kinase inhibitor.

We present a 37 year-old female with initial diagnosis of clear cell RCC underwent radical nephrectomy, then recurrence in the femoral bone after 7 years with CEA elevation as the presentation. There is yet no case report of CEA elevation as metastatic RCC presentation.