Ipsilateral adrenalectomy in the surgical treatment of renal carcinoma

OBJECTIVES: To assess the value of ipsilateral adrenalectomy during radical nephrectomy for the treatment of renal cell carcinoma as a function of preoperative computed tomography findings. METHODS: Between May 1985 and June 1994, 194 patients underwent radical nephrectomy for renal cell carcinoma in our institution. Preoperative radiological reports and postoperative pathological reports were reviewed for 185 patients. RESULTS: 148 patients underwent abdominal computed tomography before surgery. 94 adrenalectomies were performed in this group of patients. None of the 77 patients in whom computed tomography showed a normal adrenal gland had adrenal metastasis on the definitive histological examination. 17 patients had an adrenal mass on computed tomography, 3 of which proved to be neoplastic. Preoperative CT had a sensitivity of 100%, a specificity of 82%, a positive predictive value of 18% and a negative predictive value of 100%. The 185 files reviewed included 114 adrenalectomies, including 4 adrenal glands invaded by renal cell carcinoma (3.5%). In these 4 cases, the smallest diameter of the renal tumour was 4 cm and the minimum pathological stage was T3. CONCLUSIONS: It therefore appears justified not to perform adrenalectomy during nephrectomy, in the presence of a renal tumour and negative adrenal computed tomography.     

Ultrasonographic study of adrenal gland tumors (report of 5 cases)

The authors study the ultrasound signs of the adrenal gland based on 5 different types of operated adrenal tumours (a lipoma, an adrenal cortical adenoma, a cyst, a corticoadrenaloma, an adrenal metastasis from a renal cell carcinoma). The ultrasonographic morphological criteria of the normal adrenal gland and each type of tumour are recalled and are illustrated by clinical cases. The value of ultrasonography in the investigation of this organ was evaluated in comparison with other imaging techniques. It constitutes a good first-line diagnostic guiding examination, but needs to be completed by other investigations (computed tomography, magnetic resonance imaging, etc.). Ultrasonography can also reveal asymptomatic adrenal tumours ("adrenal incidentalomas") in which the therapeutic decision (surveillance or surgery) must be based on criteria of size and appearance after a complete laboratory and morphological assessment.     

A comparison of A103 and inhibin reactivity in adrenal cortical tumors: distinction from hepatocellular carcinoma and renal tumors

Distinguishing adrenal cortical neoplasms from either hepatocellular carcinomas or renal tumors can be difficult. Two recently described antibodies, A103 and inhibin A, are most often reported to be reactive with adrenal cortical neoplasms but with neither hepatocellular carcinoma nor renal cell carcinoma. To compare the sensitivity and specificity of these two antibodies in the diagnosis of adrenal cortical tumors, we stained 22 adrenal cortical adenomas, 4 adrenal cortical carcinomas, 25 hepatocellular carcinomas, and 43 renal tumors, including 33 renal cell carcinomas and 8 oncocytomas, with the A103 and inhibin A using an avidin-biotin complex technique. Fifteen (68%) of 22 adrenal adenomas and 2 (50%) of 4 adrenal cortical carcinomas were reactive with A103. Nineteen (86%) of 22 adrenal adenomas and 3 (75%) of 4 adrenal cortical carcinomas were reactive for inhibin A. None of the renal tumors or hepatocellular carcinomas reacted with A103, but 1 (4%) of 25 hepatocellular carcinomas (a high-grade pleomorphic tumor) and 1 (2%) of 43 renal tumors (a clear-cell renal cell carcinoma) were reactive with inhibin A. The cytoplasmic reactivity for A103 in adrenal tumors was coarsely granular and most common in clear-cell areas. Reactivity for inhibin was either cytoplasmic or membranous and stained both clear-cell and granular areas. We conclude that both antibodies are useful in the immunohistochemical diagnosis of adrenal cortical neoplasms and that A103 is slightly more specific and inhibin slightly more sensitive.     

Adrenal cortical carcinoma with a liver metastasis in a child. Report of a case with fine needle aspiration findings and image analysis of nuclear DNA

BACKGROUND: Adrenal cortical carcinoma is a rare and highly malignant neoplasm. Liver metastases from it may require special differential techniques in addition to cytologic findings. CASE: A 14-month-old child had adrenal cortical carcinoma and a liver metastasis confirmed by fine needle aspiration biopsy (FNAB). Histologic and clinical criteria of malignancy only partially applied to this tumor. Immunohistochemical analysis of both the primary tumor and metastasis supported an adrenal cortical origin. Other ancillary tests-DNA ploidy, proliferation index (proliferating cell nuclear antigen, Ki-67) and p53 protein immunolocalization-were utilized in a diagnostic sequence. Flow cytometric and image analysis of DNA ploidy of the primary tumor gave similar results. Assessment of DNA content of the adrenal cortical carcinoma and liver metastasis by image analysis showed identical patterns. CONCLUSION: The applicability of new diagnostic techniques to FNAB material may provide new objective measures of the biologic potential of adrenal cortical carcinoma. The validity of these tests is enhanced with the use of image-based quantitative approaches that provide greater reproducibility and objectivity of their results.     

