Is adrenalectomy an indispensable part of nephrectomy? Results of a multivariate statistical analysis

Since in the absence of clinically overt metastatic disease tumorous lesions within the adrenal gland are found in only 2-10% of cases, the majority of renal cell cancer patients are overtreated by adrenalectomy as an integral part of nephrectomy. The medical records of 847 patients undergoing adrenalectomy in combination with nephrectomy irrespective of the local extent of the primary tumor or the clinical stage at first diagnosis were reviewed to determine the reliability of currently available imaging modalities regarding the prediction of adrenal gland metastases. Several patient and tumor characteristics correlated with the presence of intra-adrenal metastases, and their prognostic value was determined by a multivariate logistic regression model. Metastatic spread into the adrenal gland was observed in 27 of 847 (3%) patients. In only three of eight patients in whom the adrenal was identified as the only metastatic site, preoperative abdominal CT scans were interpreted as false negative. During multivariate statistical analysis, only the presence of distant metastases, vascular invasion within the primary tumor, and multifocal growth of renal cell cancer within the tumor-bearing kidney were identified to independently predict the likelihood for the presence of intra-adrenal metastases. None of the patient or tumor characteristics evaluated reliably predicted the likelihood for the presence of adrenal metastases in patients without evidence of disseminated metastatic spread. As we believe and as the current investigation demonstrates, routine adrenalectomy should not be recommended in cases of preoperatively normal radiological examinations.     

The therapeutic value of adrenalectomy in case of solitary metastatic spread originating from primary renal cell cancer

INTRODUCTION: Solitary adrenal metastases occur in about 1.2-10% of renal cell cancer patients. Since the vast majority of intraadrenal lesions can be detected preoperatively, we and others have recently recommended to renounce a routine adrenalectomy during surgery of renal cell cancer. However, the impact of adrenalectomy on the patients' clinical prognosis in case of a solitary metastatic lesion within the adrenal gland remains an issue of controversial discussion. Whereas some authors suggest adrenalectomy as a potentially curative treatment option in these cases, others compare its clinical value with that of a mere lymphadenectomy. PATIENTS AND METHOD: Between 1981 and 2000, 648 patients (440 males and 208 females) underwent nephrectomy in combination with adrenalectomy in our clinic for the diagnosis of renal cell cancer. The median age at first diagnosis was 59 (range 33-84) and 60 (range 20-85) years for male and female patients, respectively. The median postoperative follow - up was 2.4 years (0.2-18 years). According to the TNM - classification system (2003) tumor stages were classified as follows: T1, 228 pat. (37%); T2, 70 pat. (11%); T3, 287 pat. (46%); T4, 37 pat. (6%). In total, 339 patients revealed regional lymph node or distant metastases at the time of the surgical treatment. Although metastases of the adrenal gland were diagnosed in 48 patients, solitary intraadrenal metastases without further systemic spread were observed in only 13 cases. Several patients' and tumor characteristics (age, tumor stage and size, the presence of regional lymph node metastases, the presence of metastatic lesions at different organ sites as well as the detection of solitary intraadrenal metastases) were correlated with the patients' overall survival by univariate and multivariate statistical analysis (logistic Cox regression analysis). RESULTS: The median long - term survival was 4.8 years for the entire cohort of patients investigated. The median long - term survival was 13.8 years and 11.7 years for patients with no evidence of metastatic spread as well as for patients with a solitary intraadrenal metastatic lesion, respectively. Accordingly, the long - term survival rates at 5 and 10 years after surgery were 66%/50% and 51%/51% for patients with no evidence of metastatic spread or isolated intraadrenal metastases. This difference was not statistically significant. In contrast, for patients revealing lymph node or distant metastases at other organ sites, the median long - term survival was significantly decreased (lymph node metastases: 0.7 years; distant metastases: 1.2 years). DISCUSSION: For patients with a solitary intraadrenal metastatic lesion, adrenalectomy is a potentially curative treatment option. The observation that the long - term survival of the latter patients is comparable to that of patients with organ - confined disease might suggest the establishment of a separate TNM - category for patients revealing a solitary metastasis within the adrenal gland and no hint at further systemic metastatic spread.     

