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CASE REPORT
Year : 2006  |  Volume : 22  |  Issue : 4  |  Page : 368-369
 

Renal cell carcinoma with ipsilateral adrenal involvement with synchronous contralateral adrenal metastases


Department of Urology, Muljibhai Patel Urological Hospital, Dr. Virendra Desai Road, Nadiad - 387 001, Gujarat, India

Correspondence Address:
Mahesh R Desai
Department of Urology, Muljibhai Patel Urological Hospital. Nadiad - 387 001, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.29128

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   Abstract 

Renal cell carcinoma (RCC) can metastasize to practically all organs; however, all routes and patterns are not yet fully understood. Adrenal metastasis is a good example of that. Adrenal metastasis may be ipsilateral or contralateral and usually it is metachronous. We report a rare case of RCC with ipsilateral adrenal gland involvement and isolated synchronous contralateral adrenal metastasis.


Keywords: Adrenal metastasis, renal cell carcinoma


How to cite this article:
Sharma R, Gupta R, Manohar T, Desai MR. Renal cell carcinoma with ipsilateral adrenal involvement with synchronous contralateral adrenal metastases. Indian J Urol 2006;22:368-9

How to cite this URL:
Sharma R, Gupta R, Manohar T, Desai MR. Renal cell carcinoma with ipsilateral adrenal involvement with synchronous contralateral adrenal metastases. Indian J Urol [serial online] 2006 [cited 2019 Aug 22];22:368-9. Available from: http://www.indianjurol.com/text.asp?2006/22/4/368/29128



   Introduction Top


One-fourth of all patients with Renal cell carcinoma (RCC) have metastases at presentation. Metastases to the ipsilateral adrenal gland are common and are found in 7-23% of cases.[1] However, incidence of synchronous metastases to the contralateral adrenal gland is rare.


   Case report Top


We report a case of RCC with ipsilateral adrenal involvement with synchronous contralateral adrenal metastases. A 60-year-old gentleman presented to us with a history of mild fever of 20 days duration and bilateral vague upper abdominal pain.

Abdominal examination revealed an ill-defined, mobile, nontender left renal mass. On further evaluation, CT scan abdomen revealed a large heterogeneous enhancing mass of size 10.8 x 8.7 cm involving the upper and mid pole of the left kidney with faint specks of calcification along with enlargement of the left suprarenal gland which measured 9 x 5.9 cm. A contrast enhancing mass lesion was also seen in the right suprarenal region. [Figure - 1]a and b X-ray of chest and the liver function tests were within normal limits. All the metastatic workup was negative. In view of good performance status (ECOG-1) and no other co-morbidities patient then underwent left laparoscopic radical nephrectomy followed by right laparoscopic retroperitoneoscopic adrenalectomy.

Histopathology of the left radical nephrectomy specimen was reported as renal cell carcinoma of Fuhrman's nuclear Grade 3, with focal sarcomatoid differentiation, with direct extension of tumor into the adrenal gland. Thirteen hilar lymph nodes were identified which were all free of tumor. Histopathology of right adrenalectomy specimen revealed a poorly differentiated carcinoma [Figure - 2]a and b.


   Discussion Top


The presentation of RCC is varied, ranging from a small incidentally detected lesion to a large palpable mass to a rare small lesion with extensive metastases.[1]

The overall incidence of solitary adrenal metastases in RCC is 6-29% in autopsy series, but from clinical diagnosis the incidence is 2-10%, of which the ipsilateral adrenal is involved in 5.5% whereas synchronous contralateral adrenal gland involvement has been reported in less than 60 cases.[2],[3],[4] In a series of 1179 RCC patients, 0.3% of patients had bilateral synchronous adrenal involvement.[5]

In patients with solitary metastases, radical nephrectomy with metastatectomy has been advocated, with 20% to 30% five-year survival rates. The survival of patients with widespread metastases is very poor, but the patients with solitary metastases who undergo nephrectomy with metastatectomy have good freedom rate and prolonged survival (30% for >five years), indicating an aggressive treatment for such tumors.[6]

Although the incidence of synchronous metastases to the contralateral adrenal gland is rare, preoperative identification of these patients is important, as the treatment modality of choice in such patients is radical nephrectomy with the contralateral adrenalectomy.[4] After bilateral surgical excision of adrenals these patients require substitution of the adrenal cortical hormones. Our patient required replacement with prednisolone (5 mg in morning and 2.5 mg in afternoon) and fludrocortisone (0.1 mg daily).

For patients having renal tumor with ipsilateral adrenal involvement with synchronous solitary contralateral adrenal metastases and with good performance status, ipsilateral radical nephrectomy and contralateral adrenal metastatectomy may be the preferred option, as surgery is the only effective option in such patients, offering good survival rates.

 
   References Top

1.Neal PM, Leach GE, Kaswick JA, Lieber MM. Renal cell carcinoma: Recognition and treatment of synchronous solitary contralateral adrenal metastases. J Urol 1982;128:135-6.  Back to cited text no. 1  [PUBMED]  
2.Lau WK, Zincke H, Lohse CM, Cheville JC, Weaver AL, Blute ML. Contralateral adrenal metastases of renal cell carcinoma: Treatment, outcome and a review. BJU Int 2003;91:775-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Dieckmann KP, Wulbrand A, Kroizig G. Contralateral adrenal metastases in renal cell cancer. Scand J Urol Nephrol 1996;30:139-43.  Back to cited text no. 3    
4.Kessler OJ, Mukamel E, Weinstein R, Gayer E, Konichezky M, Servadio C. Metachronous renal cell carcinoma metastasis to the contralateral adrenal gland. Urology 1998;51:539-43.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Antonelli A, Cozzoli A, Simeone C, Zani D, Zanotelli T, Portesi E, et al . Surgical treatment of adrenal metastases from renal cell carcinoma: A single-center experience of 45 patients. BJU Int 2006;97:505-8.  Back to cited text no. 5    
6.O'Dea MJ, Zinke H, Utz DC, Bernatz PE. The treatment of renal cell carcinoma with solitary metastasis. J Urol 1978;120:540-2.  Back to cited text no. 6    


    Figures

  [Figure - 1], [Figure - 2]

This article has been cited by
1 Laparoscopic management of adrenal lesions larger than 5 cm in diameter
Sharma, R., Ganpule, A., Veeramani, M., Sabnis, R.B., Desai, M.
Urology Journal. 2009; 6(4): 254-259
[Pubmed]



 

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    Abstract
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