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Bilateral Simultaneously-Occurring Adenocarcinoma of the Kidney
Vol. 116, July
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
BILATERAL SIMULTANEOUSLY-OCCURRING ADENOCARCINOMA OF THE KIDNEY ALEX FINKBEINER,* ROBERT MOYAD
AND
KARL HERWIG
From the Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
ABSTRACT
Our 3 patients with simultaneously-occurring hypernephromas treated with simultaneouslydirected surgical therapy on both kidneys are described. One patient died with residual neoplasm 2 ½ years postoperatively, while the other 2 patients are alive and presumably free of tumor 60 and 22 months postoperatively. Bilateral simultaneously-occurring adenocarcinomas of the kidney are unusual but aggressive operative intervention can result in some expectation of survival. The treatment of 3 recent patients supports this opinion. CASE REPORTS
Case 1. N. I., UMMC 1161832, a 42-year-old man, complained of left flank pain and total, gross hematuria in November 1968. Urologic evaluation did not determine the cause. The symptoms persisted and were accompanied by fatigue, chronic cough and weight loss. In September 1969 repeat urologic evaluation was done. Urinalysis at this time was normal, serum creatinine was 1.3 mg. per cent and blood urea nitrogen (BUN) 50 mg. per cent. An excretory urogram (IVP) showed bilateral tumor deformities (fig. 1, A). These were shown to be tumors angiographically (fig. 1, B). In addition, a 7 mm. nodule was seen in the left lung. A needle biopsy of this lesion showed adenocarcinoma, probably metastatic. Planned therapy for this patient was excision of the renal tumors followed by excision of the pulmonary nodule, since it was suspected to be metastatic from the kidney. The patient underwent simultaneous left radical nephrectomy and right partial nephrectomy in 1969. Within 2 weeks of the operation a chest x-ray showed mediastinal widening. Biopsy revealed adenocarcinoma. Irradiation therapy and hormonal therapy were begun but the tumor did not respond well. The serum creatinine remained at 1.9 mg. per cent. Death occurred 2 Vz years postoperatively. Case 2. E. F., UMMC 1220510, a 59-year-old woman, had recurrent urinary tract infection and mild hypertension in 1970. An IVP showed bilateral renal masses with typical characteristics of adenocarcinoma angiographically (fig. 2, A). Urinalysis was acellular, serum creatinine 0.7 mg. per cent and BUN 11 mg. per cent. No evidence of metastases was found. A radical right nephrectomy and simultaneous partial left nephrectomy were performed in 1971. Presently, the patient is free of symptoms and has no evidence of tumor recurrence. Serum creatinine i~ 0.9 mg. per cent, BUN 22 mg. per cent and blood pressure 160/90 mm. Hg. An IVP 4 V2 years postoperatively revealed good function of the remaining left kidney (fig. 2, B). Case 3. N. B., SJMH 534324, a 51-year-old man, had recurrent urinary calculi. The patient complained of hematuria, weight loss and left flank pain in December 1971. An IVP revealed a possible tumor deformity of the left kidney and this Accepted for publication November 26, 1975. Read at annual meeting of North Central Section, American Urological Association, Phoenix, Arizona, October 5-12, 1975. * Current address: Department of Urology, University of Arkansas College of Medicine, Little Rock, Arkansas 72201. 26
was confirmed angiographically (fig. 3, A). In addition, the angiogram revealed an unsuspected neoplasm of the right kidney (fig. 3, B). Radical left nephrectomy and partial right upper pole nephrectomy were done simultaneously for pathologically confirmed adenocarcinoma. Presently the patient is free of symptoms and has no evidence of metastases. Serum creatinine is 2 mg. per cent. DISCUSSION