Management of contralateral adrenal metastasis from renal cell carcinoma: possibility of inferior vena cava tumour thrombus

OBJECTIVE: The contralateral adrenal gland is a rare metastatic site in renal cell carcinoma (RCC). We describe our experiences with this metastasis in a cohort of 610 radical nephrectomy patients analysed. To our knowledge this study is the first to demonstrate an inferior vena cava tumour thrombus from metachronous contralateral adrenal metastasis. PATIENTS AND METHODS: After radical nephrectomy for RCC, 610 patients treated at our institution from 1985-99 were retrospectively investigated for the incidence of contralateral adrenal metastasis, additional clinical findings, treatment modalities and survival after treatment for contralateral adrenal gland metastasis. RESULTS: The incidence of contralateral adrenal metastasis was 1.1% (7/610 patients), while the incidence of ipsilateral metastasis was 3.4% (21/610). In 3 of 7 cases the contralateral adrenal metastasis occurred simultaneously with primary RCC in the kidney. The contralateral adrenal gland was affected by distant tumour spread metachronously in 4 of 7 cases (3/4 bilateral adrenal involvement, 1/4 unilateral disease). In 1 case a metachronous contralateral adrenal metastasis caused vena cava tumour thrombus by propagation via the suprarenal venous route. After a mean follow-up of 20 months (range 1-54 months), 4 of 6 patients showed no evidence of disease after contralateral adrenalectomy. CONCLUSIONS: The probability of contralateral adrenal metastasis from RCC is 1.1%. Adrenalectomy in these cases offers a good chance of cure. In 71% of cases contralateral adrenal metastasis occurs in conjunction with ipsilateral disease, which provides a strong argument for routine ipsilateral adrenalectomy during radical nephrectomy. Care must be taken in preoperative diagnostics, as metachronous adrenal metastasis is capable of causing vena cava tumour thrombus.     

Surgical treatment of adrenal metastasis from renal cell carcinoma: a single-centre experience of 45 patients

OBJECTIVE: To report, in a retrospective study, the diagnostic problems and oncological results of surgery in patients with either synchronous or metachronous adrenal metastasis, which are uncommon in renal cancer, at 2-10% of patients. PATIENTS AND METHODS: Of 1179 patients treated for renal cancer between 1987 and 2003, 914 had renal surgery with concomitant ipsilateral adrenalectomy (routinely in 875 and for abnormal findings on computed tomography, CT, in 39) and 15 contralateral adrenalectomy (all after suspicious findings on CT). During the follow-up after renal surgery, another 14 patients had adrenalectomy for CT evidence of an abnormal adrenal gland, contralateral to the previous renal tumour in 12 and bilaterally in two. RESULTS: Of 914 ipsilateral adrenal glands removed during renal surgery, 854 (93.5%) were normal on pathological examination, 28 (3%) had a benign pathology, six (0.8%) were directly infiltrated by the tumour and 26 (2.7%) were metastatic. For both benign and metastatic ipsilateral adrenal pathology, CT had sensitivity, specificity and positive/negative predictive values of 47%, 99%, 73% and 96%, respectively. Of 29 contralateral glands removed because of suspicious CT findings (15 at diagnosis of renal cancer, 14 during the follow-up) there was no abnormality in one (3.4%), a benign pathology in seven (24%) and a metastasis in 21 (72%). Thus there were 32 synchronous (incidence 2.7%; ipsilateral to the renal tumour in 24, contralateral in six and bilateral in two), and 13 metachronous adrenal metastases (incidence 1.0%; contralateral in 11 and bilateral in two). The metachronous metastases were diagnosed at a mean (range) interval of 30.6 (8-73) months after renal surgery. No ipsilateral adrenal metastases were discovered at diagnosis or during the follow-up in the 382 patients with an organ-confined renal tumour of <4 cm in diameter. Twenty-seven patients with an isolated adrenal metastasis (synchronous in 14, metachronous in 13) had statistically significantly (P < 0.001) better survival than the 18 (all synchronous) with multiple sites of metastatic disease. In particular, there was long-term survival (mean 83 months) in 10 patients with an isolated adrenal metastasis. CONCLUSION: Sparing the ipsilateral adrenal is advisable only for organ-confined renal tumours of <4 cm in diameter; clinical local staging of renal cancer is the best predictor of the risk of adrenal metastasis. Conversely, CT had good diagnostic ability for the contralateral adrenal gland, especially during the follow-up. Some patients with isolated adrenal metastasis could be treated by metastasectomy, with long-term survival free of disease and confirming that, even if in a few and unselectable patients, removing all the neoplastic bulk can be curative. Nevertheless, the high rate of relapse underlines the need for an effective systemic therapy, and more so for widespread metastatic disease that currently cannot be cured.     

