Year : 2000 | Volume
: 11 | Issue : 4 | Page : 587--592
Renal Cell Carcinoma of Contralateral Kidney with Secondaries in Gallbladder Eight Years After Nephrectomy
Mohamed Kechrid1, Ghulam Hassan Malik1, Suleiman Al-Mohaya1, Jamil F Shaikh1, Jamal Saleh Al-Wakeel1, Hazem El Gamal1, Hamid Farouk2, Abdullah Jasser3, Mohammad Sabry Shetia1,
1 Department of Internal Medicine, Security Forces Hospital Program, Riyadh, Saudi Arabia
2 Department of Radiology, Security Forces Hospital Program, Riyadh, Saudi Arabia
3 Department of Urology, Security Forces Hospital Program, Riyadh, Saudi Arabia
Ghulam Hassan Malik
Department of Internal Medicine, Security Forces Hospital Program, P.O. Box 3643, Riyadh 11481
A 55-year-old female underwent right nephrectomy for renal cell carcinoma (RCC). The histopathology showed clear cell carcinoma. There was no evidence of metastasis. After remaining asymptomatic for eight years, she developed pain in the right loin. Abdominal ultrasound, computerized tomography (CT) Scan and magnetic resonance imaging (MRI) were suggestive of a tumor mass in the right renal area, multiple tumor masses in the left kidney and a mass in the gallbladder. Cholecystectomy, left radical nephrectomy and right adrenal mass with excision of adjacent lymph nodes were performed. The histopathology from all sites was suggestive of RCC. She was maintained on hemodialysis. Two and half years later she died after surgical exploration for spinal cord decompression due to metastasis to the dorsal spine.
|How to cite this article:|
Kechrid M, Malik GH, Al-Mohaya S, Shaikh JF, Al-Wakeel JS, El Gamal H, Farouk H, Jasser A, Shetia MS. Renal Cell Carcinoma of Contralateral Kidney with Secondaries in Gallbladder Eight Years After Nephrectomy.Saudi J Kidney Dis Transpl 2000;11:587-592
|How to cite this URL:|
Kechrid M, Malik GH, Al-Mohaya S, Shaikh JF, Al-Wakeel JS, El Gamal H, Farouk H, Jasser A, Shetia MS. Renal Cell Carcinoma of Contralateral Kidney with Secondaries in Gallbladder Eight Years After Nephrectomy. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2021 Dec 5 ];11:587-592
Available from: https://www.sjkdt.org/text.asp?2000/11/4/587/36648
Though renal cell carcinoma (RCC) accounts for two percent of all cancers,  bilateral tumors are uncommon and are found in only 0.5 to 1.5% of all RCC.  Out of 329 cases treated surgically at the Massachussetts General Hospital from 1935 to 1965, only six (1.8%) had bilateral RCC.  Smith et al found that 13 out of 26 bilateral RCC were asynchronous. 
The frequent metastatic sites include lungs, bones, liver and brain.  However, unusual sites of metastasis are characteristic of renal cancer, and organs such as thyroid, pancreas, skeletal muscle, skin or underlying soft tissue can be involved. 
The treatment options in a solitary kidney with RCC are limited. Partial nephrectomy was found to be the most successful treatment.  However total nephrectomy and subsequent dialysis or transplantation are other alternative modes of therapy. 
We describe a case who had nephrectomy for right RCC and who, eight years later, developed the carcinoma in the other kidney with metastasis to the gallbladder. After left nephrectomy, she was successfully managed with dialysis till she died 2 ½ years later.
A 55-year-old female underwent right nephrectomy for RCC in another hospital in 1988. The tumor was 6.5 cm in diameter and confined to the capsule in the lower pole of the kidney, not invading the perinephric fat, adrenal gland, renal pelvis or the renal vessels. Histopathology showed clear cell carcinoma. There was no evidence of local or distant metastasis on investigations including technetium bone scan. She was classified as Stage II, T 2 No Mo.
She was apparently well for eight years when she started complaining of pain in the right hypochondrium, radiating to the back and the right shoulder. The pain was associated with nausea, vomiting and loss of weight for three weeks before she presented to our hospital in 1996.
The clinical examination at admission showed that she was in fair general condition, with body weight of 51 kg and height of 155 cm, pulse 80/min, blood pressure 120/80 mm Hg and temperature of 36.8°C. The clinical examination of the chest, the nervous and cardiovascular systems was unremarkable. Abdominal examination showed an old scar of right nephrectomy, tenderness in the right hypochondrium and epigastrium with no palpable mass or guarding. There was no lymphadenopathy or skin rash. Her movement was restricted due to osteoarthropathy of the knees.
Laboratory investigations included urinalysis that showed no proteinuria with benign sediment. Hemoglobin was 106 g/L, leukocytes 9.4 x 10 9 /L, serum urea 4.4 mmol/L, creatinine 93 pmol/L, calcium 2.15 mmol/L, phosphorus 1.43 mmol/L and alkaline phosphatase 127 U/L. Liver function tests and coagulation profile were normal.
The chest X-Ray showed normal heart size and clear lung fields. The ultrasound of the abdomen showed a tumor in the right kidney area, a mass inside the gallbladder and multifocal tumors in the left kidney.