Bilateral renal adenocarcinomas occur in 1.8 per cent of all renal adenocarcinomas. 1 Most of these cases represent tumors in solitary kidneys after prior nephrectomy of the contralateral kidney for adenocarcinoma. i-a Bilateral tumors can occur in tuberous sclerosis and Lindau-van Hippel's disease, 2 hereditary neurological syndromes.•. 5 None of the patients described had evidence of neurological disease or family history of adenocarcinoma of the kidney. Neither the history nor physical examination of these patients suggested bilateral tumors. As a matter of fact, only arteriography demonstrated the presence of bilateral tumors in 1 patient, which showed the importance of examining the opposite kidney when a tumor is found. The dilemma faced when bilateral simultaneously-appearing tumors are found is the ability to distinguish bilateral de novo occurrence from metastatic disease. There may be therapeutic as well as philosophic considerations. If the tumor in 1 kidney is metastatic from the other metastasis is more likely to be found elsewhere than if both tumors arise de novo. In the second patient histological examination of the tumors suggested 2 distinct patterns that were interpreted as being de novo tumors. The tumors in the first patient were identical, suggesting possible metastases from 1 kidney. In the third patient no distinction was made histologically. Therapy of bilateral simultaneously-occurring hypernephromas varies. Surgical therapy remains the cornerstone. In the past a staged procedure had been recommended. 1• 2 • 6 • 7 A radical nephrectomy of the more seriously involved kidney is performed followed in a short time by a partial nephrectomy. The purpose of the staged procedure was to decrease the risk of renal insufficiency or even failure. Dialysis, transplantation and better postoperative care do not appear to support this approach any longer. In addition, perhaps metastases from the unresected tumor could occur while awaiting removal. Bilateral nephrectomy with dialysis and transplantation is an alternative•· 8 but immunosuppression necessary in the transplanted patient may unmask or accelerate the growth of metastases. Simultaneously removing the tumors appears to be the most warranted therapy at this time, if metastases are not present. A transabdominal transperitoneal approach with early control of the renal pedicle allows for rapid and accurate dissection.
BILATERAL ADENOCARCINOMA OF KIDNEY
27
Fm. 1. Case 1. A, preoperative nephrotomogram shows marked distortion ofleft renal collecting system and only slight distortion of right renal collecting system. B, both renal tumors appear in preoperative arteriogram. Left renal tumor occupies more than half of kidney and right renal tumor is smaller mass in lower pole.
FrG. 2. Case 2. A, preoperative IVP shows bilateral tumor deformities. Right kidney has large tumor occupying mid portion of kidney and left kidney has tumor arising from lower pole. B, IVP 4½ years postoperatively reveals appearance has not changed.
28
FINKBEINER, MOYAD AND HERWIG
Fm. 3. Case 3. A, selective arteriography reveals left renal tumor occupying mid portion of left kidney. B, selective arteriography reveals right renal tumor confined to upper pole.
Bench operations and autotransplantation may be used but were found unnecessary in the patients presented. Others have used these techniques and have had some problems with leakage of urine.• We recommend the simultaneous approach not using bench operations unless absolutely necessary for these patients. The presence of metastatic disease does not preclude the surgical attack on hypernephromas. 10 It was thought that the pulmonic lesion was solitary in our first patient and would be amenable to removal after the renal tumors had been removed. Despite our failure we would continue to advocate this approach in the selected patient. The discussion of the non-operative therapy of hyperne, phromas is beyond the scope of this presentation. One would expect no difference than its use in other types of hypernephromas. No conclusion concerning prognosis can be drawn from this group of patients because of the small number of patients involved. All 3 of our patients maintained adequate renal function postoperatively and 2 remain alive with no evidence of tumor, 60 and 22 months postoperatively. Others have had similar results with treatment for tumor of solitary kidneys.'· 3 If bilateral hypernephromas occur simultaneously aggressive surgical extirpation appears to offer the best chance for patient survival. The surgical approach is simple and direct. We chose to perform a radical nephrectomy for the more seriously involved side and a partial nephrectomy for the side that was less seriously involved. We do not believe that bench operations and autotransplantation are necessary to accomplish total tumor removal with preservation of renal function. REFERENCES
