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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  Acknowledgements
 ::  References
 ::  Article Figures

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ARTICLE
Year : 1978  |  Volume : 24  |  Issue : 1  |  Page : 55-57

Renal cell carcinoma with unusual metastases (A case report)


Departments of Surgery and Pathology and Microbiology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012., India

Correspondence Address:
S D Deodhar
Departments of Surgery and Pathology and Microbiology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012.
India
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Source of Support: None, Conflict of Interest: None


PMID: 731614

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 :: Abstract 

A case of renal cell carcinoma with secondaries in the opposite suprarenal is described and the relevant literature reviewed.



How to cite this article:
Deodhar S D, Mehendale V G, Bhave GG. Renal cell carcinoma with unusual metastases (A case report). J Postgrad Med 1978;24:55-7

How to cite this URL:
Deodhar S D, Mehendale V G, Bhave GG. Renal cell carcinoma with unusual metastases (A case report). J Postgrad Med [serial online] 1978 [cited 2019 Nov 17];24:55-7. Available from: http://www.jpgmonline.com/text.asp?1978/24/1/55/42687



 :: Introduction Top


Metastases of hypernephroma are commonly seen in the lungs, liver, bones and the central nervous system. They are however rare in the suprarenal. Hence we are prompted to report one such case which came under our care recently, in the King Edward VII Memorial Hospital, Bombay-400 012.


 :: Case report Top


M. M., male, aged 60 years, farmer by occu­pation, was admitted on 12th January 1977 with the complaints of a lump in the right side of the abdomen, haematuria. and irregular fever of one month's duration; there was no history of urinary stones.

On examination, he was poorly built and nourished with evidence of anaemia. Abdominal examination revealed a right renal lump, 15 cm x 10 cm, having a lobular surface; the lower border of the liver was barely palpable. Rest of the abdomen and scrotum were normal.

Investigations

Urine: Albumin ++

R.B.Cs ± +

Average daily urinary output was 1200 ml.

Blood: Blood urea nitrogen - 16 mg%

Serum creatinine - 1 mg

Serum electrolytes - Na : 125 mEq/litre

- K 3.9 mEq/litre

- Cl- : as NaCl 102 mEq/litre

Hb. 7.5 gms%

P.C.V. 23%

A plain X-ray of the urinary tract showed diffuse opacification in the right renal region with spotty calcification. There was no radio-­opaque calculus. Intravenous pyelography showed a non-functioning right kidney. the left pelvicalyceal system was slightly distorted and rotated see [Figure 1] on page 54A.

A right nephro-ureterectomy was carried out on 21st January 1977 under intratracheal gas­oxygen anaesthesia.

The excised right kidney showed a large tumour mass measuring 15 cm x 10 cm, replac­ing most of the renal parenchyma. The cut sur­face showed a greyish white appearance with areas of necrosis and haemorrhage. At the up­per pole the tumour had invaded the right su­prarenal gland see [Figure 2] on page 54A. Histo­logical examination showed typical appearance of renal cell carcinoma. The cells were poly­gonal with clear cytoplasm and were arranged in lobular and glandular fashion see [Figure 3] on page 54B. The right supra-renal was complete­ly replaced by the tumour tissue.

In the pest-operative period the patient was normal for about 24 hours. After that his uri­nary output dropped and 42 hours after the operation he suddenly expired.

Autopsy Findings

The left kidney was normal in size and shape, and showed two yellowish white nodules 0.5 cm x 0.5 cm in size on the anterior surface. Cut surface of the kidney showed normal cortex and medulla. The left suprarenal was markedly enlarged, 10 cm x 7.5 cm, well capsulated, having a variegated consistency. Cut surface showed greyish white lobulated tumour deposit completely replacing the normal suprarenal tis­sue see [Figure 2] on page 54A.

Histology of the sections of the left kidney through the nodule showed metastases from renal cell carcinoma. Microscopically the left suprarenal gland showed similar appearance as the right kidney tumour. The cells were cuboi­dal or polygonal in shape with clear or faint pink granular cytoplasm and showed tubular arrangement see [Figure 4] on page 54B.

The liver was markedly enlarged in size. The right lobe showed an abscess, 20 cm x 15 cm, containing thick, purulent material. The wall of the abscess was formed by the necrotic mate­rial. The abscess had burst on its superior sur­face into the peritoneal cavity. The saline preparation from the abscess material showed vegetative forms of Entasnoeba hystolytica; cul­ ture did not grow any bacteria. The colon showed multiple amoebic ulcers, oval or cir­cular, with undetermined edges.

Cause of death

Peritonitis following ruptured amoebic liver abscess and shock.


 :: Discussion Top


Renal cell carcinoma usually spreads by the blood route and the common sites of metastases are the lungs, liver, bones and the central nervous system. [2],[3],[4] Campbell and Hartwell , mention the opposite kidney, skin, thyroid and most organs as possible sites of secondaries. Ackerman [1] states that metastases may ap­pear in unusual locations e.g. gingiva, larynx and bronchus. Eye and vagina are the other rare sites of metastasis. [6] Thus it will be seen that the standard text books of surgery, pathology and urology do not indicate the suprarenal as the possible site of metastasis. However, Willis [7],[8] in a series of ten cases had metastases in the suprarenal in two cases. Robins [6] also mentions the suprarenal as one of the sites of metastases.

In our case the involvement of the right suprarenal was obviously by direct spread from the right kidney following penetration of its capsule. The secondaries in the left suprarenal and the two malignant nodules on the surface of the left kidney were probably of haematogenous origin.

Since both the suprarenals were replac­ed by tumour tissue, the patient was in state of severe cortisol insufficiency, not suspected prior to the operation. The stress of the operation further aggravated the cortisol inadequacy. Finally, the rupture of the pre-existing asymptomatic amoebic abscess of the liver provided the proverbial "last straw on the camel's back" and led to the patient's death.


 :: Acknowledgements Top


Thanks are due to the Dean, K. E. M. Hospital, Bombay, for permission to re­port this case.

Thanks are also due to the members of the resident and nuri ing staff for the help rendered in the management of this case.

 
 :: References Top

1.Ackermann, L. V. and Juan Rcsai: "Surgical Pathology," C. V. Mosby & Co., St. Louis, 1974, p. 664.  Back to cited text no. 1    
2.Aird Ian: "A Companion in Surgical Studies", E. S. Livingstone Ltd., Edin­burgh & London, 1958, p. 1113.  Back to cited text no. 2    
3.Anderson, W. A. D.: "Pathology" Vol. 1, C. V. Mosby & Co., St. Louis, 1971, p. 822.  Back to cited text no. 3    
4. Boyd William: "A text book of Pathology," Lea & Febiger, Philadelphia. 7th Edition, Reprint 1964, p. 615.  Back to cited text no. 4    
5.Campbell, M. F. and Harrison, J. H.: "Urology," Vol. II, 3rd Ed., W. B. Saunders Co., Philadelphia, London, Toronto,1970, p. 908.  Back to cited text no. 5    
6.Robins, S. L.: 'pathology," 3rd edition, W. B. Saunders & Co., Philadelphia, London, Igaku Shoin Ltd., Tokyo, 1967,p. 1041.  Back to cited text no. 6    
7.Willis, R. A.: "Pathology of tumours," 4th Edition, Butterworths, London, 1967, p . 466.  Back to cited text no. 7    
8.Willis, R. A.: "Spread of tumours in the human body," Butterworths, London, 1973, p. 198.  Back to cited text no. 8    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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