Real indications for adrenalectomy in renal cell carcinoma

OBJECTIVES: Adrenalectomy is a part of radical nephrectomy because of the surgical oncology principle of a 'wide margin beyond the malignancy' and due to concern over possible metastases to the ipsilateral adrenal gland, especially in upper pole tumors. But, neither the frequency, predisposing factors of the renal cell carcinoma nor mechanisms of involvement of the adrenal gland are well defined. We assessed the ipsilateral adrenal involvement in renal cell carcinoma to determine whether ipsilateral adrenalectomy during radical nephrectomy is essential. MATERIAL AND METHOD: In a series of 15,347 autopsies in Jena from 1985 through 1996, 272 renal cell carcinoma with 24 adrenal metastases were found. In the same period 9 adrenal metastases were found in 639 radical nephrectomies. Contralateral and bilateral metastases were seen in 15 cases of the autopsy series and in 2 cases of the operative series. RESULTS: The risk of adrenal metastases correlated with multifocal tumors, pleomorphic cell type, anaplastic growth pattern and tumors that were larger than 2.5 cm. Of the 24 renal cell carcinomas with adrenal metastases in the autopsy series, 23 had evidence of widespread disease and 22 had lymph node metastases. A preoperative abdominal computerized tomography was performed in all 9 patients of the operative series with renal cell carcinoma and adrenal involvement. The adrenal gland was considered abnormal in 8 of the 9 cases (88.9%). Only in 1 patient was the computerized tomography incorrectly interpreted as negative. CONCLUSION: We think adrenalectomy should only be performed if there is radiographic evidence of metastases in the adrenal gland or adrenal infiltration by a large upper-pole tumor is possible. Macroscopically normal adrenal glands should not be removed during tumor nephrectomy because the need and benefit of routine adrenalectomy are extremely limited.     

肾癌根治术中切除肾上腺的适应证

目的:探讨行肾癌根治术时切除肾上腺的适应证.方法:对484例患者行肾癌根治术中,213例同时切除同侧肾上腺,2例切除对侧肾上腺,1例切除双侧肾上腺;270例保留同侧肾上腺.结果:216例切除肾上腺经病理检查,11例(5.1%)发现有肾上腺转移,4例肾上腺良性病变.11例转移病例中8例术前CT(MRI)提示有肾上腺转移,肾卜腺转移患者的肿瘤直径均值>8 cm;1例为T1期肿瘤,6例为T3期肿瘤,4例为T4期肿瘤.268例保留肾上腺组中,1例于术后14个月发现同侧肾上腺肿瘤转移,1例于术后28个月发现双侧肾上腺转移.结论:CT是肾癌术前诊断及术后随访的重要影像诊断方法;保留同侧肾上腺手术仅在肿瘤局限于肾内且直径≤4 cm才是安全的;怀疑对侧肾上腺有肿块时,均应手术探查.孤立的肾上腺转移,是肾上腺转移瘤切除术的适应证.     

The adrenal gland and renal cell carcinoma: is ipsilateral adrenalectomy a necessary component of radical nephrectomy?

The ipsilateral adrenal gland may be involved by renal cell carcinoma through direct invasion or embolic metastases, and usually it is removed as part of the radical nephrectomy specimen. We reviewed retrospectively 44 patients with stage A and 8 patients with stage B renal cell carcinoma, 25 of whom had undergone ipsilateral adrenalectomy. The 5-year and 9-year survival of these 25 patients was 79 and 65 per cent, respectively, and was not statistically different from the 78 per cent 5-year and 9-year survival of those 27 patients who did not undergo ipsilateral adrenalectomy. These findings suggest that the ipsilateral adrenal gland need not be removed routinely as part of perifascial nephrectomy for renal cell carcinoma. Those patients who are found to have a contralateral adrenal lesion during preoperative evaluation should be spared bilateral adrenalectomy if there is no ipsilateral adrenal gland involvement at exploration. Those patients with lower pole lesions also need not undergo routine ipsilateral adrenalectomy. Preoperative computerized tomography scans will help to select those tumors that can be managed by perifascial nephrectomy with sparing of the ipsilateral adrenal gland.     

Radical nephrectomy for renal cell carcinoma: Is adrenalectomy necessary?

