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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2011  |  Volume : 22  |  Issue : 6  |  Page : 1243-1245
Arterial embolization for spontaneous rupture of renal cell carcinoma

Cardiologist, European Gaza Hospital, Cardiac Catheterization Unit, Gaza, Palestine

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Date of Web Publication8-Nov-2011

How to cite this article:
Habib M. Arterial embolization for spontaneous rupture of renal cell carcinoma. Saudi J Kidney Dis Transpl 2011;22:1243-5

How to cite this URL:
Habib M. Arterial embolization for spontaneous rupture of renal cell carcinoma. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2022 Oct 2];22:1243-5. Available from: https://www.sjkdt.org/text.asp?2011/22/6/1243/87245
To the Editor,

Renal Cell Carcinoma (RCC) accounts for 2.3% of all adult malignancies. At the time of diagnosis, metastatic disease is detected in 25%-30% of patients. [1] Metastatic RCC to the suprarenal gland is a clinical problem. The suprarenal gland may be affected by either direct extension of primary or recurrent tumor from the renal bed. Retroperitoneal hematoma related to RCC metastases and rupture of suprarenal gland are rarely encountered in clinical practice and mostly managed surgically.

We would like to share our experience with a 47-year-old male patient, came to the our hospital emergency room with sudden onset of right-side upper abdominal pain, irradiating to right flank, accompanied sweating, palpitation, and hematuria for the past 24 hours. He had visited another hospital and underwent an urgent abdominal Computed Tomography (CT) scan with contrast and revealed a large tissue mass at the right adrenal gland region with intracpsular bleeding and a large hematoma in the right retroperitoneal space [Figure 1] and subcapsular hematoma in the right kidney. He was then referred to our hospital; on admission, his blood pressure was 170/100 mmHg and pulse rate was 115 beats/min/regular. He did not have any medical history of hypertension. Ophthalmoscopic examination showed no hypertensive retinopathy. A complete blood cell count revealed white blood cells 10300/μL, hemoglobin 10.3 g/dL, hematocrit 39.2%, and platelets 415000/mL. Blood chemistry examination showed some abnormal values as follows: total protein 7.1 g/dL, serum albumin 5.1 g/dL, aspartate aminotransferase 32 IU/L, alanine aminotransaminase 41 IU/L, serum creatinine 1.7 mg/dL, and fasting plasma glucose 113mg/dL. Urinalysis showed urinary protein 2+ and urinary occult blood 3+. Electrocardiography showed sinus tachycardia. Chest X-ray findings were within normal limits with a cardiothoracic ratio of 50% and no lung abnormalities. The 24-hour urine test conducted in the laboratory demonstrated high vanillylmandelic acid (VMA) level of 31 mg per 24 hours (Reference range, 1-10 mg per 24 hours). We decided on an abdominal aortography, performed by right femoral approach. Selective angiograms of the celiac, superior mesenteric and right renal artery were obtained. Then selective cannulation of right renal and adrenal artery was performed with 6 french right judkins catheter. Transcatheter arterial embolization (TAE) by coil were then performed with medial and lateral branches of the right adrenal and renal artery using three french microcatheter, subsequent dye injection demonstrated no further tumor vascularity [Figure 2]. Following embolization, his vital sign stabilized and blood pressure normalized to 140/90 mmHg and after 48 hours abdominal and flank pain completely resolved. A repeat abdominal CT, two weeks post transarterial embolization, showed significant resolution of retroperitoneal hematoma, and the tumor was also better delineated compared to the study performed [Figure 3]. One month after the coil embolization, the patient underwent elective right adrenalectomy and nephrectomy. The pathological findings confirmed the diagnosis of renal cell carcinoma.
Figure 1: Right adrenal mass with retroperitoneal hematoma and intratumoral bleeding.

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Figure 2: Coil in the right adrenal and renal artery branches

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Figure 3: After 2 weeks, showed significant resolution of retroperitoneal hematoma.

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Adrenal hemorrhage is not a rare event. It is mostly bilateral, consecutive to anticoagulation therapy, bleeding diathesis, and trauma. [2] Moreover, it is observed in severe stress situations with excessive adrenocortical stimulation, such as acute myocardial infarction, congestive heart failure, and specticemia. [3] Massive unilateral hemorrhage is uncommon, but it is a recognized complication of primary adrenal tumors, among which pheochromocytoma is the most commonly encountered. [4],[5] The spontaneous rupture of adrenal gland related to primary or metastatic tumor is extremely rare, the exact mechanism of rupture is unknown, but a high intracapsular pressure caused by rapid tumor growth may tear the capsule. [6]

Immediate surgical operation is associated with high mortality in these cases because of high blood pressure and bleeding. Therefore, if initial conservative therapy can control retroperitoneal hemorrhage, blood pressure, and stabilizes the patient, a watch-and-wait approach is safe and less invasive for the patient without the risk of re-bleeding. On the other hand, if the patient becomes unstable or still hypertensive despite medical treatment or bleeding persists, we should consider arterial embolization to achieve hemostasis before an open surgical approach to reduce mortality and to maintain the patient in a good condition.

   References Top

1.Stoller ML, Presti JC, Carroll PR. Urology. In: Tierney LM, McPhee SJ, Papadakis MA, eds. Current medical diagnosis and treatment. 41 st ed. New York: Lange Medical Books/ McGraw-Hill; 2002. p. 955-98.  Back to cited text no. 1
2.Pode D, Caine M. Spontaneous retroperitoneal hemorrhage. J Urol 1992;147:311-8.  Back to cited text no. 2
3.Rowinsky EK, Jones RJ, Abeloff MD. Massive adrenal hemorrhage secondary to metastatic lung carcinoma. Med Pediatr Oncol 1986;14: 234-7.  Back to cited text no. 3
4.Yamada AH, Sherrod AE, Boswell W, Skinner DG. Massive retroperitoneal hemorrhage from adrenal gland metastasis. Urology 1992;40:59-62.  Back to cited text no. 4
5.Swift DL, Lingeman JE, Baum WC. Spontaneous retroperitoneal hemorrhage: a diagnostic challenge. J Urol 1980;123:577-82.  Back to cited text no. 5
6.Maruyama M, Sato H, Yagame M, Shoji S, Terachi T, Osamura RY. Spontaneous rupture of pheochromocytoma and its clinical features: a case report. Tokai J Exp Clin Med 2008;33 (3):110-5.  Back to cited text no. 6

Correspondence Address:
Mohammed Habib
Cardiologist, European Gaza Hospital, Cardiac Catheterization Unit, Gaza
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Source of Support: None, Conflict of Interest: None

PMID: 22089794

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  [Figure 1], [Figure 2], [Figure 3]

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