1644 Isolated Metastatic Colorectal Cancer Involving the Kidney and Adrenal Gland: A Rare Occurrence

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INTRODUCTION: Distant metastases in colorectal cancer (CRC) commonly involve liver, lung, brain and bone. Adrenal gland involvement is not uncommon on autopsy in the setting of diffuse metastatic disease. In most reported cases, it is seen as metachronous disease and is diagnosed during extensive work up or on follow up. Isolated synchronous disease involving the kidney and adrenal gland is extremely rare. We present a case where the diagnosis was established intraoperatively during a laparotomy performed for suspected primary adrenocortical malignancy. CASE DESCRIPTION/METHODS: A 66-year-old man presented with sudden worsening lower abdominal pain for 6 hours. The pain had started 4 weeks ago and was persistent, non-radiating. He reported a 50 pounds weight loss over the last 3 months. Physical exam was significant for tenderness over the right lower quadrant. Laboratory data showed anemia with hemoglobin of 8.3 g/dl. CT of abdomen and pelvis revealed a mass that was possibly originating from the right adrenal gland. MRI revealed a large heterogeneous, multilobulated, adrenal mass measuring 10 × 7.4 × 13.2 cm. A primary adrenocortical malignancy was suspected. Endocrine and metastatic work up was negative and a laparotomy was planned for adrenalectomy and possible nephrectomy. Intraoperatively, he was found to have an ulcerative tumor involving the terminal ileum and appendix penetrating through the serosa. Right hemicolectomy and nephrectomy with adrenalectomy were performed. Histopathology was consistent with poorly differentiated adenocarcinoma of colon with metastasis to right adrenal gland and kidney. DISCUSSION: Common primary tumors that metastasize to the adrenal gland include breast, lung and kidney. In most cases of CRC, adrenal or kidney metastases usually indicate distant hematogenous spread and are associated with poor prognosis. The mean survival is 7 to 8 months. However, CRC with isolated metastasis to adrenal gland and kidney is extremely rare. Retrospectively, an interesting feature in this case was the presumption of the metastatic lesion as the primary tumor as there was no radiologic abnormality involving the gastrointestinal tract. Surgical resection followed by chemotherapy has been shown to promote long term survival in several studies, but there is no prospective data due to the rarity of this condition. In patients with incidental finding of an isolated adrenal/renal mass, an evaluation for occult GI malignancy should be considered.