Combined robotic lobectomy and adrenalectomy for lung cancer and solitary adrenal metastasis

Background and Objectives:

Surgical resection of isolated adrenal metastasis in primary lung cancer is associated with improved survival. We report a combined robotic lobectomy and adrenalectomy for resection of a primary lung cancer and metastasis to the adrenal gland.

Methods:

A 69-year-old male with a significant smoking history and shortness of breath was found to have a 3-cm left upper lobe mass with an enlarged left adrenal gland measuring 1.5cm. The adrenal gland was biopsied confirming metastatic poorly differentiated carcinoma, likely lung cancer. Computed tomography, positron emission tomography, and mediastinoscopy revealed no evidence of disease outside the adrenal gland.

Results:

Following induction chemotherapy, the patient underwent combination robotic lobectomy, lymphadenectomy, and adrenalectomy while in the same lateral decubitus position. Thoracic and urologic oncology teams performed their respective portions of the operation. Overall operative time was 4 hours, and length of hospital stay was 3 days. Estimated blood loss was 150mL with no narcotic requirements beyond the first postoperative day. Final pathology revealed large cell carcinoma of the lung with metastasis to the adrenal. All surgical margins were negative.

Conclusions:

Combination robotic lobectomy and adrenalectomy is feasible and can be associated with a short convalescence, minimal pain, and an oncologically sound approach.     

Surgical treatment of solitary adrenal metastasis from non-small cell lung cancer

BACKGROUND: Management of solitary adrenal metastasis from non-small cell lung cancer is still debated. Although classically considered incurable, various reports with small numbers of patients have shown that surgical treatment might improve long-term survival. The aim of this study was to review our experience and to identify factors that could affect survival. METHODS: From January 1989 through April 2003, 23 patients underwent complete resection of an isolated adrenal metastasis after surgical treatment of non-small cell lung cancer. There were 19 men and 4 women, with a mean age of 54 +/- 10 years. The diagnosis of adrenal metastasis was synchronous with the diagnosis of non-small cell lung cancer in 6 patients and metachronous in 17 patients. The median disease-free interval for patients with metachronous metastasis was 12.5 months (range, 4.5-60.1 months). RESULTS: The overall 5-year survival was 23.3%. Univariate and multivariate analysis demonstrated that a disease-free interval of greater than 6 months was an independent and significant predictor of increased survival in patients after adrenalectomy. All patients with a disease-free interval of less than 6 months died within 2 years of the operation. The 5-year survival was 38% after resection of an isolated adrenal metastasis that occurred more than 6 months after lung resection. Adjuvant therapy and pathologic staging of non-small cell lung cancer did not affect survival. CONCLUSIONS: Surgical resection of metachronous isolated adrenal metastasis with a disease-free interval of greater than 6 months can provide long-term survival in patients previously undergoing complete resection of the primary non-small cell lung cancer.     

Metachronous adrenal masses in resected non-small cell lung cancer patients: therapeutic implications of laparoscopic adrenalectomy.

OBJECTIVE: In literature only few reports focused on the resection of solitary adrenal gland metastasis in patients operated on for non-small cell lung cancer (NSCLC). We report our experience on laparoscopic adrenalectomy for suspected or confirmed metachronous solitary adrenal metastasis from NSCLC and discuss its therapeutic role. METHODS: From June 1993 to March 2003, 14 patients (pts), who had been undergone lung resection for NSCLC, with suspected or confirmed solitary adrenal gland metastasis at the follow-up, underwent 15 laparoscopic adrenalectomy (in 1 patient it was bilateral). All the patients had enlarged adrenal glands at the abdominal ultrasound or CT. All but 2 pts underwent at least 1 adrenal fine needle aspiration. All the patients underwent a careful staging to exclude other sites of metastasis. The adrenal gland was in 6 cases the right, in 9 cases the left. RESULTS: In 7 cases we had a preoperative cytological diagnosis of metastasis. In 1 case adrenalectomy was not performed because of infiltration of vena cava and in 1 case it was necessary to perform a small laparotomy because of bleeding. The pathologic examination confirmed in 11 cases a NSCLC metastasis while in 4 cases it was a cortical adenoma. Regarding the 10 patients with NSCLC metastases, 3 are still alive and well at 37-80 months from the lung resection. One patient (who underwent bilateral adrenalectomy) is still alive at 44 months with local relapse. Two patients died 5 and 6 months after the adrenalectomy for other causes, 1 died at 14 months for local and systemic relapse and the remaining 3 patients died at 12 to 38 months for systemic relapse. CONCLUSIONS: Laparoscopic adrenalectomy in patients resected for NSCLC is a safe mini-invasive procedure. Even though this series is still too small, laparoscopic adrenalectomy should be considered an effective therapeutic tool in case of progressive adrenal gland enlargement, also with negative cytological examinations. A bigger series and other institution experiences will clarify its oncological value.     

