Adrenalectomy for metastatic adrenal tumors

The indications for adrenalectomy in cases of metastatic adrenal tumor remain controversial. To clarify indications and outcomes of adrenalectomy for adrenal metastasis, we performed a retrospective review of all 8 patients who underwent adrenalectomy for adrenal metastasis between 1990 and 2006 in Asahikawa Medical College Hospital. The Primary tumor was renal cell carcinoma in 2 cases, and eccrine poro carcinoma, rectal cancer, lung cancer, melanoma, bladder cancer and cancer of unknown origin in 1 case each. Open adrenalectomy was performed in all cases, including 1 case that was converted from laparoscopic adrenalectomy. Of the 4 patients with solitary adrenal metastasis, 3 were considered tumor-free after adrenalectomy, while the remaining patient was not due to unresectable primary tumor. Of the 3 patients with complete resection, one remained alive as of 88 months after adrenalectomy but was then lost to follow-up, and the other 2 patients remain alive 12 and 7 months after adrenalectomy. Of the 2 patients with other resectable metastasis who were tumor-free after removal of all metastases, one was alive 31 months postoperatively and the other died 23 months after operation. The remaining 2 cases with other unresectable metastasis died within 6 months after adrenalectomy. At least in cases of solitary adrenal metastasis, adrenalectomy can be effective if other valid methods are unavailable.     

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.     

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.     

Operable lung cancer and synchronous adrenal masses: role of laparoscopic adrenalectomy combined with pulmonary resection

STUDY AIM: Assessment of laparoscopic adrenalectomy in the management of operable non-small cell lung cancer (NSCLC) associated with solitary and synchronous adrenal mass. PATIENTS AND METHODS: In a retrospective study, we reviewed 3 patients with operable NSCLC proved by pulmonary biopsy and an isolated synchronous adrenal mass shown by abdominal CT scan. We first performed a laparoscopic adrenalectomy followed by pulmonary resection. RESULTS: All patients had a laparoscopic adrenalectomy without any conversion or treatment-related death. Hospitalization stay ranged from 5 to 6 days. A left pneumonectomy has been performed immediately after this first hospitalization in 2 cases and after a first cycle of chemotherapy in the third case. Pathologic examination showed a NSCLC adrenal metastasis in 2 cases and an adrenocortical adenoma in the last case. During the follow-up 2 patients died of other distant metastasis and a mediastinal lymph node recurrence has been diagnosed in the third patient, actually treated by a second line chemotherapy. CONCLUSION: Despite those bad results that concern patients T3 M+ in 2 cases, laparoscopic adrenalectomy seems to be very interesting in selected cases. Considering that pulmonary resection can be done after, it represents a mean of diagnosis at least better than fine needle aspiration biopsy. Laparoscopic adrenalectomy might also be considered in the resection of a synchronous and isolated metastasis as a way to improve survival.     

Combined lung resection and transdiaphragmatic adrenalectomy in patients with non-small cell lung cancer and homolateral solitary adrenal metastasis.

Surgery may offer a long-term survival benefit to a small proportion of patients with operable non-small cell lung cancer (NSCLC) and solitary adrenal metastasis. Several approaches to lung resection with a separate open or laparoscopic adrenalectomy have been advocated. We describe a technique that allows a single incision, single operation through a transdiaphragmatic approach to the ipsilateral adrenal gland following a standard lung resection through a postero-lateral thoracotomy. By using this approach, along with the harmonic scalpel to aid adrenal dissection, both lobectomy and adrenalectomy can be carried out safely and effectively with minimal perioperative and postoperative morbidity.     

Surgical treatment for adrenal metastasis from lung cancer

Several long-term survivors after surgical resection for a solitary adrenal metastasis from non-small cell lung cancer (NSCLC) have been reported in case reports and case series with a small number of patients. We have experienced 6 cases of patients who had adrenalectomy (ADR) for a metastasis from NSCLC. The median survival time (MST) after ADR was 24 months, and there was only 1 case of 3-year survivor. To elucidate the surgical indication and the prognostic factors of patients with a solitary adrenal metastasis from NSCLC, we analyzed 104 patients including our 6 patients who had ADR for a metastasis from NSCLC. The MST after ADR and 5-year survival were 24 months and 31%, respectively. Univariate and multivariate analysis demonstrated that lymph node metastasis at the surgery for primary lung cancer was the only significant and independent predictor of poor survival in patients after ADR. The results suggest that aggressive surgical treatment of a solitary adrenal metastasis from NSCLC may be effective when a patient have N0 disease.     