OBJECTIVES: The role of simultaneous adrenalectomy in combination with radical nephrectomy in the treatment for renal cell carcinoma (RCC) remains controversial. With nephron-sparing surgery being commonly applied, the indication for adrenalectomy has to be critically assessed. PATIENTS AND METHODS: In a retrospective analysis the outcome of 589 patients, who underwent ipsilateral adrenalectomy along with radical nephrectomy in the treatment for RCC between 1985 and 1997 at our institution, was evaluated. The mean follow-up time was 34 months (range 1-95). RESULTS: Histologically an ipsilateral adrenal metastasis was found in 19/589 patients (3.2%). 16/19 patients had >/= T3, 3/19 had T1 tumours. The average size of the primary tumours with adrenal metastasis was 7.8 cm (range 2.3-13) in diameter with no preferential primary tumour site within the kidney (6/19 upper, 4/19 middle and 9/19 lower third). Only 4/19 patients had suspect adrenal findings in preoperative diagnostics (ultrasound, CT scan). 6/19 (31.5%) patients with adrenal metastasis are alive without evidence of disease at a mean of 41 months (range 11-95) after surgery for RCC. CONCLUSIONS: The probability of adrenal metastasis correlates with primary tumour stage, but not with its location within the kidney. The preoperative diagnostics are not reliable concerning small adrenal metastases. We thus still recommend simultaneous adrenalectomy in those cases where radical nephrectomy in patients with RCC is indicated.     

Adrenal metastasis from renal cell carcinoma: Significance of adrenalectomy

BACKGROUND: The present study examined adrenal metastasis resulting from renal cell carcinoma (RCC), with the aim of assessing the need for routine ipsilateral adrenalectomy during radical nephrectomy. METHODS: Ipsilateral and contralateral adrenal metastases were investigated in 256 patients with RCC who had undergone radical nephrectomy from 1977 to 1996 at the Tohoku University School of Medicine. RESULTS: Twelve of the 256 patients (4.7%) had adrenal metastasis. Ten of these 12 patients had progressed to disseminated disease with very poor prognosis. Two patients who had solitary adrenal metastases remained disease-free for 21 and 7 years. Four patients showed metastases to the contralateral adrenal gland. Adrenal metastases in seven of 12 patients were identified by pre- or postoperative computed tomography (CT), and in another five macroscopically during surgery. CONCLUSIONS: Adrenalectomy was regarded as a possible curative treatment for patients with solitary adrenal metastasis. However, the incidence of this kind of metastasis was minimal and contralateral adrenal metastases may occur in RCC cases. We therefore believe that adrenalectomy should only be performed if radiographic evidence reveals metastases in the adrenal gland or if gross disease is present at the time of nephrectomy.     

Incidence of adrenal involvement and assessing adrenal function in patients with renal cell carcinoma: Is ipsilateral adrenalectomy indispensable during radical nephrectomy?

OBJECTIVE: To determine the value of ipsilateral adrenalectomy with radical nephrectomy, by investigating the clinical aspects of adrenal involvement and adrenocortical function in patients with renal cell carcinoma (RCC). PATIENTS AND METHODS: The demographic, clinical and pathological data of adrenal involvement were reviewed in 247 patients with RCC. To evaluate adrenocortical function, 14 patients (adrenalectomy in eight, adrenal-sparing in six) had a rapid adrenocorticotropic hormone (ACTH) stimulation test before and 2 weeks after surgery. RESULTS: There was adrenal involvement with RCC in seven of the 247 (2.8%) patients (a solitary adrenal metastatic tumour in four and direct extension into the adrenal gland in three). All adrenal involvement was detectable on abdominal computed tomography before surgery, and these patients had a large primary renal tumour of > pT2 and/or distant metastasis. Plasma cortisol levels declined significantly more in response to the rapid ACTH stimulation test in those treated by adrenalectomy than in those with spared adrenal glands at 2 weeks after surgery (P < 0.05), while there was no significant difference between the groups before surgery. CONCLUSIONS: These results suggest that unconditional ipsilateral adrenalectomy with radical nephrectomy for RCC should be avoidable, and thus preserve the reserve of adrenocortical function, as preoperative imaging, especially thin-slice multidetector helical computed tomography, can detect adrenal involvement with RCC in most cases. Unilateral adrenalectomy might cause an irreversible impairment of the reserve of adrenocortical function.     