Treatment recommendations for adrenal metastasis of non-small cell lung cancer

To evaluate the optimum treatment strategy for metastatic adrenal tumors derived from non-small cell lung cancer (NSCLC), we retrospectively analyzed 17 consecutive cases (8 resection cases: 4 synchronous and 4 metachronous: 9 non-resection cases: 3 synchronous and 6 metachronous) who received surgical resection for NSCLC. The patients included 12 males and 5 females with a mean age of 63.9 years. Of these, 9, 3, 2, 2, and 1 patient (s) were diagnosed as having adenocarcinoma, squamous cell carcinoma, pleomorphic carcinoma, large cell carcinoma, and adenosquamous cell carcinoma, respectively. The mean interval after lung resection and treatment of metachronous adrenal metastasis was 9.9 months. The mean time to progression from treatment of metachronous adrenal metastasis to disease progression was 8.9 months. A survival analysis showed no significant prognostic difference between the patient age, gender, pathological stage, synchronous/metachronous classification, CEA, and site of metastases. However, patients who received an adrenalectomy had a more favorable prognosis. The 2-year survival of patients following resection versus those who did not undergo a resection for adrenal metastasis was 62.5 and 22.8%, respectively. These data indicate that metastatic adrenal tumors should be resected if the patient can tolerate surgery after appropriate selection.     

Laparoscopic adrenalectomy for solitary metachronous adrenal metastasis from lung cancer: Report of a case

We report herein the case of a 69-year-old man who underwent laparoscopic adrenalectomy for a solitary adrenal metastasis 10 months after a left lower lobectomy for T2N1M0 lung cancer. A 30×20 mm tumor was found in the left adrenal gland, and dissected using an ultrasonically activated scalpel. Histological examination revealed metastatic squamous cell carcinoma. The patient recovered uneventfully and his condition is now stable 18 months after the second operation, with no evidence of local recurrence or metastatic disease. Although laparoscopic resection for malignant adrenal tumors is still controversial, we consider that laparoscopic adrenalectomy may be an optional treatment for metastatic adrenal tumors, provided the tumor is solitary, small in size, and well-localized. To our knowledge, only 14 cases of laparoscopic adrenalectomy for malignant tumors have been reported to date; however, this is the first case of successful laparoscopic adrenalectomy for a metastasis from lung cancer.     

Lobe-specific skip nodal metastasis in non-small cell lung cancer patients.

PURPOSE: The purpose of this study is to clarify the lobe-specific nodal metastasis and optimal range of mediastinal nodal dissection in lung cancer patients with skip metastasis. MATERIALS AND METHODS: A total of 136 patients with pN2/3 disease were treated between 1988 and 2002, and these patients were divided into two groups according to whether skip metastasis was identified or not. We drew a comparison of the lobe specificity of mediastinal nodal involvement between skip positive and negative groups. RESULTS: Skip metastasis was identified in 48 (35.3%) of 136 pN2/3 patients. The lymph nodal regions most frequently found (target nodes) were as follows: right upper-#3 and right #4, middle & lower-#3, right #4 and #7, left upper-left #4, #5, and #6, and left lower-#7, #8, and #9. Skip metastasis can be detected at a rate of 82.6% to 91.7% by means of a histological examination of these target nodes. However, the frequency of skip metastasis in other mediastinal nodal regions excluding the target nodes was found to progress to a level of 33.3% to 57.1% insofar as tumor metastasis to these target nodes was identified. CONCLUSIONS: The examination of lobe-specific nodal regions may be helpful for determining patients with skip metastasis. If metastasis is found somewhere in these target nodes, then a systematic nodal dissection may be acceptable for a complete resection even if N1 metastasis is not identified.     