Metastasis to the Adrenal Gland: The Emerging Role of Laparoscopic Surgery

Background:It is unclear whether resection of clinically isolated metastasis to the adrenal gland improves survival. Also, the role of laparoscopic adrenalectomy (LA) for metastasis is controversial. This study aimed to (1) identify patients who are most likely to have prolonged survival after resection of adrenal metastasis and (2) compare oncological outcomes of LA and open adrenalectomy (OA).Methods:A retrospective review of 41 patients, who underwent either OA or LA for metastasis to the adrenal gland during 1997–2002 at a single institution, was conducted.Results:There were 20 women and 21 men, with a median age of 59 years. The most common disease was non-small-cell lung carcinoma (n = 23), followed by renal cell carcinoma (n = 6). With a median follow-up of 16 months, the overall five-year actuarial survival was 29% (median, 28 months). Four patients were actually alive at four years after adrenalectomy. Disease-free interval (DFI) > 6 months was the only significant predictor of improved survival. LA was performed for 11 patients. There was no difference in the incidence of positive resection-margins or survival between patients with OA or LA.Conclusions:Adrenalectomy for metastasis, with intent to prolong survival, should be offered to patients with favorable tumor biology, such as those with significant DFI. The oncological outcome from LA appears similar to that from OA.     

Laparoscopic Adrenalectomy for Metachronous Metastasis from Renal Cell Carcinoma

BACKGROUND: Metachronous adrenal metastases (AM) from renal cell carcinoma (RCC) are rare. We report our experience of surgical resection in this setting, with particular respect to laparoscopic approach and long-term outcome. METHODS: A retrospective review of 11 patients who underwent adrenalectomy for metachronous AM from RCC was conducted between 2002 and 2005 in a tertiary referral center. RESULTS: CT scan findings were those of an adrenal mass ranging from 2 to 13 cm in diameter with a basal density of 12 to 28 Hounsfield Units and strong heterogeneous enhancement following contrast injection. The surgical procedure consisted of controlateral (n = 5), ipsilateral (n = 2), and bilateral (n = 1) laparoscopic adrenalectomy, whereas three patients underwent controlateral open adrenalectomy for adrenal mass >10 cm. Nine patients were recurrence-free with a median follow-up of 34 months. In the remaining two patients, lung metastases were discovered at postoperative months 28 and 11, respectively. The former patient is alive and free of disease recurrence 32 months after lung metastasis resection, whereas the latter is currently being treated with sunitinib. CONCLUSIONS: This study confirms that prolonged overall and disease free-survival can be achieved in selected patient after laparosocpic adrenalectomy for AM from RCC.     

Resection of adrenal metastases from non-small cell lung cancer: a multicenter study

BACKGROUND: In recent case reports and limited series, adrenalectomy was recommended for an isolated adrenal metastasis from non-small cell lung cancer (NSCLC). METHODS: We retrospectively studied patients with a solitary adrenal metastasis from NSCLC who had undergone potentially curative resection in eight centers. RESULTS: Forty-three patients were included. Their adrenal gland metastasis was discovered synchronously with NSCLC in 32 patients, and metachronously in 11. It was homolateral to the NSCLC in 31 patients and contralateral in 12 (p < 0.01). Median survival was 11 months, and 3 patients survived more than 5 years. There was no difference between the synchronous and metachronous groups regarding recurrence rate or survival. Survival was not affected by the homolateral location of the metastasis, the histology of the NSCLC, TNM stage, any adjuvant and neoadjuvant treatment, or, in the metachronous group, a disease-free interval exceeding 6 months. CONCLUSIONS: We confirm the possibility of long-term survival after resection of isolated adrenal metastasis from NSCLC, but no clinical or pathologic criteria were detected to identify patients amenable to potential cure.     

