Images in Clinical Urology Renal Cell Carcinoma and an Incidental Adrenal Lesion: Adrenal Collision Tumors Zachary Piotrowski, Jeffrey J. Tomaszewski, Aaron L. Hartman, Kristin Edwards, and Robert G. Uzzo Incidental adrenal lesions are common in patients with primary renal cell carcinoma (RCC). Modern crosssectional imaging, especially phase-shift, magnetic resonance imaging, is an important adjunct in evaluating adrenal lesions. We present the case of an incidental left adrenal nodule consistent with an adenoma in a patient with a history of pT2 RCC status post right nephrectomy. He subsequently developed multiple renal lesions in the contralateral solitary kidney. Despite meeting radiographic criteria for an adenoma, surgical resection of the adrenal at the time of partial nephrectomy demonstrated RCC metastatic to the adrenal. UROLOGY 85: e17ee18, 2015. 2015 Elsevier Inc.
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43-year-old man with a history of renal cell carcinoma was found to have multiple new contralateral left-sided renal lesions on surveillance imaging (Fig. 1). Additionally, a radiographic 1.4cm adrenal adenoma was noted to have enlarged to 1.8 cm (Fig. 2). The adrenal lesion was metabolically inactive and demonstrated signal dropout on opposedphase, chemical-shift magnetic resonance imaging sequences consistent with lipid-containing adenoma (Fig. 3). Given the growth kinetics, adrenalectomy was planned at the time of open partial nephrectomy for multifocal recurrence. Final pathology demonstrated an adrenal collision tumor with metastatic renal cell carcinoma (RCC) amid coexistent adrenal adenoma. Because of small amounts of cytoplasmic fat, RCC metastases can demonstrate signal dropout on chemicalshift magnetic resonance imaging, similar to adrenal adenomas.1-4 This can render radiographic findings inadequate to differentiate benign and metastatic disease. “Collision tumors” occur when 2 biologically distinct neoplasms coexist in the same site, which can confuse the diagnostic picture.5,6 Collision tumors are rarely found in the adrenal gland, but when present, typically contain at least 1 histologic component arising from a primary adrenal tumor.6 Growth characteristics and size criteria should be considered and evaluated in light of radiographic findings.7 Clinical suspicion for metastatic deposits should drive the decision to excise concerning adrenal lesions in the setting of known RCC8,9 Financial Disclosure: The authors declare that they have no relevant financial interests. From the Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA; the Department of Pathology, Fox Chase Cancer Center, Philadelphia, PA; and the Department of Radiology, Fox Chase Cancer Center, Philadelphia, PA Address correspondence to: Zachary Piotrowski, M.D., Division of Urologic Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111. E-mail: [email protected] Submitted: October 24, 2014, accepted (with revisions): December 8, 2014
ª 2015 Elsevier Inc. All Rights Reserved
Figure 1. Initial T1-weighted postcontrast MR image. Arrow indicates 1.4 cm left adrenal lesion.
References 1. Boland GW, Lee MJ. Magnetic resonance imaging of the adrenal gland. Crit Rev Diagn Imaging. 1995;36:115-174. 2. Shinozaki K, Yoshinmitsu K, Honda H, et al. Metastatic adrenal tumor from clear-cell renal cell carcinoma: a pitfall of chemical shift MR imaging. Abdom Imaging. 2001;26:439-442. 3. Boland GW, Blake MA, Hahn PF, Mayo-Smith WW. Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. Radiology. 2008;249:756-775. 4. Johnson PT, Horton KM, Fishman EK. Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls. Radiographics. 2009;29:1333-1351. 5. Thorin-Savoure A, Tissier-Rible F, Guignat L, et al. Collision/ composite tumors of the adrenal gland: a pitfall of scintigraphy imaging and hormone assays in the detection of adrenal metastasis. J Clin Endocrinol Metab. 2005;90:4924-4929.
http://dx.doi.org/10.1016/j.urology.2014.12.010 0090-4295/15
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6. Untch BR, Shia J, Downey RJ, et al. Imaging and management of a small cell lung cancer metastasis/adrenal adenoma collision tumor: a case report and review of the literature. World J Surg Oncol. 2014; 12:45. 7. O’Malley RL, Godoy G, Kanofsky JA, Taneja SS. The necessity of adrenalectomy at the time of radical nephrectomy: a systematic review. J Urol. 2009;181:2009-2017.
8. Kutikov A, Piotrowski ZJ, Canter DJ, et al. Routine adrenalectomy is unnecessary during surgery for large and/or upper pole renal tumors when the adrenal gland is radiographically normal. J Urol. 2011;185: 1198-1203. 9. Kutikov A, Crispen P, Uzzo R. Pathophysiology, evaluation and medical management of adrenal disorders. In: Wein AJ, et al., eds. Campbell-Walsh Urology. Philadelphia: Elsevier; 2012:1685-1736.
