Background

Renal cell carcinoma (RCC) presents with metastasis at the time of diagnosis in up to one third of the patients. Most frequently involved organs are the lung, bones and lymph nodes. Metastasis in adrenal glands are rare. An autopsy study described isolated adrenal metastasis in 2.5% of ipsilateral glands and 0.7% of contralateral glands. In most cases, the lesion is asymptomatic and is often found in the follow-up imaging studies. We present the management of a case of a metachronous adrenal metastasis in the contralateral adrenal gland after a primary clear cell RCC.

Case Presentation

Female patient, 69 years old, former smoker (10cig/day), with a past medical history of hypertension, medicated with lisinopril. In November 2018, she underwent a right laparoscopic radical nephrectomy. The histology revealed a clear cell RCC, pT3aN0M0, R0. Five years later, the follow-up CT showed a left adrenal mass with 32x21mm, suspicious of secondary origin. Metabolic study was negative.

The patient was proposed for a transperitoneal robotic-assisted laparoscopic excision of the left adrenal lesion. The patient was positioned in right decubitus. The first 3 ports were placed in the midclavicular line. The fourth port was placed more lateral in the direction of the iliac crest. The assistant port was placed medial to the midclavicular line, close to the umbilicus. After mobilization of the descending colon, dissection of the superior pole of the left kidney was performed. The adrenal mass was clearly identified over the left renal vein. Enucleation of the tumor was performed with careful hemostatic control. There were no intraoperative complications.  Surgical time was 23 minutes. Estimated blood loss was 50 mL. The patient was discharged on the following day. Final histology revealed clear cell RCC metastasis, with negative surgical margins. 

Conclusion

Robotic-assisted partial adrenal gland excision is feasible and safe. The robotic approach was crucial for lesion enucleation, which enabled preservation of the adrenal gland. Moreover, dissection of the lesion in proximity with the renal hilum was eased by the robotic approach.