Simultaneous bilateral adrenal metastases from renal cell carcinoma. Surgical implications and review of the literature

Bilateral adrenal metastases from renal cell carcinoma after robot-assisted partial nephrectomy

Renal cell carcinoma often metastasizes to the adrenals; however, bilateral adrenal metastases are rare. We here report a patient with bilateral adrenal metastases from renal cell carcinoma after robot-assisted partial nephrectomy and review relevant published reports. A 64-year-old man underwent robot-assisted partial nephrectomy for a left renal tumor. During follow-up, he was diagnosed with bilateral adrenal metastases. He underwent left adrenalectomy followed by right partial adrenalectomy to preserve adrenal function. The renal tumor later metastasized to other parts of the body. He continues to receive systemic treatment and remains in partial remission. Patients with pT1aN0M0 renal cell carcinoma generally have a favorable prognosis. However, occasional such patients develop multiple metastases. To the best of our knowledge, this is the first reported case of bilateral adrenal metastases after partial nephrectomy. Clinicians should keep this rare scenario in mind.

Surgical Treatment of Solitary Metachronous Adrenal Metastasis from Urothelial Carcinoma of the Urinary Bladder

Urothelial cancer is a common neoplasm and metastatic disease correlates with a poor prognosis. Isolated adrenal gland metastases of urothelial carcinoma are quite rare, and management options can decide a patient's prognosis. Herein we report the case of a 76-year-old man with a metachronous solitary adrenal metastasis from a bladder carcinoma, who underwent adrenalectomy as part of his treatment. Furthermore, we discuss the cases of solitary adrenal metastases of urothelial carcinoma available in the literature, to identify key features to direct appropriate treatment of this rare metastatic site of urothelial cancer and improve prognosis and survival. Still, further prospective studies are needed to design effective therapeutic strategies.

Metastatic Renal Cell Carcinoma and Unforeseen Adrenal Insufficiency: A Case Report and Literature Review

Renal cell carcinoma (RCC) can metastasize to nearly every organ, yet rarely metastasizes to the adrenal glands despite their anatomical proximity. Adrenal metastases are typically incidental findings on medical imaging and are vastly clinically asymptomatic. The adrenal glands can maintain hormonal homeostasis if a tenth of total adrenal gland function is preserved. We present a patient with synchronous bilateral adrenal metastases from RCC with rapid and unexpected development of adrenal insufficiency (AI).

Outcomes of synchronous and metachronous bilateral small renal masses (< 4 cm): a population-based cohort study

OBJECTIVES

To report longitudinal outcomes of a population-based cohort of patients diagnosed with bilateral small renal masses from a period of over 11 years.

PATIENTS AND METHODS

Consecutive patients diagnosed with bilateral small renal masses (synchronous or metachronous) of a defined geographical area were recorded in a large database (TUCAN database) between January 2005 and December 2016. Patients had a unique identifier number and followed during this period using an agreed upon protocol. Clinicopathological characteristics and outcomes of bilateral small renal masses on active surveillance were analysed and compared to propensity score-matched sporadic unilateral small renal masses. Data were analysed for renal mass growth rate, rate of intervention and development of metastatic disease and patient survival.

RESULTS

A total of 1060 patients were diagnosed with renal cancer, of which bilateral small renal masses accounted for 70 (6.6%) cases. Synchronous SRMs were observed in 63 patients, whereas metachronous lesions were found in seven patients during the study period. Metachronous lesion mean time to appearance was 62 ± 41 months (range 9-149 months). While most cases were sporadic, four were found to be hereditary. Growth rate of bilateral small renal masses did not differ from that of unilateral sporadic small renal masses. Similarly, there were no differences between the groups for rate of interventions and survival.

CONCLUSIONS

Progression, rate of metastases and survival for patients diagnosed with bilateral small renal masses are similar to those diagnosed with unilateral disease.

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.

Bilateral Metachronous Adrenal Metastases of Operated Renal Cell Carcinoma

Background

The adrenal glands are among the target metastatic organs due to the potential of systemic metastasis from renal cell carcinoma (RCC). The number of cases with bilateral metachronous metastases from RCC is about twenty.

Patients and Methods

A sixty-one-year-old man presented for routine checks due to an operated left renal tumor (clear cell carcinoma, PT2N0M0, Fuhrman grade III). The patient underwent 18FDG-PET/CT in order to restage the disease upon observation of bilateral adrenal masses on ultrasound and CT. A bilateral metachronous metastasis was found, whose SUVmax was 6.7 × 50 × 38 × 20 cm on the left adrenal gland, and another metastasis whose SUVmax was 5.5 40 × 29 × 20 on the right adrenal gland.

Results

The patient underwent a CT-guided biopsy and diagnosis of adrenal metastasis was made by pathological and immunohistochemical examination. The laparoscopic treatment was performed.