Long-term Survival and Occasional Regression of Distant Melanoma Metastases after Adrenal Metastasectomy

Background Human melanoma cells express high-affinity glucocorticoid receptors, and adrenalectomy has been shown to have antimelanoma effects in animal models. Long-term regression of distant metastatic melanoma was observed in one patient after bilateral adrenalectomy, prompting a review of adrenalectomy for melanoma metastases performed at this center. Methods A retrospective study in which all patients treated at the Sydney Melanoma Unit and recorded as having adrenal gland metastases between January 1987 and January 2004 were identified and their survival analyzed. Results One hundred eighty-six patients with adrenal gland metastases were identified. Adrenalectomy was performed in 23 patients; the other 163 patients were treated nonsurgically. The adrenal glands were the sole site of disease in five patients. All symptomatic patients were free of pain after recovery from the surgical procedure. Thirteen patients were rendered clinically and radiologically disease-free by their surgery. There was no postoperative mortality within 30 days. Median overall survival after adrenalectomy was 16 months (2-year survival, 39%), compared with 5 months for patients with documented adrenal metastases treated nonsurgically (P < .00001). In one patient, nonresected visceral metastases elsewhere regressed completely after bilateral adrenalectomy; he remained well and free of disease 80 months after adrenalectomy. Regression of distant visceral metasatatic disease also occurred in a second patient after unilateral adrenalectomy. Conclusions Adrenalectomy for melanoma metastatic to the adrenal gland provides good palliation of symptoms and is associated with prolonged survival in a selected cohort of patients. We report for the first time sustained complete regression of distant metastatic melanoma after bilateral adrenalectomy, suggesting a possible role for adrenal hormones in modifying melanoma progression in certain patients.     

Clinical evaluation for adrenal metastasis of renal cell carcinoma in a single institute

OBJECTIVE: Clinicopathogical features and prognosis of patients with renal cell carcinoma (RCC) concomitant with adrenal involvement (metastasis or invasion) were evaluated in a single institute. METHODS: In 380 patients with RCC who underwent radical nephrectomy 18 patients had adrenal involvement (13 ipsilateral adrenal involvement). Clinicopathological factors were compared between patients with ipsilateral adrnal involvement and control patients. Cause-spesific survival was calculated by Kaplan-Meier Method. RESULTS: Patients with ipsilateral adrenal involvement had significantly higher percentage of tumor>5.5 cm, upper pole tumor, pathological stage (pT) 3< or =, lymph node metastasis, distant metastasis outside ipsilateral adrenal gland, histological grade 3 and microvascular invasion than control patients (p<0.05). Therefore, large tumor (especially 5.5 cm<), upper pole tumor, clinical T3 (especially patients with tumor thrombus), lymph node metastasis and distant metastasis were candidates for risk factors of ipsilateral adrenal involvement. 76.9% of ipsilateral adrenal metastasis could be diagnosed by computed tomography (CT). Thus, preoperative adrenal finding by CT is very important to determine the indication of ipsilateral adrenalectomy. All 3 patients with small ipsilateral adrenal metastasis that could not be detected preoperative CT died within one and half year postoperatively. Patients with solitary adrenal metastasis appeared to have better prognosis compared to those with both adrenal and other metastases. In 4 patients who survived more than 2 years after the presentation of adrenal metastasis, 3 patients had solitary adrenal metastasis and underwent adrenalectomy. CONCLUSION: From the results in a single institute, radiological finding of adrenal grand, tumor size, tumor location, T stage, lymph node metastasis and distant metastasis outside ipsilateral adrenal gland are possible important factors to determine the indication of ipsilateral adrenalectomy preoperatively.     

Adrenalektomie im Rahmen der Tumornephrektomie – ein Overtreatment?

Metastatic spread to the ipsilateral adrenal gland occurs in 1.2-10% of patients with renal cell carcinoma (RCC). In the majority of these cases, the primary tumor is locally advanced with poor differentiation, venous invasion, and involvement of the regional lymph nodes. Adrenal metastases are usually detected preoperatively by CT scan or MRI. Adrenal metastases are indicators of systemic disease with poor prognosis quo ad vitam. Only 0.5-2.3% of patients with RCC and adrenal metastases are free of venous invasion or lymphatic disease. In this small subset of patients, cure is possible by surgical removal of the adrenal gland. In 97.7-99.5% of patients with RCC, ipsilateral adrenalectomy has no impact on their prognosis. We therefore conclude that this procedure should be performed only if there is radiological suspicion of an adrenal mass.     