1. Vermillion, C. D., Skinner, D. G. and Pfister, R. C.: Bilateral renal cell carcinoma. J. Urol., 108: 219, 1972.
2. Small, M. P., Anderson, E. E. and Atwill, W. H.: Simultaneous bilateral renal cell carcinoma: case report and review of the literature. J. Urol., 100: 8, 1968. 3. Grabstald, H. and Aviles, E.: Renal cell carcinoma in the solitary or sole-functioning kidney. Cancer, 22: 973, 1968. 4. Jochimsen, P. R., Braunstein, P. M. and Najarian, J. S.: Renal allotransplantation for bilateral renal tumors. J.A.M.A., 210: 1721, 1969. 5. York, W. N. and Mawn, T. J.: Aggressive surgical management of bilateral adenocarcinoma of the kidney. Cancer, 31: 1160, 1973. 6. Marchetti, L. J., Gonick, P. and Ciavarra, V.: Partial nephrectomy in bilateral renal carcinoma: discussion and case report. J. Urol., 106: 818, 1971. 7. Kolin, C. P., Boldus, R. A., Kelley Brandon, D. N. and Flocks, R. H.: Bilateral partial nephrectomy for bilateral renal cell carcinoma: a case report. J. Urol., 105: 45, 1971. 8. Stroup, R. F., Shearer, J. K., Traurig, A. R. and Lytton, B.: Bilateral adenocarcinoma of the kidney treated by nephrectomy: a case report and review of the literature. J. Urol., 111: 272, 1974. 9. Caine, R. Y.: Treatment of bilateral hypemephromas by nephrectomy, excision of tumour, and autotransplantation. Report of three cases. Lancet, 2: 1164, 1973. 10. Middleton, R. G.: Surgery for metastatic renal cell carcinoma. J. Urol., 97: 973, 1967. COMMENT A simultaneous bilateral transabdominal approach (particularly via the chevron incision of Chute) is an aggressive but expedient procedure when sufficient renal tissue can be preserved to sustain life. While not described in the authors' experience renal hypothermia may maximize the function of the remaining normal kidney and enable the best establishment of surgical margins. It would seem questionable to take this aggressive approach in cases of synchronous bilateral hypemephroma in the presence of metastatic disease-unless palliation alone is the goal. K.B.C.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
BILATERAL SIMULTANEOUSLY-OCCURRING ADENOCARCINOMA OF THE KIDNEY ALEX FINKBEINER,* ROBERT MOYAD
AND
KARL HERWIG
From the Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
ABSTRACT
Our 3 patients with simultaneously-occurring hypernephromas treated with simultaneouslydirected surgical therapy on both kidneys are described. One patient died with residual neoplasm 2 ½ years postoperatively, while the other 2 patients are alive and presumably free of tumor 60 and 22 months postoperatively. Bilateral simultaneously-occurring adenocarcinomas of the kidney are unusual but aggressive operative intervention can result in some expectation of survival. The treatment of 3 recent patients supports this opinion. CASE REPORTS
Case 1. N. I., UMMC 1161832, a 42-year-old man, complained of left flank pain and total, gross hematuria in November 1968. Urologic evaluation did not determine the cause. The symptoms persisted and were accompanied by fatigue, chronic cough and weight loss. In September 1969 repeat urologic evaluation was done. Urinalysis at this time was normal, serum creatinine was 1.3 mg. per cent and blood urea nitrogen (BUN) 50 mg. per cent. An excretory urogram (IVP) showed bilateral tumor deformities (fig. 1, A). These were shown to be tumors angiographically (fig. 1, B). In addition, a 7 mm. nodule was seen in the left lung. A needle biopsy of this lesion showed adenocarcinoma, probably metastatic. Planned therapy for this patient was excision of the renal tumors followed by excision of the pulmonary nodule, since it was suspected to be metastatic from the kidney. The patient underwent simultaneous left radical nephrectomy and right partial nephrectomy in 1969. Within 2 weeks of the operation a chest x-ray showed mediastinal widening. Biopsy revealed adenocarcinoma. Irradiation therapy and hormonal therapy were begun but the tumor did not respond well. The serum creatinine remained at 1.9 mg. per cent. Death occurred 2 Vz years postoperatively. Case 2. E. F., UMMC 1220510, a 59-year-old woman, had recurrent urinary tract infection and mild hypertension in 1970. An IVP showed bilateral renal masses with typical characteristics