Management of the pancreatic metastases from renal cell carcinoma: report of four resected cases

The pancreas is an uncommon site for metastasis from renal cell carcinoma. In most cases, pancreatic metastases occur as part of widespread nodal and visceral involvement, and there is thus evidence of metastatic disease elsewhere in the body. We present 4 cases with resectable pancreatic metastases arising from renal cell tumors without involvement of the regional lymph nodes at the operation. Three cases out of 4 were asymptomatic and the pancreatic metastases were detected by routine follow-up examination of renal cell carcinoma. Aggressive surgical treatment for the solitary metastatic lesion is advocated. Spread of renal cell carcinoma to the pancreas is, however, via the hematogenous route, and even solitary pancreatic metastasis may be one of the manifestations of the systemic metastasis of renal cell carcinoma. No pancreatic regional lymph nodes metastases were noted. Pancreatectomy should be undertaken to remove the tumor with adequate resection margins while preserving as much of the gland as possible. The prognosis of pancreatic metastases arising from a renal cell carcinoma is discussed with a review of the literature. Adjuvant chemo- and endocrine therapy should also be considered in these cases.     

Multiple organ metastasis following nephrectomy for renal carcinoma]

We report a case of TNM stage II renal carcinoma with metastasis to lungs, contralateral adrenal gland and skin within 5 years following nephrectomy. The patient underwent lobectomy, adrenalectomy and cutaneous excision biopsy. The clinical course and management of metastases are discussed.     

Cytokine levels in cystic renal masses associated with renal cell carcinoma

PURPOSE: We compared cytokine levels in fluid from renal cysts with and without renal cell carcinoma. MATERIALS AND METHODS: Fluid was aspirated from 18 renal cysts without (benign) and 21 with renal cell carcinoma (malignant). Serum from patients with renal cell carcinoma and healthy controls was collected and cytokines were measured by enzyme-linked immunosorbent assay. RESULTS: Interleukin-6 (IL-6) and basic fibroblast growth factor concentrations were higher in malignant than benign cysts or serum (p <0.006). Epidermal growth factor levels were significantly higher in malignant cysts and serum than in benign cysts (p <0.01). IL-6 levels in malignant cysts positively correlated with the erythrocyte sedimentation rate (R=0.80) and C-reactive protein (R=0.86), and they were higher in grade 3 than in grade 2 tumors. Basic fibroblast growth factor levels were significantly higher in malignant cysts associated with hypervascular than hypovascular tumors (p=0.029). CONCLUSIONS: Cytokine levels in aspirated fluid may help to identify malignant renal cysts and indicate the characteristics of coexisting tumors.     

The effects of steroid instillations and hematomas on the pseudosheaths around miniature breast implants in rats

The syndrome of hypercalcemia in patients with renal cell carcinoma without metastasis to bone, in association with elevated levels of immunoreactive prostaglandin E and normal parathyroid hormone levels, prompted the investigation of an etiologic relationship of increased prostaglandin in this syndrome. Ethyl acetate extracts of tissue culture effluents, primary and metastatic renal cell carcinoma, and plasma were chromatographed on silicic acid columns and assayed by double antibody immunoprecipitative methods for immunoprecipitative methods for immunoreactive prostaglandins A and E. Increased levels of immunoreactive prostaglandins A and E were found 1) to be generated in parallel with cell growth during a period of time by renal cell carcinoma in monolayer growth, 2) in extracts of primary and metastatic renal cell carcinoma tissue and 3) in the venous effluent of a kidney bearing a renal cell carcinoma. These findings support the hypothesis that renal cell carcinoma can produce prostaglandins. Furthermore, reported syndromes of patients with renal cell carcinoma associated with elevated prostaglandin levels may result from the autonomous production of prostaglandins in vivo by the tumor.     