Figure 2. Follow-up T1-weighted precontrast (left) and postcontrast (right) MR image at the 4-month interval. Left adrenal lesion increased in size to 1.8 cm (arrow).
Figure 3. Follow-up T1-diffusion-weighted images demonstrating dropout between in-phase (left) and out of phase (right). Left adrenal lesion demonstrating signal dropout (arrow).
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UROLOGY 85 (3), 2015
A
43-year-old man with a history of renal cell carcinoma was found to have multiple new contralateral left-sided renal lesions on surveillance imaging (Fig. 1). Additionally, a radiographic 1.4cm adrenal adenoma was noted to have enlarged to 1.8 cm (Fig. 2). The adrenal lesion was metabolically inactive and demonstrated signal dropout on opposedphase, chemical-shift magnetic resonance imaging sequences consistent with lipid-containing adenoma (Fig. 3). Given the growth kinetics, adrenalectomy was planned at the time of open partial nephrectomy for multifocal recurrence. Final pathology demonstrated an adrenal collision tumor with metastatic renal cell carcinoma (RCC) amid coexistent adrenal adenoma. Because of small amounts of cytoplasmic fat, RCC metastases can demonstrate signal dropout on chemicalshift magnetic resonance imaging, similar to adrenal adenomas.1-4 This can render radiographic findings inadequate to differentiate benign and metastatic disease. “Collision tumors” occur when 2 biologically distinct neoplasms coexist in the same site, which can confuse the diagnostic picture.5,6 Collision tumors are rarely found in the adrenal gland, but when present, typically contain at least 1 histologic component arising from a primary adrenal tumor.6 Growth characteristics and size criteria should be considered and evaluated in light of radiographic findings.7 Clinical suspicion for metastatic deposits should drive the decision to excise concerning adrenal lesions in the setting of known RCC8,9 Financial Disclosure: The authors declare that they have no relevant financial interests. From the Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA; the Department of Pathology, Fox Chase Cancer Center, Philadelphia, PA; and the Department of Radiology, Fox Chase Cancer Center, Philadelphia, PA Address correspondence to: Zachary Piotrowski, M.D., Division of Urologic Oncology, Fox Chase Cancer Center, 333 Cottman Avenue, Philadelphia, PA 19111. E-mail: [email protected] Submitted: October 24, 2014, accepted (with revisions): December 8, 2014
ª 2015 Elsevier Inc. All Rights Reserved
Figure 1. Initial T1-weighted postcontrast MR image. Arrow indicates 1.4 cm left adrenal lesion.
References 1. Boland GW, Lee MJ. Magnetic resonance imaging of the adrenal gland. Crit Rev Diagn Imaging. 1995;36:115-174. 2. Shinozaki K, Yoshinmitsu K, Honda H, et al. Metastatic adrenal tumor from clear-cell renal cell carcinoma: a pitfall of chemical shift MR imaging. Abdom Imaging. 2001;26:439-442. 3. Boland GW, Blake MA, Hahn PF, Mayo-Smith WW. Incidental adrenal lesions: principles, techniques, and algorithms for imaging characterization. Radiology. 2008;249:756-775. 4. Johnson PT, Horton KM, Fishman EK. Adrenal mass imaging with multidetector CT: pathologic conditions, pearls, and pitfalls. Radiographics. 2009;29:1333-1351. 5. Thorin-Savoure A, Tissier-Rible F, Guignat L, et al. Collision/ composite tumors of the adrenal gland: a pitfall of scintigraphy imaging and hormone assays in the detection of adrenal metastasis. J Clin Endocrinol Metab. 2005;90:4924-4929.
http://dx.doi.org/10.1016/j.urology.2014.12.010 0090-4295/15
e17
6. Untch BR, Shia J, Downey RJ, et al. Imaging and management of a small cell lung cancer metastasis/adrenal adenoma collision tumor: a case report and review of the literature. World J Surg Oncol. 2014; 12:45. 7. O’Malley RL, Godoy G, Kanofsky JA, Taneja SS. The necessity of adrenalectomy at the time of radical nephrectomy: a systematic review. J Urol. 2009;181:2009-2017.
8. Kutikov A, Piotrowski ZJ, Canter DJ, et al. Routine adrenalectomy is unnecessary during surgery for large and/or upper pole renal tumors when the adrenal gland is radiographically normal. J Urol. 2011;185: 1198-1203. 9. Kutikov A, Crispen P, Uzzo R. Pathophysiology, evaluation and medical management of adrenal disorders. In: Wein AJ, et al., eds. Campbell-Walsh Urology. Philadelphia: Elsevier; 2012:1685-1736.
Figure 2. Follow-up T1-weighted precontrast (left) and postcontrast (right) MR image at the 4-month interval. Left adrenal lesion increased in size to 1.8 cm (arrow).
Figure 3. Follow-up T1-diffusion-weighted images demonstrating dropout between in-phase (left) and out of phase (right). Left adrenal lesion demonstrating signal dropout (arrow).
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UROLOGY 85 (3), 2015
