since the early 1980s , adrenalectomy has been shown to be a good treatment for single adrenal metastasis .
indeed , adrenal metastasis surgery is proven to be a good therapy among patients in whom the previous disease , with an isolated adrenal metastasis , is controllable .
report a 30% increase in survival rates among patients who underwent surgery of a single adrenal metastasis in lung cancer . despite a lack of guidelines , surgery for isolated adrenal metastasis trends to become a reference   and
consists in a total resection of the adrenal gland with disease - free margins . in rare instance of adrenal tumors
, a tumor thrombus can be found in the renal vein or even in the vena cava .
in such a case , no recommendations are available on how to perform the adrenalectomy .
the consensual therapeutic attitude consists in a one - time surgery with  en bloc resection of the tumoral vein thrombus , the adrenal and the ipsilateral kidney .
herein , we report the case of a 74-year - old man with a single adrenal mass associated to a renal vein tumor thrombus treated by adrenalectomy , renal vein thrombectomy without ipsilateral nephrectomy .
a 74-year - old man was referred in december 2011 to our hospital for an adrenal mass , discovered during the follow - up of a pt3-n1 m0 large cells neuroendocrine lung carcinoma , treated in june 2011 by surgery .
his main past medical history was hypertensive cardiopathy and non - insulin - dependent diabetes mellitus . on a clinical point of view
the computed tomography ( ct ) scan showed a left adrenal mass ( 7  10 cm enhanced with contrast ) associated with a renal vein tumor thrombus ( fig .  1 ) .
a positron emission tomography scanner showed adrenal mass and renal vein tumor thrombus hypermetabolism proving their tumoral hallmarks .
surgical treatment was decided after anticoagulation treatment initiated ( continuous intravenous administration of sodic heparin at the dose of 500 international unit / kg / day ) ; after a left subcostal incision , the left colon was mobilized and the retroperitoneal space approached .
once the adrenal gland was visualized , its main vein was isolated and followed until the renal vein to localize the tumor thrombus . using kidney cancer surgical technique for vena cava thrombectomy
after quadruple clamping ( renal vein x2 , spermatic vein and lumbar vein ) , the left renal vein was laterally opened in order to perform the thrombectomy , and the main adrenal vein was cut .
total clamping time was 12 min with no arterial clamping and no renal cooling required .
the renal vein was washed with a heparinized saline solution and closed with a polypropylene 6/0 running suture .
then , the veins were unclamped , and finally the adrenal gland was removed with macroscopically disease - free margins taking away the adrenal fat along the upper renal pole capsule . 

figure  1:(1 ) preoperative ct scan showing the adrenal mass ( a ) and in the renal vein a hypodense mass ( b ) corresponding to the renal vein tumor thrombus .
( 2 ) postoperative ct scan showing the left kidney and its permeable vein . ( 3 ) flow in the left renal vein on postoperative doppler ultrasound .
( 1 ) preoperative ct scan showing the adrenal mass ( a ) and in the renal vein a hypodense mass ( b ) corresponding to the renal vein tumor thrombus . ( 2 )
the postoperative management was simple except for an aeromonas hydrophila pulmonary infection , which was successfully treated by a 15-day cure of antibiotics .
histopathological studies revealed a 7-cm  round cells undifferentiated tumor with a vein tumor thrombus .
no adjuvant treatment was proposed because there was no relation with the lung carcinoma , and tumor 's resection margins were negative .
the postoperative ct scan showed no thrombus in the left renal vein ( fig .  1 ) .
doppler ultrasound performed 1 month after adrenalectomy proved a good left renal vein flux ( fig .  1 ) .
at 36 months of follow - up , the patient is alive without signs of recurrence .
if adrenalectomy is a well - admitted treatment of single adrenal metastasis , no recommendation exists concerning adrenal masses with renal vein or vena cava tumor thrombus .
perez utrilla et al .   have presented a case of an adrenal carcinoma with renal vein tumor thrombus treated by adrenalectomy , thrombectomy without ipsilateral nephrectomy .
described a series of 206 patients with adrenalectomy for cancer among which 6 had an adrenal vein tumor thrombus and 3 , only , associated with a renal vein thrombus . in these three cases ,
our case is the first description of such a procedure with ipsilateral kidney preservation for supposed lung adrenal metastasis with renal vein tumor thrombus .
nephron sparing makes sense in the case of metastasis because good renal function permits optimal adjuvant chemotherapy and thus better survival . indeed , sun youn et al .  
reviewed 8223 cancer patients with a measurement of the serum creatinine at least once during treatment .
they demonstrated that chronic kidney disease is associated with an increased risk of cancer - specific mortality .
the hazard ratio was between 1.12 and 1.75 according to the level of chronic renal disease .
.   showed that patients with chronic kidney disease were frailer ( tool to define individuals who lack functional reserve and are at risk for functional decline ) than the standard population .
even though more studies are necessary , this surgery seems to be a good treatment for adrenal gland tumors with a tumoral vein thrombus .
 if single adrenal metastasis surgery is well admitted , no recommendation exists about the management of a renal vein tumor thrombus , even though the actual consensual attitude consists in a nephrectomy associated to an adrenalectomy . 
 we report , here , the case of a 74-year - old man with a suspected adrenal metastasis of a lung carcinoma associated with a left adrenal and renal vein tumor thrombus treated by adrenalectomy and renal vein thrombectomy and ipsilateral kidney sparing . 
 the postoperative computed tomography scan showed no thrombus in the left renal vein . 
 doppler ultrasound performed 1 month after adrenalectomy proved a good left renal vein flux . at 36 months of follow - up 
 , the patient is alive without signs of recurrence . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST STATEMENT