Renal cell carcinoma with unusual metastases (A case report)SD Deodhar, VG Mehendale, Geeta G Bhave
Departments of Surgery and Pathology and Microbiology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Bombay-400 012., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 731614
Source of Support: None, Conflict of Interest: None
A case of renal cell carcinoma with secondaries in the opposite suprarenal is described and the relevant literature reviewed.
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.
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.
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%
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.
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.
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. ,, Campbell and Hartwell , mention the opposite kidney, skin, thyroid and most organs as possible sites of secondaries. Ackerman  states that metastases may appear in unusual locations e.g. gingiva, larynx and bronchus. Eye and vagina are the other rare sites of metastasis.  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 , in a series of ten cases had metastases in the suprarenal in two cases. Robins  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.
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.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]