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.     

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.     

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.     

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.     

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.     

Laparoscopic adrenalectomy for large adrenal metastasis from contralateral renal cell carcinoma.

We present herein the case of a patient with solitary metachronous contralateral adrenal metastasis from renal cell cancer. The patient had undergone left radical nephrectomy and adrenalectomy for localized renal cancer 7 years previously. Laparoscopic transperitoneal right adrenalectomy was performed. The postoperative period was uneventful. Histology showed right adrenal metastasis from renal cancer. At 6-month follow-up, there was no evidence of recurrence.     

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.     

Long-Term Survival After Resection of Metachronous Bilateral Adrenal Metastases of Mucinous Gastric Carcinoma: Report of a Case

We report a case of metachronous bilateral adrenal metastases from mucinous adenocarcinoma of the stomach. A 68-year-old man who had undergone surgery for advanced gastric cancer 5 months earlier had a follow-up computed tomography (CT) scan, which showed a right adrenal tumor. We performed a right adrenalectomy, and histopathological examination revealed a mucinous adenocarcinoma with features consistent with those of gastric cancer. A routine follow-up CT scan done 41 months after the right adrenalectomy showed a left adrenal mass. Chemotherapy had no apparent effect, and left adrenalectomy was performed 65 months after the right adrenalectomy. Histopathological examination also revealed a metastasis from gastric cancer. The patient was alive without recurrence 40 months after the left adrenalectomy. This case suggests that resection of adrenal metastasis from gastric cancer is an effective treatment option that may prolong survival in selected patients.     

Renal cell carcinoma with contralateral synchronous adrenal and lung metastasis: A rare case report

Renal cell carcinomas have propensity to metastasise to almost any organ. About 4.7–10.0% of these cases present with ipsilateral adrenal metastasis. The incidence of contralateral adrenal metastases are rare, they, however, can occur before, simultaneously or even after the primary neoplasm manifests clinically. Only a few synchronous and metachronous contra lateral adrenal metastases have been reported. We report a case of renal cell carcinoma with synchronous contralateral adrenal and lung metastasis.     

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.     

Isolated bilateral adrenal metastasis from renal cancer. Case report

The authors report an uncommon case of bilateral synchronous adrenal gland metastases from left renal cell carcinoma. The diagnosis was established by abdominal ultrasound and computed tomography. The surgical approach initially consisted of left radical nephrectomy and ipsilateral adrenalectomy. Histologically, the tumor of the left adrenal gland was identical to the left renal cell carcinoma. Subsequent contralateral adrenalectomy showed an adrenal metastasis identical to the left renal cell carcinoma. Patient follow-up was good with no recurrence of the disease after one year. This is an uncommon case for renal cancer. The treatment and prognosis are discussed.     

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.     

The need for routine adrenalectomy during surgical treatment for renal cell cancer: the Hannover experience

OBJECTIVES: To further clarify the need for routine adrenalectomy during the surgical treatment of renal cell cancer, as in the absence of clinically overt metastatic disease, tumorous lesions within the adrenal gland are found in only 2-10% of patients, with most being over-treated by adrenalectomy. PATIENTS AND METHODS: The medical records of 819 patients undergoing adrenalectomy combined with nephrectomy, irrespective of the local extension of the primary tumour or the clinical stage at first diagnosis, were reviewed to determine the reliability of currently available imaging methods in predicting adrenal gland metastases. Several patient and tumour characteristics were correlated with the presence of intra-adrenal metastases, and their possible independent prognostic value was determined by a multivariate logistic regression model. RESULTS: There was metastatic spread into the adrenal gland in 27 of 819 (3.3%) patients. In only three of eight patients in whom the adrenal was identified as the only metastatic site were preoperative abdominal computed tomography scans interpreted as false-negative. On multivariate statistical analysis only the presence of distant metastases, vascular invasion within the primary tumour and multifocal growth of renal cell cancer within the tumour-bearing kidney were identified as independent predictors of the presence of intra-adrenal metastases. CONCLUSIONS: None of the patient or tumour characteristics evaluated reliably predicted the likelihood of adrenal metastases in patients with no evidence of disseminated metastatic spread. However, previously published data indicate that the frequency of metachronous metastases within the contralateral kidney (1.8-3.8%) is significantly higher than the risk of a preoperatively undetected isolated intra-adrenal metastatic lesion when currently available imaging modalities are applied. Therefore, routine adrenalectomy should not be recommended if the preoperative radiological examinations are normal.     