of adenocarcinoma angiographically (fig. 2, A). Urinalysis was acellular, serum creatinine 0.7 mg. per cent and BUN 11 mg. per cent. No evidence of metastases was found. A radical right nephrectomy and simultaneous partial left nephrectomy were performed in 1971. Presently, the patient is free of symptoms and has no evidence of tumor recurrence. Serum creatinine i~ 0.9 mg. per cent, BUN 22 mg. per cent and blood pressure 160/90 mm. Hg. An IVP 4 V2 years postoperatively revealed good function of the remaining left kidney (fig. 2, B). Case 3. N. B., SJMH 534324, a 51-year-old man, had recurrent urinary calculi. The patient complained of hematuria, weight loss and left flank pain in December 1971. An IVP revealed a possible tumor deformity of the left kidney and this Accepted for publication November 26, 1975. Read at annual meeting of North Central Section, American Urological Association, Phoenix, Arizona, October 5-12, 1975. * Current address: Department of Urology, University of Arkansas College of Medicine, Little Rock, Arkansas 72201. 26
was confirmed angiographically (fig. 3, A). In addition, the angiogram revealed an unsuspected neoplasm of the right kidney (fig. 3, B). Radical left nephrectomy and partial right upper pole nephrectomy were done simultaneously for pathologically confirmed adenocarcinoma. Presently the patient is free of symptoms and has no evidence of metastases. Serum creatinine is 2 mg. per cent. DISCUSSION
Bilateral renal adenocarcinomas occur in 1.8 per cent of all renal adenocarcinomas. 1 Most of these cases represent tumors in solitary kidneys after prior nephrectomy of the contralateral kidney for adenocarcinoma. i-a Bilateral tumors can occur in tuberous sclerosis and Lindau-van Hippel's disease, 2 hereditary neurological syndromes.•. 5 None of the patients described had evidence of neurological disease or family history of adenocarcinoma of the kidney. Neither the history nor physical examination of these patients suggested bilateral tumors. As a matter of fact, only arteriography demonstrated the presence of bilateral tumors in 1 patient, which showed the importance of examining the opposite kidney when a tumor is found. The dilemma faced when bilateral simultaneously-appearing tumors are found is the ability to distinguish bilateral de novo occurrence from metastatic disease. There may be therapeutic as well as philosophic considerations. If the tumor in 1 kidney is metastatic from the other metastasis is more likely to be found elsewhere than if both tumors arise de novo. In the second patient histological examination of the tumors suggested 2 distinct patterns that were interpreted as being de novo tumors. The tumors in the first patient were identical, suggesting possible metastases from 1 kidney. In the third patient no distinction was made histologically. Therapy of bilateral simultaneously-occurring hypernephromas varies. Surgical therapy remains the cornerstone. In the past a staged procedure had been recommended. 1• 2 • 6 • 7 A radical nephrectomy of the more seriously involved kidney is performed followed in a short time by a partial nephrectomy. The purpose of the staged procedure was to decrease the risk of renal insufficiency or even failure. Dialysis, transplantation and better postoperative care do not appear to support this approach any longer. In addition, perhaps metastases from the unresected tumor could occur while awaiting removal. Bilateral nephrectomy with dialysis and transplantation is an alternative•· 8 but immunosuppression necessary in the transplanted patient may unmask or accelerate the growth of metastases. Simultaneously removing the tumors appears to be the most warranted therapy at this time, if metastases are not present. A transabdominal transperitoneal approach with early control of the renal pedicle allows for rapid and accurate dissection.
BILATERAL ADENOCARCINOMA OF KIDNEY
27
Fm. 1. Case 1. A, preoperative nephrotomogram shows marked distortion ofleft renal collecting system and only slight distortion of right renal collecting system. B, both renal tumors appear in preoperative arteriogram. Left renal tumor occupies more than half of kidney and right renal tumor is smaller mass in lower pole.