Adrenal metastases from adenocarcinoma of the esophagogastric junction: adrenalectomy and long-term survival

Treatment of adrenal metastases from cancer of the esophagogastric junction (EGJ) is not defined. The aim of the present work is to analyze retrospectively our experience in treating patients with adrenal metastases from EGJ adenocarcinoma. 102 patients with Siewert 1 or 2 EGJ adenocarcinoma underwent esophagectomy between May 2001 and Jan 2009. Five patients were diagnosed an adrenal metastases from EGJ adenocarcinoma, synchronous (s) in one and metachronous (m) in four, in the latter 11 months (mean) after esophagectomy. At diagnosis, three patients had synchronous metastases to mediastinal nodes (1 s and 2 m), 1 (m) had synchronous metastases to bone, and 1 (m) had an isolated adrenal metastasis. Three patients with synchronous node metastasis received chemotherapy followed by adrenalectomy 3, 8 and 16 months (mean 9) after diagnosis; one patient also received postoperative mediastinal radiotherapy. These patients are alive with no evidence of disease 16, 40 and 50 months after diagnosis of adrenal metastasis. The patient with bone metastasis received chemotherapy only and died 12 months after diagnosis of metastatic disease. The patient with isolated metastasis underwent laparoscopic adrenalectomy only, developed early bone metastases and died 15 months after surgery. In conclusion, our experience indicates that patients with adrenal metastases from adenocarcinoma of the EGJ may benefit from adrenalectomy if the gland is the only site of metastasis beyond lymphnodal disease. Chemotherapy should be considered before adrenalectomy to achieve better disease control and identify aggressive disease that would contraindicate adrenalectomy.     

Right Adrenal Metastases of Hepatocarcinoma After Liver Transplantation: Case Report and Literature Review

Background

Hepatocellular carcinoma (HCC) represents one of the most common malignancies globally, accounting for nearly one million new cases per year. Although the treatment of extrahepatic metastases from primary liver tumors is essentially palliative, a solitary metastasis from such tumors offers a possibility of cure by surgical resection. The adrenal gland is an uncommon site for metastasis from primary liver tumors.

Methods

We report a liver transplantation case of HCC and hepatitis B virus in a 23-year-old man with an excellent postoperative result. However, because an increased alpha-fetoprotein was evident and complete radiologic and blood tests were performed, all of which were normal. Three years posttransplantation, a right adrenal mass was identified by CT. PAAF was performed as well as adrenalectomy for a solitary adrenal metastasis from hepatocellular carcinoma.

Results

The patient underwent adrenalectomy for the right adrenal metastasis at 3 years following liver transplantation for HCC. He is presently alive and disease-free 24 months after adrenalectomy.

Conclusion

Carefully selected patients with solitary metastasis from HCC may be considered for resection.     

Adrenal metastasis from carcinoma of the colon and rectum: A report of three cases

We report herein three cases of patients with adrenal metastases from colorectal carcinoma. Recurrent disease was suspected following markedly elevated levels of serum carcinoembryonic antigen (CEA), and adrenal metastases were confirmed by computed tomography (CT) scanning in all three patients. The adrenal metastasis was solitary in one patient and this patient is still alive and free from disease 1 year after undergoing complete removal of the adrenal metastasis. On the other hand, metastatic disease was not limited to the adrenal gland in the other two patients and both died of recurrent disease, 33 months and 4 months after undergoing removal of the adrenal metastases, respectively. Thus, although the prognosis of adrenal metastasis from colorectal cancer is usually poor, we believe that patients with a solitary adrenal metastasis will benefit from complete removal of the metastasis.     

Surgical management of metastases to the adrenal gland: Open, laparoscopic, and ablative approaches

The adrenal gland is a potential site of metastasis for various malignancies. Metastases to the adrenal gland are the second most common type of adrenal mass lesion after adenomas. Differentiation of a metastatic lesion from a primary adrenal lesion can be challenging and requires the selective use of radiologic imaging, serologic testing, and adrenal biopsy. In patients who present with an isolated adrenal metastasis, adrenalectomy is often considered to aid in cancer control. Numerous studies have reported improved survival with resection of solitary adrenal metastases for various types of primary tumors. Traditionally, open adrenalectomy was the preferred option for these patients. More recently, laparoscopic adrenalectomy has offered a minimally invasive approach, with its resultant advantages of improved perioperative parameters. Proper patient selection for the laparoscopic versus open approach remains paramount in deciding the best treatment for the individual patient.     