The intravenous urogram showed enlarged left kidney with stretching of the lower calyx and distortion with dilatation of the upper calyx, suggestive of a spaceoccupying lesion.
The CT scan of the abdomen showed an eight-cm mass in the right renal area, a well delineated and slightly hypodense six-cm mass in the upper pole of left kidney, with hypodense center, enhancing after contrast injection [Figure 1].
The MRI of the abdomen showed an eight-cm mass in the right renal area, with low signal intensity in the T 1 weighted images, enhancing after contrast. The left kidney showed multiple tumors. The gallbladder body and neck were occupied by an iso-intense lesion [Figure 2]. There was no evidence of metastasis to the liver or paraaortic lymphatic glands. The impression was of a mass lesion in the right renal area and gallbladder with multiple tumors affecting the left kidney.
The bone scan showed no evidence of metastasis. Abdominal aortogram showed a tumor blush in the upper and lower poles of the left kidney and in the region of the gallbladder.
Cholecystectomy was performed and the right adrenal gland and the adjacent paracaval lymph nodes were excised. The histopathological appearance from all the sites was consistent with RCC (clear cell type). After the histopathologic confirmation, a left radical nephrectomy was performed and the immediate post-operative course was uneventful.
Hemodialysis was started via a left jugular vein permcath. A left forearm arteriovenous (AV) fistula was created but did not function well. An AV graft created in left upper arm also failed. Hemodialysis was continued using permcath, which had to be changed frequently due to infection and clotting, although repeated coagulation profile was normal. While on maintenance hemodialysis, she gained seven kilograms of weight. The periodic follow-ups of chest x-ray, technetium bone scan and ultrasound abdomen failed to detect any new metastasis.
In the end of 1998, the patient complained of back and right shoulder pain, with weakness of lower limbs. An MRI of the spine showed dorsal (D 4 ) vertebral body collapse with cord compression. D 3 and D 4 laminectomy and transpedicle decompression were performed. The histopathological report of the laminectomy confirmed clear cell infiltration, consistent with metastatic RCC. During surgery, the patient developed severe bleeding and persistent hypotension despite extensive transfusion, and died after four days post-operation.
Bilateral involvement of RCC is well known in patients with Wilm's tumors and Von-Hippel-Lindau disease , but uncommon as primary malignant disease. , In a review from the Mayo Clinic,  out of 20 cases with RCC in a solitary kidney, only eight had undergone nephrectomy for renal cell carcinoma, three months to 12 years (mean 3.8 years) before a tumor was found in the remaining kidney. Hellsten et al  found bilateral involvement in only 2% of their post-mortum series of 235 cases with confident diagnosis of true bilateral primary lesions as opposed to metastasis from the opposite kidney. Parker et al  reported on four cases of bilateral RCC, none of which occurred simultaneously. Similarly, asynchronous involvement of both kidneys was described by Kaufman  in three cases and Stackpole  in two.
In 40 to 51% of RCC cases in the remaining kidney, the contralateral kidney had been removed for a similar lesion, , suggestive of a renal carcinogen in a susceptible individual. Describing the follow-up of 20 cases of RCC from the Mayo Clinic and review of the literature, Malek et al  suggested that most, if not all, RCC occurring in the solitary kidney after contralateral nephrectomy for hypernephroma represent early or late metastasis.
In our patient, despite the long interval of eight years between the right nephrectomy and diagnosis of RCC in the left kidney, the possibility of it being a secondary in other kidney cannot be excluded. It is well known that the growth of RCC and its metastasis are variable. 
The question in our case remains whether it is a primary lesion in the remaining kidney or simply a metastasis from the remains of the original tumor. It developed eight years after the nephrectomy. During that period, the patient was asymptomatic and serum alkaline phosphatase, which is considered as a strong indicator of disease progression, was only marginally increased. Moreover, nuclear bone scan performed at the time of first or the second nephrectomy did not reveal any evidence of metastasis, though doubt has been raised on excluding metastasis by whole body bone scintigraphy. 
Shaler et al  in a study of 299 radical nephrectomies found that ipsilateral adrenal glands were involved only in 3.8%, and recommended that macroscopically normal adrenal glands at radical nephrectomy should not be routinely extirpated. This is contrary to the earlier recommendation of Robson  in 1963, who emphasized routine removal of the ipsilateral adrenals at the time of nephrectomy. In our patient, there remains doubt about the possible involvement of the leftover ipsilateral adrenal gland that was not ruled out, which might have been the source of the metastasis to the contralateral kidney.
Different modes of therapies have been suggested in patients with bilateral RCC. Systemic therapy advocated for advanced disease is still experimental and continues to be unimpressive, although there are new approaches using novel therapeutic agents including gene and immunotherapy. 
Overall, RCC has been proven to be a chemotherapy-resistant tumor despite the use of combination regimes.  Partial nephrectomy is the most successful treatment for hypernephroma in the solitary kidney.  If partial nephrectomy is not feasible, surgical removal of the solitary kidney followed by dialysis and possibly a renal transplant at a later stage are the options for managing such cases.
Schiff et al reported three cases that had total nephrectomy followed by dialysis.  The present case lived for 2½ years on maintenance hemodialysis till she finally died following decompression of spinal cord due to secondary deposits in the dorsal spine.
The authors are grateful to Ms. Sita J. Benedicto for her secretarial assistance in the preparation of this manuscript.
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