High-dose epirubicin in platinum-pretreated patients with ovarian carcinoma: the EORTC-GCCG experience

A follow up study of 20 cases of renal cell carcinoma with regional lymph node metastasis at the department of urology in Niigata Cancer Center Hospital from 1979 to 1993 is presented. During this period, we treated 249 patients with renal cell carcinoma with or without lymph node metastasis. Lymph node metastasis could be estimated in 188 out of 249 patients. Histologically, lymph node metastasis was classified as pN1 in 8 cases, pN2 in 7 cases, and pN3 in 5 cases. The 3- and 5-year survival rates of 20 patients with lymph node metastasis were 45.0% and 16.4%, respectively. Nine of the 20 cases had no distant metastasis and 11 cases had distant metastasis. Three of the 9 patients with distant metastasis had no recurrence. Two of these 3 patients are still alive after 10 years and 3 years and 1 patient died because of acute heart failure. These 3 patients had pN1 metastasis smaller than 1 cm lymph node. Four of the 11 patients with distant metastasis had more than a two-year survival. However, 3 patients died due to renal cell carcinoma although primary and metastatic regions were resected and IFN with chemotherapy were given. Only one patient is still alive without recurrence after 3 years. This case detected as right renal cell carcinoma with pN2 metastasis and bilateral pulmonary metastasis was treated with radical nephrectomy with regional lymph node dissection and administered Methotrexate, VP16 and CisPlatinum chemotherapy and IFN.(ABSTRACT TRUNCATED AT 250 WORDS)     

Isolated late metastasis of a renal cell cancer treated by radical distal pancreatectomy

A 53-year-old man underwent right nephrectomy for a locally renal cell carcinoma with concomitant resection of a solitary metastasis in the right lung. Ten years later, he presented with haematochezia caused by a tumour in the tail of pancreas, invading the transverse colon and the greater curvature of the stomach. The tumour was radically resected, and histological examination revealed a solitary metastasis of the previous renal cell carcinoma. This case illustrates a rare indication for pancreatic resection because of pancreatic metastasis.     

Ischiogluteal bursitis mimicking soft-tissue metastasis from a renal cell carcinoma

We report a case of ischiogluteal bursitis mimicking a soft-tissue metastasis from a renal cell carcinoma. A 66-year-old woman suffered from pain over the left buttock 6 months after she was operated on for renal cell carcinoma of the left kidney. CT of the abdomen and pelvis revealed a tumor-like lesion adjacent to the left os ischii, which was suspected to be a soft-tissue metastasis. Percutaneous biopsy revealed no evidence of malignancy, but the histopathological diagnosis of chronic bursitis.     

Lower gastrointestinal bleeding as the initial presenting symptom of renal cell carcinoma

Renal cell carcinoma is known as one of the "great mimics encountered in clinical medicine," along with syphilis and tuberculosis. It can present clinically as a wide range of symptoms, with a classic triad described as hematuria, pain, and a palpable abdominal mass. However, this triad is present only in <20% of patients with renal cell carcinoma. Gastrointestinal bleeding has been described in renal cell carcinoma, although mainly secondary to metastasis in the upper gastrointestinal tract, with few cases due to local invasion. Lower gastrointestinal bleeding as a presenting symptom of an invasive primary renal cell carcinoma has been described in only one patient in the literature. Our patient is the first in whom a colonoscopic biopsy was used as a successful diagnostic modality.     

A case of multiple intracerebral cavernous angioma presenting with seizures at the onset

Herein we describe a patient in whom a renal mass had been detected. He had no previous urological symptoms or signs, but had undergone laryngectomy in 1989 for well-differentiated squamous cell carcinoma of the glottic region. The radiological and ultrasound evaluations disclosed a right renal mass, a mass in the ipsilateral adrenal gland and a polypoid mass in the gallbladder. The patient underwent radical nephrectomy, adrenalectomy and cholecystectomy. The surgical specimens of the gallbladder and adrenal gland showed histological evidence of clear cell carcinoma with the same characteristics as those of the primary renal tumor.     

Relationship between vascular factors and white matter low attenuation of the brain

There are few reports on contralateral or metachronous adrenal gland metastases in renal cell carcinoma (RCC) in the literature. Since sonography has been more frequently used in follow-up examinations these metastases have been found more often. We report on five patients with solitary metastases from RCC to the ipsi- or contralateral adrenal gland.     