Isolated Adrenal Metastasis: The Role of Laparoscopic Surgery

Background Solitary adrenal metastases (AM) are rare and their management unclear. Surgery, especially laparoscopic adrenalectomy (LA), is debatable in the management of AM. This retrospective study analysed the feasibility and the results of LA for AM. Methods From 1997 to 2003, 16 patients underwent LA for isolated AM. Completeness of resection, postoperative morbidity and follow-up (FU) were recorded. Results There were 10 synchronous AM and 6 metachronous AM. Primary tumours included lung cancer (n = 9), melanoma (n = 3), mesothelioma (n = 1), rhabdomyosarcoma (n = 1), colonic adenocarcinoma (n = 1) and renal cell carcinoma (n = 1). Five patients required conversion to an open procedure. Minor complications occurred in three patients. Pathology confirmed the diagnosis of AM. Mean tumour size was 60 (range: 15–110) mm. Nine patients (56%) had complete resections, 3 had positive margins and 4 had incomplete macroscopic resections. Mean observed FU was 25 (range: 1–68) months. Median overall calculated survival was 23 months. Overall 5-year survival was 33% (Kaplan–Meyer). At the end of study, 8 patients were alive with a mean FU of 35 months (3 without evidence of disease). No patient presented with local relapse or port-site metastasis. We did not identify any predictive factors. All patients with incomplete macroscopic resection died within 24 months. Conclusions LA can achieve an acceptable 5-year survival, comparable to open surgery but with better postoperative comfort. It should be considered for AM with the intention of complete resection. It offers the patient the possibility of tumour resection with the benefit of a laparoscopic approach.     

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.     

Surgical treatment of isolated adrenal metastasis from lung carcinoma

A surgical treatment of patients with lung cancer non-microcitoma and isolated adrenal metastasis has been reported in literature although limited in number and follow up. The Authors report 12 cases of patients operated for lung cancers non-microcitoma and isolated adrenal metastasis. One patients was lost in the follow up, two patients died 3 and 6 months after the adrenalectomy. The other patients are alive after 88, 39, 36, 17, 13 months after the adrenalectomy. Four of these patients are also disease free. Other 4 patients, more recently operated, are alive and disease free after 3, 3, 9 and 9 months after the adrenalectomy. The Authors believe that a surgical treatment is justified in these patients, considering the results of the series reported in literature and also their own results.     

Renal cell carcinoma with solitary metachronous contralateral adrenal metastasis. Experience with 2 cases and review of the literature.

We report on 2 cases of renal cell carcinoma with solitary metachronous contralateral adrenal metastasis occurring up to four years after radical nephrectomy. Both patients were treated with adrenalectomy and steroid replacement. One patient died with distant metastases twenty-eight months after adrenalectomy and the other is alive with no evidence of disease four years postoperatively. Such a presentation of hypernephroma is rare, with only 1 such case having been found in the literature.     

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.     

原发性肾上腺节细胞神经瘤的诊治分析

目的：总结肾上腺节细胞瘤的诊治方法。方法：回顾性分析1992年10月～2011年1月诊治19例肾上腺节细胞瘤患者的临床资料,并复习相关文献资料。结果：19例患者中12例经开放手术切除肾上腺肿瘤,7例行腹腔镜肾上腺肿瘤切除术,术后病理均证实为肾上腺节细胞神经瘤,术后随访2个月～14年,因心脏疾病死亡4例,脑出血死亡1例,车祸伤死亡1例,无一例患者因原发性肾上腺节细胞神经瘤死亡,随访期间肿瘤无复发和转移,预后良好。结论：肾上腺节细胞神经瘤为神经源性良性肿瘤,临床主要与静息型嗜铬细胞瘤相鉴别,对伴有疑似嗜铬细胞瘤临床表现的患者,且实验室检查与嗜铬细胞瘤相关的指标有异常时,术前准备需按嗜铬细胞瘤的要求。腹腔镜肿瘤切除可作为一线治疗方法,对于伴有周围血管脏器界限不清的肿瘤,建议行开放手术治疗。     

Adrenal Metastasis from Rectal Cancer: Report of a Case

We report a case of heterochronic adrenal metastasis from colorectal carcinoma in a 51-year-old woman. A left adrenal metastasis was found by computed tomography and magnetic resonance imaging 8 months after an anterior resection for advanced rectal carcinoma, and a left hepatectomy for a solitary liver metastasis. The level of serum carcinoembryonic antigen was still within the normal range. A left adrenalectomy was performed, and histopathological examination revealed adenocarcinoma, compatible with the rectal carcinoma resected 8 months earlier. The patient died of lung metastases 6 months after the adrenalectomy. A review of autopsy series in the world literature revealed that adrenal metastasis from colorectal cancer is not rare. Therefore, the possibility of adrenal metastasis should be considered in the follow-up of patients after primary surgery for colorectal cancer, even though the liver and lung are the main metastatic sites. Received: March 7, 2002 / Accepted: July 2, 2002 Reprint requests to: S. Murakami