Blanche Biagini, k, Downstate Medical Center, Brooklyn, NY; Harvey G. Moore,
Research Assistant New York Harbor Healthcare System Brooklyn, NY
Yulia Zak, BS
Medical StudentState University of New York Downstate Medical Center Brooklyn, NY
Harvey G. Moore, MD
Attending Surgeon Assistant Professor of Surgery State University of New York Downstate Medical Center Brooklyn, NY
Ivan Colon, MD
Attending Urologist Assistant Professor of Urology State University of New York Downstate Medical Center Brooklyn, NY
Bimal C. Ghosh, MD
Professor and Vice Chairman Department of Surgery State Universityof New York Downstate Medical Center Surgeon-in-Chief New York Harbor Healthcare System Brooklyn, NY
An association between renal cell carcinoma and colorectal cancer is well documented. One study showed several tumor types occurred significantly more often in patients with a history of renal cell carcinoma compared with the predicted incidence based on Surveillance, Epidemiology, and End Re?sults (SEER) data. Of these tumors, colorectal cancer was the third most common.1 Patients with a history of both co?lorectal cancer and renal cell cancer also appeared to have a predilection for the development of additional primary malignancies. In one study of 49 patients with a history of both colorectal and renal cell cancer (diagnosed either synchronously or metachronously), 35% were found to have at least one additional primary malignancy.2 Lymphoma and breast, carcinoid, and pancreatic tumors were the most commonly observed additional malignancies. Although metastasis or direct extension of renal cell carcinoma to the ipsilateral adrenal gland is fairly common, synchronous renal and ad?renal primary tumors are rare. We report the case of a patient with previously diagnosed rectal cancer who presented with synchronous primary renal and adrenal tumors. Given the patient's surgical history of multiple abdominal procedures, a carefully tailored surgical ap?proach was required.
A 61-year-old man came to the hospital with the chief symptom of vague abdominal pain. He had undergone an abdominoperineal resection for rectal carcinoma 16 years earlier and had re?ceived a full course of postoperative pe?l?vic radiation at that time. The patient also had multiple previous abdominal surgeries for intestinal obstruction attribut?able to adhesions, as well as an ex?ploratory laparotomy and splenectomy after a motor vehicle accident. He was not taking any medication.
On physical examination, he had multiple abdominal surgical scars and a left lower quadrant colostomy. The patient had no clinical evi?dence of tumor recurrence. Lab?ora?tory examinations were within normal limits. During radiological examination, including computed tomography (CT) scanning and magnetic resonance imaging (MRI), a large tumor of the left adrenal gland separate from the kidney and a large left renal mass were identified (Figure 1). No other abnormal findings were identified.
Since the patient was free of rectal cancer for over 16 years, metastatic in?volvement of the kidney and adrenal gland was thought to be unlikely. The adrenal mass also did not appear on imaging studies to be a direct extension or metastatic spread of the renal tumor; thus, a diagnosis of synchronous primary tumors of the left kidney and adrenal gland was made. The renal tumor was thought to be renal cell carcinoma confined to the capsule and close to the hilum, requiring complete nephrectomy. In our institution, percutaneous needle biopsy of a suspected renal tumor is not performed in order to avoid tumor seeding along the biopsy tract.
The procedure was performed under general anesthesia. The patient was placed in the right lateral decubitus position. The colostomy was covered with a sterile Steri-drape? with adhesive, isolating it from the operating field. An incision was made over the 11th rib, which was then removed after separating it from its periosteum (Figure 2). Careful dissection was then carried out under direct vision, and the peritoneum and pleura were separated without entering either cavity. The tumor was very close to the pleura and peritoneum, and there were adhesions extending to the tail of the pancreas and colostomy. The left kidney was mobilized followed by ligation of the renal artery and vein at the hilum. After resection of the kidney, the adrenal tumor was located away from the kidney, and an adrenalectomy was performed in a standard fashion.
Pathological examination of the renal tumor revealed a 6-cm renal cell car-cinoma localized within the renal capsule without nodal metastasis (T2 N0 M0; Stage I; Figure 3). The adrenal tu?mor was found to be a benign adrenocortical adenoma.
