Metachronous periadrenal Fatty tissue metastasis from contralateral renal cell carcinoma

[SMALL RENAL CELL CARCINOMA METASTASIS TO THE IPSILATERAL PERIRENAL FAT SYNCHRONOUSLY: A CASE REPORT]

Small renal cell carcinoma with metastases is rare; thus, to the best of our knowledge, this is the first case of synchronous metastasis to the ipsilateral perirenal fat.A 70-year-old man visited our hospital because of early gastric carcinoma. Contrast-enhanced computed tomography revealed a right renal tumor and two small nodules in the ipsilateral perirenal fat. The renal tumor was 3 cm in diameter and consistent with clear cell renal cell carcinoma. The enhancement pattern of the nodules was similar to that of the renal tumor, we diagnosed cT1aN0M1. Transperitoneal laparoscopic radical nephrectomy of the right kidney was performed. Postoperative pathological analysis showed clear cell renal cell carcinoma of the right kidney, pT1a, G2>1, INFa, v0, ly0, and two nodules in ipsilateral perirenal fat had comparable pathological findings. At 11th month of postoperative follow-up, CT revealed multiple nodules in the left pleura. Pembrolizumab plus axitinib was administered every 3 weeks. Multiple pleural metastases disappeared 3 months after the therapy; however, grade 2 (CTCAE v5.0) diarrhea and hoarseness emerged. Owing to the persistence of symptoms despite axitinib cessation, pembrolizumab was also discontinued. After 2 months of withdrawal, the patient's symptoms resolved spontaneously. After consultation with the patient, he was followed up with no further treatment. He is alive with no evidence of recurrence 36 months after surgery.

Robotic sequential right adrenalectomy and zero ischemia left partial nephrectomy in a patient with synchronous pheochromocytoma and renal cell carcinoma

Currently, most renal masses are detected incidentally while still small in size because of the widespread use of radiological imaging, and most pheochromocytomas are localized in the adrenal glands as unilateral lesions. A 5 × 4-cm right adrenal mass and a 19 × 13-mm exophytic left renal mass were synchronously detected by contrast enhancement on computed tomography and magnetic resonance imaging in a 47-year-old male with hypertension. The patient's preoperative serum and 24-h urine catecholamine levels were elevated. Initially, robotic transperitoneal right adrenalectomy was performed, and histopathology confirmed a 4 cm pheochromocytoma. After 3 months, transperitoneal zero ischemia robotic left partial nephrectomy was performed, and histopathology demonstrated clear cell renal cell carcinoma, Fuhrman grade II, 17 mm in size with clear surgical margins. This case indicates that sequential robotic surgery is feasible and safe as a minimally invasive approach to remove bilateral renal and adrenal masses. Zero ischemia robotic partial nephrectomy is also feasible and safe for selected small renal masses.

Bilateral synchronous adrenal metastases of renal cell carcinoma: A case report and review of the literature

Renal cell carcinomas (RCCs) metastasize to the adrenal glands via various mechanisms, including lymphatic vessel arterial embolism and retrograde venous embolism. The rate of ipsilateral metastasis is 3–5% and the rate of contralateral metastasis is ~0.7%, however, synchronous bilateral adrenal metastases are extremely rare. Therefore, the optimal diagnosis and treatment strategy for this condition is yet to be thoroughly defined. In the present study, a 50-year-old male patient presented with right flank pain. Ultrasonography (US) revealed a right renal mass and bilateral adrenal metastases, and a computerized tomography (CT) scan determined the size of the lesions: An 86×83×66-mm mass in the lower pole of the right kidney, an 18×12×10-mm mass in the right adrenal gland, and a 69×51×53-mm mass in the left adrenal gland with central necrosis and peripheral contrast uptake. A US-guided biopsy was performed which determined a diagnosis of right RCC and bilateral synchronous adrenal metastasis. Immunohistochemical examination of the biopsy revealed clear cell carcinoma (Fuhrman grade, III). Consequently, right radical nephrectomy, right partial adrenalectomy (with frozen section examination) and left adrenalectomy were planned. The bilateral synchronous adrenal metastases posed a challenge in the diagnosis and treatment of the disease, as there is no standard approach in the literature for the treatment of such patients. However, metastasectomy was selected, as it appears to be the most effective treatment strategy for increasing the rate of cancer-specific survival. As an adrenal mass was present in the current patient, a hormonal examination was recommended and an adrenal-preserving minimally invasive surgical procedure using frozen section examination during surgery was particularly important to prevent the patient from developing adrenal insufficiency.