Surgical analysis for metastatic lung tumor from renal cell carcinoma

Metastatic lung tumor from renal cell carcinoma were studied in 29 cases. Eighteen patients were treated surgically, 11 were treated non-surgically. The overall 5-year survival rate with the patients of pulmonary resection was 53.5%, and that with those of conservative therapy was 0%, and this difference is statistically significant (p < 0.05). There was no significant difference in any characteristics such as sex, age, stage, grade, disease free interval, metastatic pattern and combination with or without interferon therapy. There was no significant difference in surgically treated patients with pulmonary metastasis in terms of any factors such as age, sex, stage, grade, disease free interval, pulmonary metastasis pattern, metastatic number, surgical procedure, combination with or without interferon therapy statistically. Analysis for the surgically treated patients with pulmonary metastasis from renal cell carcinoma shows no significant difference in prognosis with any characteristics. This result shows efficacy of surgery even if for the patients with synchronous bilateral multiple pulmonary metastasis from renal cell carcinoma.     

Pulmonary infarcts can mimic pulmonary metastases from renal cancer

PURPOSE: Spontaneous regression of pulmonary metastases from renal cell carcinoma is a rare but well documented event. We present 2 recent cases that were radiographically consistent with pulmonary metastases from renal cell carcinoma but were pathologically shown to be pulmonary infarcts with no evidence of metastatic cells. Stable pulmonary infarcts can be misconstrued as metastatic disease in patients with renal cell carcinoma while resolving pulmonary infarcts may represent a subpopulation of patients with apparent spontaneous regression. Clinical implications of these findings are discussed. MATERIALS AND METHODS: Clinical and pathological data from 2 patients with large primary renal tumors, venous thrombi and lung masses were reviewed. Data from these cases, as well as pertinent urological and pathological literature, are presented. RESULTS: Although preoperative assessment was consistent with stage IV renal cell carcinoma, pathological examination of the lung masses in these patients showed no evidence of tumor cells. CONCLUSIONS: Pulmonary infarcts may mimic resolving or stable pulmonary metastasis in patients with renal cell carcinoma. Accurate clinical staging is crucial for the prognosis and treatment of renal cell carcinoma. Mistaking pulmonary infarcts for metastatic lesions can lead to inaccurate prognoses and inappropriate treatment.     

Incorporation of nuclear matrix attachment regions into the herpes simplex virus type 1 genome does not induce long-term expression of a foreign gene during latency

We report two cases of skull base metastasis from renal cell carcinoma. Case 1: A 55-year-old female presented with a skull base tumor located on the clivus. Partial removal of the tumor was performed via the transsphenoidal approach. Case 2: A 44-year-old male presented with a skull base tumor occupying the orbital, nasal, and paranasal cavities. The first operation, partial removal of the tumor, was performed via the transsphenoidal approach. Thereafter, the tumor regrowth and the patient's symptoms were progressive, so a second operation was performed via Le-Forte I craniotomy to prevent cranial nerve dysfunction and air way obstruction. The initial symptom of these two cases was abducens nerve paresis, which is caused by the tumor extending from the clivus to the cavernous sinus. The neuroradiological features were the destruction of skull base bone and angiographic tumor stain. Histopathological examination of the surgically resected specimens revealed clear cell carcinoma, and thereafter they were diagnosed as skull base metastasis from renal cell carcinoma. We emphasize the necessity of a thorough medical workup to enable speedy diagnosis of renal cell carcinoma in such cases.     

A case of surgical resection for metachronous multiple liver metastases of chromophobe cell renal carcinoma

A 64-year-old female was hospitalized because of multiple liver metastasis, during the postoperative observation of chromophobe cell renal carcinoma. Injection of Epirubicin/Lipodol into the right hepatic artery followed by transcatheter arterial embolization was performed two times, and the metastatic foci responded favorably to this therapy. Since no new metastatic tumors were observed in the liver nor any other organs, a partial hepatectomy was thus performed. The liver tumor was pathologically diagnosed to be metastasis of the chromophobe cell renal carcinoma. The postoperative course has been uneventful and at present, 6 months after the operation, no further tumors have been observed.     

Metastatic hypernephroma to the larynx: an unusual presentation

We report a renal cell carcinoma which presented as a metastasis to the larynx. The only preoperative clue to the diagnosis was its hypervascularity.     

Large granular lymphocyte leukemia associated with hepatocellular carcinoma: a case report

Both primary and metastatic malignancies of the masseter muscle are rare. We report a case of metastatic renal cell carcinoma to the masseter muscle. It was incidentally found as a hypervascular mass in carotid angiography for delineating a recurrent metastatic brain tumour. Prior to surgical removal, intravascular embolization via the left facial artery was performed in order to decrease intra-operative bleeding. The tumour was removed with minimum damage to the muscle fibres by the extraoral method, followed by a transient lower lip palsy. Metastatic intramuscular tumours, which are assumed to be due to haematogenous spread, are generally a sign of poor prognosis.