Conclusions

There is no standard approach for the treatment of these patients in the literature. But metastasectomy is the most realistic part of the treatment. Making definitive diagnosis with biopsy, following hormonal examination and treatment with minimally invasive adrenal sparing surgical procedure containing frozen-section are strongly recommended. Cancer specific survival significantly increases with metastasectomy.

Role of surgery in advanced/metastatic renal cell carcinoma

Metastatic renal cell cancer (RCC) is a malignant disease without curative treatment. These patients are usually symptomatic and desperate for effective palliative treatment. Radiotherapy, chemotherapy, and hormonal therapy are not effective in these patients. A multimodal approach consisting of cytoreductive nephrectomy, systemic therapy (which includes cytokines or targeted molecules), and metastasectomy have been shown to be useful in prolonging the survival and improving the quality of life in a select group of patients with metastatic renal cancer. Patients with oligometastatic disease, good performance status, and delayed presentation of the secondaries have better results following this integrated approach. Although there is some controversy regarding the order in which nephrectomy and systemic therapy are to be instituted, well-controlled studies like the South West Oncology Group and European organization research and treatment of cancer have shown that upfront nephrectomy gives better survival compared to neoadjuvant systemic therapy followed by nephrectomy. This order is the standard presently. Of late, with better understanding of the genetic basis and the biology of the various subtypes of renal cell carcinoma, targeted molecular therapies have emerged as an equally effective alternative therapy to cytokines. Recent reports have proven that targeted therapy is more effective with comparable side effects. Metastasectomy in a subgroup of patients improves survival and quality of life specifically in those with lung secondaries and painful bone metastases.

Real indications for adrenalectomy in renal cell carcinoma

OBJECTIVES

We determined the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluated the role of adrenalectomy as part of radical nephrectomy.

PATIENTS AND METHODS

From 1993 to 1999, 210 patients with renal cell carcinoma (RCC) (139 men and 71 women, mean age 60.8 years, range 12-96 years) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, group 1) and 104 with advanced (stage T3-4N01M01, group 2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared with postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis.

RESULTS

Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4-21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC.

CONCLUSIONS

Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.

Adrenal metastases from renal cell carcinoma: role of ipsilateral adrenalectomy and definition of stage

OBJECTIVES

We undertook this study to establish criteria for adrenalectomy in patients with renal cell carcinoma.

METHODS

We retrospectively reviewed the records of 162 patients undergoing radical nephrectomy from 1979 to 1993 at University Hospitals of Cleveland. Simultaneous ipsilateral adrenalectomy was performed in 57 patients (35%).

RESULTS

Three of these 57 patients (5.3%) had ipsilateral adrenal metastases. All 3 patients had large, left-sided, upper-pole tumors that extended through the renal capsule (Stage T3a). All 3 patients with adrenal metastases had progression to disseminated disease, with an average time to progression of 7.2 months, whereas only 13 (24%) of the 54 patients without adrenal metastases developed metastatic disease (none to adrenal), with an average time to progression of 27.6 months. No patient with organ-confined disease (Stage T1 or T2) or extracapsular disease in the midkidney or lower pole had adrenal metastases identified histologically.

CONCLUSIONS

The prognosis is poor for renal cell carcinoma with ipsilateral adrenal involvement, even with complete removal. Because of this poor prognosis, we believe that adrenal involvement should constitute a separate stage category. We propose that patients with ipsilateral adrenal metastases via direct extension should be classified as having pathologic Stage pT3d. If the patient has an ipsilateral adrenal metastasis not via direct extension, contralateral adrenal metastasis, or bilateral adrenal metastases, the pathologic stage should be M1. Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on computed tomographic scan or if gross disease is seen at the time of nephrectomy although its removal may not benefit the patient.

Adrenalectomy for metastatic disease to the adrenal glands

A policy of supportive treatment is frequently adopted for patients with metastatic disease to the adrenal glands. This study reports an experience with adrenalectomy for adrenal metastasis. Between 1983 and 1993, adrenalectomy was performed in 52 patients for metastasis to the adrenal glands. Survival was calculated by the Kaplan-Meier method and compared with the log rank test. Primary tumour sites included kidney (n = 15), lung (n = 11), colon (n = 7), unknown (n = 5), stomach (n = 3), melanoma (n = 3) and other (n = 8). Adenocarcinoma (69 per cent) was the most common histological cell type. Thirty-two patients were asymptomatic on initial evaluation. Symptomatic adrenal pain relief was achieved in 11 of 13 patients. Overall survival rates were 73 per cent at 1 year and 40 per cent at 2 years. Patients with potentially curative resection had better survival than those who had a palliative procedure. Patients with adrenal metastases due to adenocarcinoma had improved survival compared with that in those with other histological cell types. Although long-term survival is generally poor, highly selected patients with adrenal metastasis (symptomatic disease or adenocarcinoma) may benefit from surgical resection.