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Clinical Case Discussion

Case Presentation: A 63-year-old Man with Bilateral Adrenal Mass and Large Renal Cell Carcinoma

By: Gianluca Giannarini

EU Focus, Volume 1 Issue 3, February 2016, Pages 293-294

Published online: 01 February 2016

Abstract Full Text Full Text PDF (735 KB)

Take Home Message

The challenging case of an asymptomatic 63-yr-old man with a large renal cell carcinoma, bilateral adrenal mass, and small pancreatic and pulmonary nodules suspicious for metastases is presented. Treatment strategy is discussed by a surgeon recommending immediate cytoreductive nephrectomy and unilateral adrenalectomy as the first step and a medical oncologist favouring systemic targeted therapy at symptomatic disease progression.

A 63-yr-old man was referred to our outpatient clinic for further work-up of a solid mass of the right kidney that had been detected incidentally at an ultrasound prompted by a mild increase in serum creatinine level (1.36 mg/dl). Neither flank pain nor gross haematuria were reported.

Medical history revealed arterial hypertension and hypercholesterolemia and no previous surgery. Karnofsky performance status was 100%, and Charlson score was 0. On physical examination, a mass was palpable in the right flank.

A contrast-enhanced abdomen computed tomography (CT) scan was subsequently performed and confirmed a 8 × 6-cm large solid enhancing mass of the lower pole of the right kidney. The CT scan also showed a 7 × 5-cm large enhancing mass of the right adrenal gland, a 5 × 3-cm large mass suspicious for enlarged necrotic lymph nodes posterior to the inferior vena cava (IVC), a 4 × 2-cm large enhancing mass of the left adrenal gland, and three enhancing lesions in the pancreas, the largest with a size of 2.4 cm in the head. No venous thrombus was detected in the right renal vein or IVC (Fig. 1).

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Fig. 1 Axial contrast-enhanced computed tomography scan of the abdomen: (A) 8 × 6-cm large solid enhancing mass of the lower pole of the right kidney; (B) 7 × 5-cm large enhancing mass of the right adrenal gland; (C) 5 × 3-cm large mass suspicious for enlarged necrotic lymph nodes posterior to IVC (asterisk); (D) 4 × 2-cm large enhancing mass of the left adrenal gland.

Staging was completed with a chest CT, which revealed a few subcentimetric nodules in both lungs suspicious for metastases. Conversely, a brain CT scan and a bone scan were negative. Therefore, clinical stage was cT2N1M1.

Blood tests revealed haemoglobin, neutrophils, platelets, and serum corrected calcium within normal range limits. Moreover, serum cortisol and adrenocorticotropic hormone levels and urinary hydroxymandelic acid and vanillylmandelic acid levels were also within normal range limits. The patient was highly motivated to undergo maximal treatment.

After multidisciplinary discussion, we planned a right cytoreductive nephrectomy (CN) and systemic treatment with a tyrosine kinase inhibitor for distant metastases.

At surgery, the right adrenal mass involved the IVC wall in its segment between the renal vein and accessory hepatic veins. The patient underwent right CN including the complete removal of the ipsilateral adrenal mass and retrocaval lymphadenopathy. Removal required repair of IVC wall involved by the tumour. A paracaval lymph node dissection was then performed. Estimated blood loss was 1700 ml. Three packed red blood cell units were given. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. Haemoglobin and creatinine levels were 9.4 g/dl and 1.45 mg/dl, respectively. Adrenal function remained unchanged.

Final pathologic examination confirmed an 8-cm Fuhrman grade IV clear cell renal cell carcinoma of the right kidney with renal vein invasion and metastases to the ipsilateral adrenal gland and regional lymph nodes (pT3aN1M1).

Conflicts of interest

The author has nothing to disclose.

Footnotes

Urology Unit, Academic Medical Centre Hospital “Santa Maria della Misericordia,” Udine, Italy

Urology Unit, Academic Medical Centre Hospital “Santa Maria della Misericordia,” Piazzale Santa Maria della Misericordia 15, IT-33100 Udine, Italy. Tel.: +390432552931; Fax: +390432552930.

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