The patient did well postoperatively and had no complications. He was discharged to home on postoperative day 5. He has continued to do well and was asymptomatic at 1-year follow-up.
Theoretically, simultaneous ipsilateral nephrectomy and adrenalectomy could be accomplished using a variety of sur-gical approaches. Options include an open transperitoneal approach, a lap-aroscopic transperitoneal approach,3-5 a thoracoabdominal incision,6 a retroperitoneoscopic approach,7-11 and a left flank (11th rib) approach (as was used for our patient).
Our patient's history of multiple ab?dominal surgeries, including splenectomy and mobilization of the left colon and splenic flexure, made a laparoscopic approach unfeasible. Although a thoraco?abdominal incision would have provided excellent exposure, several factors made this approach less appealing, including the need for a significantly larger incision, creation of defects in the pleura and diaphragm, and the need for a chest tube postoperatively. More re?cently, the re?tro?peritoneoscopic approach has gained popularity7-11; however, this approach relies on the development of a potential space between the peritoneum and retro?peritoneum. Because the splenic flexure was previously mobilized in our patient, resulting in violation of the peritoneum in this location, this approach would likely have been difficult or impossible.
We used a flank incision through the bed of the 11th rib, which afforded excellent exposure and completely avoided the previous intra-abdominal adhesions and the left lower quadrant colostomy in our patient. Furthermore, this approach avoided the need to mobilize the over?lying bowel to expose the kidney and adrenal gland. Access to the renal hilum is also superior to a transperitoneal open or laparoscopic approach. Although it was still necessary to mobilize the peritoneum and pleura, this was facilitated by performing the dissection in an open fashion rather than using a retroperitoneoscopic approach.
Simultaneous organ resection in a pa?tient with multiple previous abdominal surgeries requires a carefully planned operative approach. Important goals in?clude obtaining optimal exposure, allowing safe and oncologically sound resection of multiple organs through a single incision, and minimizing postoperative morbidity and recovery time. Con?sid?eration must be given to potential distortion of normal anatomy from previous operative procedures, which might preclude certain surgical approaches.
We thank Medical Media Services, particularly Mike Yu, BS, and Anne Erickson, MA, CMI, for providing outstanding artwork.
1. Rabbani F, Grimaldi G, Russo P. Multiple primary malignancies in renal cell carcinoma.. 1998;160(4):1255-1259.
2. Moore HG, Finch R, Morarka AS, et al. Concomitant colorectal cancer and renal cell carcinoma: an apparent predisposition for other malignancies. . 2002;123(1):S25.
3. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing's syndrome and pheochromocytoma. N Engl J Med. 1992;327(14): 1033.
4. Guazzoni G, Cestari A, Montorsi F, et al. Eight-year experience with transperitoneal laparoscopic adrenal surgery. J Urol. 2001;166(3): 820-824.
5. Clayman RV, Kavoussi LR, Soper NJ, et al. Laparoscopic nephrectomy: initial case report. . 1991;146(2):278-282.
6. Kumar S, Duque JL, Guimaraes KC, et al. Short- and long-term morbidity of thoracoabdominal incision for nephrectomy: a comparison with the flank approach. J Urol. 1999;162(6):1927-1929.
7. Desai MM, Strzempkowski B, Matin SF, et al. Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy. J Urol. 2005;173(1):38-41.
8. Gaur DD, Agarwal DK, Purohit KC. Retroperitoneal laparoscopic nephrectomy: initial case report. J Urol. 1993;149(1):103-105.
9. Gasman D, Droupy S, Koutani A, et al. Laparoscopic ad?renalectomy: the retroperitoneal approach. J Urol. 1998;159(6): 1816-1820.
10. Salomon L, Rabii R, Soulie M, et al. Experience with retroperitoneal laparoscopic adrenalectomy for pheochromocytoma. J Urol. 2001;165(6 pt 1):1871-1874.
11. Zhang X, Zheng T, Ma X, et al. Comparison of retroperitoneoscopic nephrectomy versus open approaches to nonfunctioning tuberculous kidneys: a report of 44 cases. J Urol. 2005;173(5): 1586-1589.