Laparoscopic Adrenalectomy for Solitary Metachronous Contralateral Adrenal Metastasis from Renal Cell Carcinoma

Purpose

We report our experience with laparoscopic adrenalectomy for malignant adrenal disease.

Materials and Methods

Between June 1995 and January 1996, 2 patients with a solitary metachronous contralateral adrenal metastasis from renal cell cancer were evaluated. Both patients had undergone radical nephrectomy for localized renal cancer 5 years previously. Laparoscopic transperitoneal adrenalectomy was performed.

Results

The laparoscopic procedures required 2.5 and 4.3 hours. Hospital stay was 3 and 4 days. The specimens weighed 98 and 81 gm. All surgical margins were free of metastatic clear cell cancer. Both patients were begun on prednisone and fludrocortisone replacement therapy. One patient experienced an increase in creatinine, which has since stabilized at 3.0 mg./dl. Neither patient had recurrent cancer at 11 and 16 months of followup.

Conclusions

Laparoscopic adrenalectomy for metastatic renal cell cancer was performed successfully in 2 patients. However, the short-term benefits to the patient of earlier ambulation, decreased pain, minimal incisions and shortened convalescence must be weighed against the as yet unknown long-term (5 years) results.     

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.     

Laparoscopic Partial Adrenalectomy for Bilateral Pheochromocytomas

Background  Patients with hereditary pheochromocytoma are at risk of the development of bilateral disease. Partial adrenalectomy can preserve adrenal function to avoid the morbidity associated with medical adrenal replacement. Here, we report a multimedia case study of synchronous bilateral partial adrenalectomy by the laparoscopic approach. Methods  A 13-year-old patient with von Hippel-Lindau disease was found to have high urinary metanephrines and normetanephrines. Computed tomography showed bilateral adrenal tumors (2.5 cm on the right side and 0.9 cm on the left). MIBG scan showed positive uptake in the right adrenal gland without extra-adrenal uptake. After adequate adrenergic blockade, the patient underwent laparoscopic partial adrenalectomy bilaterally. Results  The left side was approached first with the patient in the right decubitus position. Intraoperative ultrasound was performed to determine the line of tumor excision, which was carefully planned to preserve most of the normal-appearing gland. Both tumors were excised completely with good hemostasis. The main adrenal veins of both sides were precisely preserved. Operative time was 228 minutes. No clinically important hemodynamic fluctuations were noted. Pathologic examination confirmed bilateral entirely excised pheochromocytomas. The patient has not required exogenous corticosteroid replacement at follow-up. Conclusion  Laparoscopic partial adrenalectomy for bilateral pheochromocytomas is safe and technically feasible. It should be considered the treatment of choice for hereditary pheochromocytoma. Electronic supplementary material  to this article is available at .     

Liver Resection for Metastases from Renal Cell Carcinoma

Background This study was conducted to evaluate the safety and efficacy of liver resection in patients with hepatic metastases from renal cell carcinoma and to identify selection criteria for patients suitable for resection. Methods Between January 1988 and March 2006, 31 patients underwent liver resection for metastases from renal cell carcinoma. Patients were identified from a prospective database and retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on long-term survival. Results The overall 1-, 3- and 5-year survival rates were 82.2%, 54.3%, and 38.9%, respectively. One patient was deceased and 4 developed complications during the postoperative course. In the univariate analysis, site of the primary tumor (P = 0.013), disease-free interval (P = 0.012), and resection margins (P = 0.008) showed significant influence on long-term survival. In the multivariate analysis, only the resection margins were identified as an independent prognostic factor after liver resection. Conclusions Liver resection is effective and safe in the treatment of patients with hepatic metastases from renal cell carcinoma and offers the chance of long-term survival and cure. Achieving a margin-negative resection is the most important criterion in the selection of suitable patients for liver resection. However, the number of patients in the present study was small, and investigations of larger series may provide further prognostic parameters in these patients.     

