Synchronous Bilateral Metastases of Renal Cell Carcinoma

Abstract

Adrenal metastases of renal cell carcinoma represent one of the forms of distant spread of this tumor. The world medical literature has isolated clinical reports about such cases. Treatment for these patients includes bilateral adrenalectomy or adrenal resection. These techniques are often complicated by adrenal insufficiency, which can lead to sudden death of the patient even with substitution therapy. The aim. Therefore, nephrectomy with ipsilateral adrenalectomy and subsequent dynamic observation of metastasis in the contralateral adrenal gland are used in some patients. Material and methods. The study included 4 patients with this pathology, who were treated and observed in Municipal Non-Commercial Enterprise of Kharkiv Regional Council “Regional Medical Clinical Center of Urology and Nephrology named after V. I. Shapoval” from 2010 to 2020. The studied sample was dominated by men (3: 1). The average age of the patients was 57.8±5.3 years. The blood cortisol level in all patients before the operation was within the normal range. The patients also did not show a tendency to arterial hypotension. The average size of renal tumors reached 8.7±2.8 cm. The stage of the neoplasm was assessed as pT3a in 3 out of 4 observation cases. At the same time, there was invasion only in the perinephric fat. The renal tumor did not penetrate into the venous system in any of the cases. The histological structure of neoplasms in all patients was represented by clear-cell renal cell carcinoma. The size of adrenal metastases averaged 38.5±11.9 mm (from 24 to 56 mm). Left-sided metastases on average did not exceed 43±12.9 mm, while right-sided metastases were 34±10.6 mm. Macroscopic spread of both adrenal tumors into the venous system took place in one case (on the left - into the main renal vein, on the right - into the inferior vena cava). The average follow-up period in the entire group averaged 21.8±17.6 months. Surgical treatment included nephrectomy and bilateral adrenalectomy or adrenalectomy with adrenal resection. All patients underwent simultaneous removal of the kidney and metastases of both adrenal glands. Operations were performed using the chevron laparotomic approach. After surgery, three patients received systemic therapy (sutent, pazopanib, axitinib). Results and discussion. The mean operation time was 195±19.1 min, and the volume of blood loss was 800±81.6 ml. Complications of Clavien-Dindo grade was ≥III, and we did not record perioperative mortality in our study. Despite hormone replacement therapy, three patients had crises of Addison's disease at different times, which led one patient to death. The examination protocol included an ultrasound scan every 3 months, and multislice computed tomography of the lungs and abdominal organs every 6 months, a study of the blood cortisol level once every 2-3 weeks. Targeted therapy was used in three patients after surgery, but two of them died from cancer progression, and one patient stayed alive with tumor progression within 48 months. Conclusion. Synchronous bilateral metastases of renal cell carcinoma to the adrenal glands are not only a difficult surgical problem, but also a major therapeutic problem. Our study has demonstrated the efficacy and safety of the synchronous surgical approach in these patients. The prognosis in patients of this group is predominantly poor, but in some patients, long-term survival is possible. The question of the possibility of targeted therapy on the background of adrenal deprivation requires further study