多发性肾上腺醛固酮瘤诊治分析

目的探讨多发性肾上腺醛固酮瘤的诊治方法。方法回顾性分析了我院自1992年10月至2006年4月18例多发性肾上腺醛固酮瘤的临床资料和诊治方法。结果一侧肾上腺同时多发性醛固酮瘤4例,三维CT检查发现同侧肾上腺3枚肿瘤,行患侧肾上腺及肿瘤切除术,同时双侧肾上腺多发性醛固酮瘤6例,行双肾上腺肿瘤切除术,异时多发性肾上腺醛固酮瘤8例,包括一侧肾上腺醛固酮瘤行肿瘤切除术后患侧复发2例,行探查和残留肾上腺及肿瘤切除术;一侧肾上腺醛固酮瘤行患侧肾上腺及肿瘤切除术后对侧肾上腺醛固酮瘤6例,行肿瘤切除术。术后复查,未见肿瘤复发,肾上腺功能测定正常。结论单侧多发性肾上腺醛固酮瘤应行肾上腺及肿瘤切除术;双侧或异时性多发性肾上腺醛固酮瘤宜行肿瘤切除术,术中尽量保留正常肾上腺组织。三维CT的诊断价值较高,可以应用于临床肿瘤直径较小的同时多发性醛固酮瘤以及异时同侧多发的醛固酮瘤。     

Routine adrenalectomy in patients with locally advanced renal cell cancer does not offer oncologic benefit and places a significant portion of patients at risk for an asynchronous metastasis in a solitary adrenal gland

Background

The indications for the removal of the ipsilateral adrenal gland in patients with renal cell carcinoma (RCC) and the long-term outcomes have not been well studied.

Objective

We evaluated the risk of synchronous and asynchronous adrenal involvement in patients with RCC and the effect of adrenalectomy on recurrence and survival in a large, single-institution cohort.

Design, setting, and participants

From 1970 to 2006, 4018 consecutive patients with RCC treated by surgical extirpation (radical nephrectomy [RN]: 3107; partial nephrectomy [PN]: 911) from Mayo Clinic were studied for adrenal involvement. Risk of asynchronous adrenal metastasis and cancer-specific survival (CSS) were also compared between those who underwent concomitant ipsilateral adrenalectomy (n = 1541) and those who did not (n = 2477) using multivariate Cox models.

Intervention

Surgical removal of the adrenal gland at the time of kidney tumor resection.

Measurements

Primary outcome is cancer specific survival; secondary outcomes are incidence of synchronous and asynchronous adrenal metastases.

Results and limitations

Median postoperative follow-up among those still alive was 8.2 yr (interquartile range [IQR]: 5.3-13.6). Synchronous ipsilateral adrenal involvement was rare (n = 88; 2.2%). Ipsilateral adrenalectomy at the time of nephrectomy did not lower the risk of subsequent adrenal metastasis (hazard ratio [HR]: 0.96; 95% confidence interval [CI], 0.64-1.42) or improve CSS (HR: 1.08; 95% CI, 0.95-1.22). The development of asynchronous adrenal metastasis occurred in 147 patients (3.7%) at a median of 3.7 yr (IQR: 1.2-7.7) after initial surgery. The risk of developing an ipsilateral versus a contralateral asynchronous adrenal metastasis was equivalent at 10 yr in those who did not undergo adrenalectomy at initial surgery. This study is limited by its single-institution, nonrandomized nature.

Conclusions

Routine ipsilateral adrenalectomy in patients with high-risk features does not appear to offer any oncologic benefit while placing a significant portion of patients at risk for metastasis in a solitary adrenal gland. Therefore, adrenalectomy should only be performed with radiographic or intraoperative evidence of adrenal involvement.     

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.     

Solitary contralateral adrenal metastasis after nephrectomy for renal cell carcinoma

Malignant involvement of the contralateral adrenal gland in cases of renal cell carcinoma is extremely rare. Solitary metachronous metastatic involvement of the contralateral adrenal gland from renal cell carcinoma is rarely diagnosed during life. In fact, clinical signs and symptoms of adrenal insufficiency are rare in these patients. We report a case of renal cell carcinoma with solitary metachronous contralateral adrenal metastasis occurring 9 years after radical nephrectomy.     

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.