Surgery in the treatment of metachronous homolateral non-small cell lung cancer

The authors describe their experience with the surgical treatment of metachronous homolateral lung cancer by completion pneumonectomy. In the Department of Thoracic Surgery of the National Cancer Institute of Milan, over a period ranging from 1982 to 1996, 30 completion pneumonectomies were performed for local relapses or second primary tumors. The patients submitted to this intervention had a lobectomy as their first operation in 23 cases (77%), a bilobectomy in 4 (13%) and a typical segmentectomy in 3 (10%). Associated with these interventions we performed 2 en bloc chest wall resections and a contralateral wedge resection. Two subjects received neoadjuvant chemo-therapy. Histology revealed squamous carcinoma in 14 cases (47%) and adenocarcinoma in 16 (53%). Seventeen patients (57%) were classified as stage I, 8 as stage II (26%), 4 as stage III (13%) and 1 as stage IV (4%). Four patients received adjuvant chemotherapy and/or radiotherapy. Lung cancer relapse occurred as a single lesion in 27 cases (90%) and as multiple lesions in 3 (10%). We performed 18 right (60%) and 12 left (40%) completion pneumonectomies. In 1 case (4%) a sleeve pneumonectomy was necessary. Associated with these interventions we performed 5 en bloc chest wall resections. The perioperative mortality was 10% and the postoperative morbidity 40%. Histological tests showed 12 squamous carcinomas (40%) and 18 adenocarcinomas (60%). Two patients (7%) had a different histology. Disease was classified as stage I in 13 cases (44%), as stage II in 9 (30%) and as stage III in 8 (26%). Four patients received adjuvant chemotherapy and/or radiotherapy. Two subjects developed a metachronous contralateral tumor (7%). The disease-free interval was 22.70 +/- 14.69 months, with a median value of 17 months (range: 7-53 months). Mean survival after completion pneumonectomy was 49.77 +/- 49.29 months, with a median value of 26.5 months (range: 4-190 months). The 5-year actuarial survival rate, calculated using the Kaplan-Meier method, was 30%. Completion pneumonectomy is a technically very demanding intervention carrying a high risk of morbidity. On the basis of the analysis of our data, we can affirm that mean postoperative survival seems to be satisfactory and to justify this aggressive attitude towards recurrent tumor. We should stress the importance of careful evaluation of indications and precise selection of patients.     

Prognostic factors in patients with ipsilateral pulmonary metastasis from non-small cell lung cancer.

OBJECTIVE: Pulmonary metastasis of non-small cell lung cancer is classified as an advanced disease stage, with limited indications for surgical treatment. However, the prognosis of patients with pulmonary metastasis of non-small cell lung cancer is better than that of patients with distant metastases. The purpose of the present study was to analyze and detect possible prognostic factors in surgically treated patients with ipsilateral pulmonary metastasis of non-small cell lung cancer. METHODS: Among 1198 patients with non-small cell lung cancer who underwent surgery at Kurashiki Central Hospital (Okayama, Japan) from April 1982 to March 2004, a total of 48 (4.0%) patients with pathologically diagnosed ipsilateral pulmonary metastasis were retrospectively evaluated. The median follow-up time was 20.5 months (range 1-103 months) and 37 patients (77.1%) were completely followed up until their death or more than 5 years after the operation. RESULTS: Among the 48 patients, 31 (64.6%) patients had metastatic nodules in the same lobe as the primary tumor (PM1) and 17 (35.4%) patients had metastatic nodules in different ipsilateral lobes (PM2). There was no significant difference in survival between patients with PM1 and the other patients with pT4-stage IIIB, or between patients with ipsilateral PM2 and the other patients with stage IV. Univariate analysis of postoperative survival stratified according to clinicopathologic factors revealed significant differences for the radicality of resection (complete vs. incomplete), tumor size (0-30 vs. >30mm) and pathological nodal (pN) factor (among pN0, pN1 and pN2-3). Multivariate analysis revealed that tumor size (0-30 vs. >30mm) and pN factor (pN0-1 vs. pN2-3) were independent prognostic factors. CONCLUSIONS: The results of our study suggest that undergoing a complete resection, having a tumor size of 30mm or less and having no mediastinal lymph node metastases were better prognostic factors for surgically treated patients with ipsilateral pulmonary metastasis of non-small cell lung cancer.     

Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer.

BACKGROUND: The impact of short-term preoperative pulmonary rehabilitation on exercise capacity of patients with chronic obstructive pulmonary disease undergoing lobectomy for non-small cell lung cancer is evaluated. METHODS: A prospective observational study was designed. Inclusion criteria consisted of an indication to lung resection because of a clinical stage I or II non-small cell lung cancer and a chronic obstructive disease on preoperative pulmonary function test. In such conditions, maximal oxygen consumption by a cardio-pulmonary exercise test was evaluated; when this resulted as being < or =15 ml/kg/min a pulmonary rehabilitation programme lasting 4 weeks was considered. Twelve patients fulfilled inclusion criteria, completed the preoperative rehabilitation programme and underwent a new functional evaluation prior to surgery. The postoperative record of these patients was collected. RESULTS: On completion of pulmonary rehabilitation, the resting pulmonary function test and diffuse lung capacity of patients was unchanged, whereas the exercise performance was found to have significantly improved; the mean increase in maximal oxygen consumption proved to be at 2.8 ml/kg/min (p<0.01). Eleven patients underwent lobectomy; no postoperative mortality was noted and mean hospital stay was 17 days. Postoperative pulmonary complication was recorded in 8 patients. CONCLUSIONS: Short-term preoperative pulmonary rehabilitation could improve the exercise capacity of patients with chronic obstructive pulmonary disease who are candidates for lung resection for non-small cell lung cancer.     

Surgical treatment of solitary metastasis in the male breast from non-small cell lung cancer

Detection of metastases in the breast from extramammary neoplasms is rare. We present a case of metastases in breast tissue from surgically treated non-small cell bronchogenic carcinoma. A histologic and immunohistologic study was essential for choosing the appropriate treatment for the patient. The patient is alive and disease-free 18 months after the breast surgery.     

Non-small cell lung cancer with a solitary hematogenous metastasis

The standard treatment for patients with stage IV non-small cell lung cancer (NSCLC) is chemotherapy. Retrospective series suggest, however, that some patients with stage IV lung cancer with a solitary synchronous site of extrathoracic metastatic (M1) disease are effectively treated by resection of both the primary tumor and the meststasis. Although these patients represent a small minority of those with stage IV lung cancer, it appears reasonable to consider highly selected patients with a solitary resectable metastasis from NSCLC for surgical resection of all evident disease or for chemotherapy without surgery. Because of the results of the current author's trial, however, it is difficult to recommend the regimen of combined medical and surgical therapies used in the current protocol in the management of solitary M1 disease. Future trials could be designed to include newer, less toxic chemotherapeutic regimens.     

胸腔镜微创切除非小细胞肺癌患者术后复发与转移的影响因素分析

目的：分析胸腔镜微创切除非小细胞肺癌（NSCLC）患者术后复发与转移的影响因素。方法：选择2019年6月—2022年5月在我院行胸腔镜微创切除术治疗的NSCLC患者90例,记录90例患者术后复发及转移情况,Logistic回归分析影响NSCLC患者术后复发及转移的危险因素。结果：随访时间截止到2022年9月,随访时间5～32(18.22±5.68)个月,术后复发32例（35.56%）,转移35例（38.04%）;Logistic回归分析结果：病理分期高、N分期高、T分期高、分化程度低、纵隔淋巴结转移、切除气管残端阳性是NSCLC患者术后复发的独立危险因素;病理分期高、N分期高、T分期高、分化程度低、纵隔淋巴结转移、淋巴结转移数量多、切除气管残端阳性是NSCLC患者术后转移的独立危险因素。术后化疗是NSCLC患者术后复发及转移的保护因素。结论：病理分期、分化程度、纵隔淋巴结转移及切除气管残端阳性为NSCLC患者术后复发与转移的共同危险因素,淋巴结转移数量为术后转移的独立危险因素,临床进行治疗策略制定时应充分考虑上述因素。     