ADRENAL SPARING SURGERY DURING RADICAL NEPHRECTOMY IN PATIENTS WITH RENAL CELL CANCER: A NEW ALGORITHM

PURPOSE: Ipsilateral adrenalectomy is usually performed during radical nephrectomy because of renal cell cancer. Because renal tumors are detected more often in the earlier stages due to widespread use of ultrasound and computerized tomography, we define a subset of patients who would be eligible for adrenal sparing surgery. In a retrospective analysis we evaluated whether parameters obtained preoperatively are able to predict adrenal metastasis. MATERIALS AND METHODS: A total of 866 consecutive patients who underwent nephrectomy and ipsilateral adrenalectomy from 1983 to 1999 were evaluated. Preoperative parameters, including tumor size, location, clinical stage, number of tumors, and patient age and sex, were retrospectively compared with the histological results. Univariate and multivariate analyses were performed. RESULTS: A total of 27 (3.1%) adrenal metastases were noted in the 866 patients, and 63% were on the left side and 37% on the right side. Mean tumor size was 10 cm. with versus 6 cm. without adrenal involvement. Of the 27 patients 21 had multiple metastases at diagnosis and only 6 (0.7% of all 866) presented with solitary ipsilateral adrenal metastasis. Univariate and multivariate analyses revealed tumor size and M stage as best preoperative predictors of adrenal involvement. CONCLUSIONS: Adrenal sparing surgery is possible, and we suggest a new algorithm. If maximum tumor size measured by computerized tomography is less than 8 cm. and staging examination does not show organ or lymph node metastases, adrenalectomy is not necessary because of oncological reasons. This algorithm has to be validated by a prospective analysis.     

肾细胞癌并发同侧肾上腺肿瘤(附三例报告)

目的分析肾细胞癌并发同侧肾上腺转移癌的发生率,探讨肾癌根治术作同侧肾上腺切除的可行性。方法报告５年间行肾癌根治术５６例,其中３例并发同侧肾上腺肿瘤,仅１例为肾上腺转移癌。结果３例均行同侧肾上腺切除的肾癌根治术,均痊愈出院。１例肾癌并发肾上腺转移癌者术后随访２年,健在。另２例分别为并发肾上腺皮质腺瘤及嗜铬细胞瘤,术后随访５年及２５年,健在。结论肾细胞癌并发同侧肾上腺肿瘤并不都是转移癌。肾癌根治术不必都作肾上腺切除,只有肾上极肾癌直接蔓延至肾上腺及肾上腺有转移癌时才作肾上腺切除。术前影像学检查及术中探查肾上腺正常者肾上腺可不必切除。     

Laparoscopic anterior adrenalectomy for the treatment of adrenal metastases

Aim of this study was to evaluate the results in 6 patients undergoing laparoscopic adrenalectomy for the treatment of solitary adrenal gland metastases. One hundred forty-five patients underwent laparoscopic adrenalectomy by transperitoneal anterior approach. In 6 patients the indication was the presence of a solitary adrenal gland metastasis. Primary tumors were the following: truncal melanoma, gastric cancer, renal cancer, lung cancer, and breast cancer. Mean age was 57 years (range 44-70 years). Three patients underwent right adrenalectomy and 3 patients a left adrenalectomy. No conversion to open surgery occurred. No mortality or intraoperative complications were observed. Mean operative time was 103 minutes (range 70-150) for right adrenalectomy and 170 minutes (range 90-280) for left adrenalectomy. No postoperative complications occurred. Mean diameter of the tumor was 3.5 cm (range 2-5 cm). Tumor free margins were obtained in every case. Mean hospital stay was 2 days (range 2-3 days). At follow-up, 2 patients have died of systemic dissemination of the disease, one 15 months and one 24 months after the operation. The remaining 4 patients are alive and disease free at a mean follow-up of 7 months (range 4-11 months). So far, no port site metastases or local recurrence have been observed. In our experience adrenal gland metastasis can be treated safely and effectively by the laparoscopic transperitoneal anterior approach.     