FrG. 2. Case 2. A, preoperative IVP shows bilateral tumor deformities. Right kidney has large tumor occupying mid portion of kidney and left kidney has tumor arising from lower pole. B, IVP 4½ years postoperatively reveals appearance has not changed.
28
FINKBEINER, MOYAD AND HERWIG
Fm. 3. Case 3. A, selective arteriography reveals left renal tumor occupying mid portion of left kidney. B, selective arteriography reveals right renal tumor confined to upper pole.
Bench operations and autotransplantation may be used but were found unnecessary in the patients presented. Others have used these techniques and have had some problems with leakage of urine.• We recommend the simultaneous approach not using bench operations unless absolutely necessary for these patients. The presence of metastatic disease does not preclude the surgical attack on hypernephromas. 10 It was thought that the pulmonic lesion was solitary in our first patient and would be amenable to removal after the renal tumors had been removed. Despite our failure we would continue to advocate this approach in the selected patient. The discussion of the non-operative therapy of hyperne, phromas is beyond the scope of this presentation. One would expect no difference than its use in other types of hypernephromas. No conclusion concerning prognosis can be drawn from this group of patients because of the small number of patients involved. All 3 of our patients maintained adequate renal function postoperatively and 2 remain alive with no evidence of tumor, 60 and 22 months postoperatively. Others have had similar results with treatment for tumor of solitary kidneys.'· 3 If bilateral hypernephromas occur simultaneously aggressive surgical extirpation appears to offer the best chance for patient survival. The surgical approach is simple and direct. We chose to perform a radical nephrectomy for the more seriously involved side and a partial nephrectomy for the side that was less seriously involved. We do not believe that bench operations and autotransplantation are necessary to accomplish total tumor removal with preservation of renal function. REFERENCES
1. Vermillion, C. D., Skinner, D. G. and Pfister, R. C.: Bilateral renal cell carcinoma. J. Urol., 108: 219, 1972.
2. Small, M. P., Anderson, E. E. and Atwill, W. H.: Simultaneous bilateral renal cell carcinoma: case report and review of the literature. J. Urol., 100: 8, 1968. 3. Grabstald, H. and Aviles, E.: Renal cell carcinoma in the solitary or sole-functioning kidney. Cancer, 22: 973, 1968. 4. Jochimsen, P. R., Braunstein, P. M. and Najarian, J. S.: Renal allotransplantation for bilateral renal tumors. J.A.M.A., 210: 1721, 1969. 5. York, W. N. and Mawn, T. J.: Aggressive surgical management of bilateral adenocarcinoma of the kidney. Cancer, 31: 1160, 1973. 6. Marchetti, L. J., Gonick, P. and Ciavarra, V.: Partial nephrectomy in bilateral renal carcinoma: discussion and case report. J. Urol., 106: 818, 1971. 7. Kolin, C. P., Boldus, R. A., Kelley Brandon, D. N. and Flocks, R. H.: Bilateral partial nephrectomy for bilateral renal cell carcinoma: a case report. J. Urol., 105: 45, 1971. 8. Stroup, R. F., Shearer, J. K., Traurig, A. R. and Lytton, B.: Bilateral adenocarcinoma of the kidney treated by nephrectomy: a case report and review of the literature. J. Urol., 111: 272, 1974. 9. Caine, R. Y.: Treatment of bilateral hypemephromas by nephrectomy, excision of tumour, and autotransplantation. Report of three cases. Lancet, 2: 1164, 1973. 10. Middleton, R. G.: Surgery for metastatic renal cell carcinoma. J. Urol., 97: 973, 1967. COMMENT A simultaneous bilateral transabdominal approach (particularly via the chevron incision of Chute) is an aggressive but expedient procedure when sufficient renal tissue can be preserved to sustain life. While not described in the authors' experience renal hypothermia may maximize the function of the remaining normal kidney and enable the best establishment of surgical margins. It would seem questionable to take this aggressive approach in cases of synchronous bilateral hypemephroma in the presence of metastatic disease-unless palliation alone is the goal. K.B.C.