Long-term results after pulmonary resection in elderly patients with non-small cell lung cancer

BACKGROUND: The number of elder by patients with lung cancer is expected to increase. But, there was no report that 10 years completely passed in surgically treated elderly patients (E-pts). This study assesses late results of surgery. METHODS: From 1981 to 1987, 160 patients with non-small cell lung cancer underwent lobectomy or pneumonectomy with mediastinal lymph node dissection. Of these, 37 (23%) were 70 years of age or older. The outcome of this group was compared with that of 123 non-elderly patients (NE-pts). RESULTS: There were no significant differences in the background between E-pts and NE-pts. Five- and 10-year survivals in the E-pts were 35.1%, and 24.3%, respectively. In outcome more than 5 years from operation, E-pts had a significantly poorer prognosis than NE-pts (p=0.04) by any causes of death, but a similar prognosis by primary death. E-pts died of nontumor-related death significantly more than NE-pts (p=0.6). CONCLUSIONS: This study showed that E-pts could consummate their lives completely. Additionally, when long-term prognosis of the postoperative E-pts was discussed, we should contemplate that E-pts had more deaths from nontumor-related causes.     

Renal cell carcinoma with solitary contralateral adrenal metastasis

We report on 2 cases of renal cell carcinoma with solitary contralateral adrenal metastasis which was demonstrated six months and one year, respectively, after radical nephrectomy. Pulmonary metastases developed six months after adrenalectomy in 1 patient; the other patient is alive without any evidence of disease twenty-two months after adrenalectomy.     

History of limited resection for non-small cell lung cancer.

A retrospective study of limited resection for lung cancer in a large number of patients was first reported in the 1970s. The reported outcome of segmentectomy was comparable to that of standard lobectomy. The North American Lung Cancer Study Group (LCSG) performed a randomized controlled clinical trial to compare limited resection (segment or wedge) with lobectomy for T1N0 (stage IA) non-small cell lung cancer (NSCLC) in the 1980s. The study revealed a significant excess of intrathoracic recurrence rate and a tendency to poorer survival in the limited resection group. Since then, limited resection has not been considered the standard operation for lung cancer. However, this situation is gradually changing, because the recent introduction of chest computed tomography (CT) to mass surveys has made peripherally located lung cancer detectable at the earliest stage. Several recent non-randomized studies of intentional limited resection from Japan demonstrated good outcomes comparable to those of lobectomy. Organ-sparing wedge resection without systematic dissection of lymph nodes may be suitable for some types of small lung cancers detected only by CT. Our meta-analysis of published data comparing survival rates after limited resection and lobectomy for stage I lung cancer revealed that limited resection was comparable to lobectomy. Further studies are necessary to define precise targets of intentional limited resection for lung cancer.     

Survival after resection of metachronous non-small cell lung cancer in 127 patients

BACKGROUND: In a number of patients with treated primary non-small cell lung cancer (NSCLC) a second primary tumor will be diagnosed. Our experience with surgery in these patients was analyzed and possible prognostic parameters were defined. METHODS: Patients with metachronous NSCLC (n = 127) who underwent resection from 1970 through 1997 were analyzed. All tumors were classified postsurgically. Median interval between the tumors was 3.7 years. Actuarial survival time was estimated and risk factors influencing survival were evaluated. RESULTS: Overall 5-year survival after the first resection was 70% and after the second resection was 26%. Patients with stage IA of the second primary tumor did have a significantly better survival (p < 0.005) as compared with patients with higher staged second primaries. Stage of second primary tumor and age were significant predictors of survival, whereas stage of first tumor, interval between resections, histology, and type of resection were not. CONCLUSIONS: Survival of patients with metachronous NSCLC and resection of both tumors is high, but poorer than after resection of the first tumor. Irrespective of the interval, patients with stage IA second primary tumor may benefit more from pulmonary resection.