Long-term disease-free survival after adrenalectomy for isolated colorectal metastases

Metastasis to the adrenal glands occurs in approximately 16% of patients with metastatic colorectal carcinoma. Historically, these metastases are found at autopsy, but due to improved imaging and diagnostic techniques, many of these lesions are now discovered on routine follow-up imaging. In general, adrenal metastasis is an indicator of widespread disease, but in rare cases, isolated adrenal metastasis can be found. Although potential improvement in overall survival after adrenalectomy for isolated colorectal metastases has been reported, there has only been one long-term disease-free survivor reported. Here, we report a patient who is a 7-year disease-free survivor after adrenalectomy for an isolated colorectal metastasis.     

嗜铬细胞瘤与同侧肾细胞癌(附二例报告及文献复习)

目的　探讨嗜铬细胞瘤与肾细胞癌的关系 ,提高对嗜铬细胞瘤与同侧肾细胞癌并存的认识及诊治水平。　方法　报告 2例嗜铬细胞瘤与同侧肾细胞癌并存患者诊治资料。　结果　 1例左肾上腺嗜铬细胞瘤者术前误诊为左肾转移癌 ,行同侧肾上腺切除的肾癌根治术 ,术中发生危象 ,经抢救治愈。 1例术前确诊为右肾上腺嗜铬细胞瘤并同侧肾癌者手术顺利。　结论　一侧肾癌并同侧肾上腺嗜铬细胞瘤临床罕见 ,应提高对“静止型嗜铬细胞瘤”的认识 ,手术治疗应有充分的围手术期准备     

Factors of importance for prediction of survival in patients with metastatic renal cell carcinoma, treated with or without nephrectomy

OBJECTIVE: The indications for nephrectomy in patients with metastatic renal cell carcinoma remain controversial. A number of variables were analysed to identify factors that might predict the survival time, and these factors were used to obtain guidance as to which patients might benefit from palliative nephrectomy. MATERIAL AND METHODS: We reviewed the medical records for 106 consecutive patients with primary metastatic renal cell carcinoma, including clinicopathological factors, routine laboratory data and metastatic spread. The association of the different factors to survival time was evaluated by univariate and multivariate analysis. RESULTS: A number of factors correlated to survival time in univariate analysis, including solitary versus multiple metastases, serum albumin and DNA ploidy, but after Cox multivariate analysis their significance was lost. The remaining independent prognostic factors were performance status, number of metastatic sites, erythrocyte sedimentation rate (ESR), calcium in serum and vein invasion with tumour thrombus formation. The factors with no association to survival time were the metastatic sites, tumour size and nuclear grade. Patients treated with nephrectomy had a significantly longer survival time than those who did not undergo nephrectomy (p < 0.001). None of the 28 patients who did not undergo nephrectomy survived for 2 years, compared with 38 of the 78 patients who were nephrectomized. CONCLUSIONS: Patients who can be expected to survive longer, and who might be recommended for nephrectomy despite metastatic disease, would have the following independent factors: a good performance status, metastases limited to one organ, low ESR, normal calcium in serum and no tumour thrombus formation.     

Contralateral adrenal metastasis of renal cell carcinoma: treatment,outcome and a review

OBJECTIVE: To report the surgical treatment of patients with renal cell carcinoma (RCC) metastatic to the contralateral adrenal gland and compare our experience with previous reports, as such metastases are found in 2.5% of patients with metastatic RCC at autopsy, and the role of resecting metastatic RCC at this site is not well defined. PATIENTS AND METHODS: We retrospectively identified 11 patients who had surgery for metastatic RCC to the contralateral adrenal gland between October 1978 and April 2001. The patients' medical records were reviewed for clinical, surgical and pathological features, and the patients' outcome. RESULTS: The mean (median, range) age of the patients at primary nephrectomy was 60.9 (64, 43-79) years; all had clear cell (conventional) RCC. Synchronous contralateral adrenal metastasis occurred in two patients. The mean (median, range) time to contralateral adrenal metastasis after primary nephrectomy for the remaining nine patients was 5.2 (6.1, 0.8-9.2) years. All patients were treated with adrenalectomy; there were no perioperative complications or mortality. Seven patients died from RCC at a mean (median, range) of 3.9 (3.7, 0.2-10) years after adrenalectomy for contralateral adrenal metastasis; one died from other causes at 3.4 years, one from an unknown cause at 1.7 years and two were still alive at the last follow-up. CONCLUSIONS: The surgical resection of contralateral adrenal metastasis from RCC is safe; although most patients died from RCC, survival may be prolonged in individual patients. Hence, in the era of cytoreductive surgery, the removal of solitary contralateral adrenal metastasis seems to be indicated.