Surgery for Metachronous Solitary Liver Metastases of Renal Cell Carcinoma

Purpose

The postoperative outcome and survival of patients undergoing surgery for metachronous solitary liver metastases of renal cell carcinoma were evaluated.

Materials and Methods

Between 1983 and 1993, 17 patients with metachronous liver metastases of renal cell carcinoma underwent laparotomy for metastatic liver disease. All patients had undergone radical nephrectomy a mean of 3.6 years before the diagnosis of liver metastases.

Results

Surgical resection was feasible in 13 of 17 patients with right hemihepatectomy in 9 (3 multivisceral resections), wedge resection in 4 and ex situ (mobilization and eversion out of the abdomen) resection in 1. Stage RO resection (complete removal, negative surgical margins with no macroscopic disease left behind) was possible in 11 of 13 cases (85%). In patients with metastatic liver tissue resection the mortality rate was 31% (4 of 13) with additional significant morbidity in another 2. Mean survival of patients with nonresectable disease was 4 months, which increased to 16 months after resection.

Conclusions

Complete resection of metachronous liver metastases can be achieved in the majority of patients. However, significant morbidity and mortality as well as the limited prognosis even after RO resection strongly suggest careful patient selection.     

Regression of Metastases after Nephrectomy for Renal Cell Carcinoma.

A case of an extensive renal cell carcinoma with temporary regression of pulmonary metastases is reported. The literature of similar reported cases is brefly reviewed.     

肾细胞癌患者同侧肾上腺侵润的风险因素

目的 在日本肾癌协会的协作下,回顾性分析了19家研究所治疗过的肾细胞癌患者,目的 是明确同侧肾上腺侵润(LADI)的危险因素.方法 30例IADI患者临床病理特征与926例无IADI的患者进行了对比研究,并且通过多变量分析证实了IADI的独立预测因素.结果 通过术前计算机断层扫描(CT),83 3%的同侧肾上腺转移可以被发现,与对照组相比,有IADI的患者明显有较大的原发性肿瘤灶,更高的PT分期和病理分级,和较高比例的肾上极浸润,微血管入侵,梭形细胞型肿瘤,淋巴结转移(LNM),和同侧肾上腺以外的远处转移(DM).临床因素的多元逻辑回归分析表明,肿瘤直径超过5.5厘米,临床病理分期为3期或更高,淋巴结转移,以及同侧肾上腺以外的远处转移(DM),但不包括侵及肾上腺上极,这些对于预测IADI,都有显著的意义.结论 肿瘤直径超过5.5厘米,临床病理分期3期或更高,淋巴结转移,以及同侧肾上腺以外的远处转移是术前诊断为同侧肾上腺侵润的重要指标.上述因素和术前CT是同侧肾上腺切除术的有效指标.肾细胞癌患者若CT结果显示肾上腺正常,肿瘤直径小于5.5cm,既没有淋巴结转移,也无远处转移则是保留肾上腺肾切除术的指征.     

The Management of Spinal Metastases from Renal Cell Carcinoma

INTRODUCTION

Osseous metastases occur in 50% of patients with renal cell carcinoma; of these, 15% occur in the spine. The treatment options for spinal metastases secondary to renal cell carcinoma are limited. This paper considers the current management options available for spinal metastases secondary to renal cell carcinoma.

PATIENTS AND METHODS

A review of four patients with spinal metastases secondary to renal cell carcinoma.

RESULTS

The presentation of four cases highlighting the current management options for spinal metastases secondary to renal cell carcinoma.

CONCLUSIONS

Historically, spinal metastases from renal cell carcinoma have been poorly managed; however, as the treatment of the primary disease improves, better treatment of the secondary disease is needed. Cement augmentation, used alone for prophylactic stabilisation or in conjunction with a posterior decompression and fixation, provides a useful addition in the management of these patients optimising their chance to remain ambulant, continent, and pain-free.     

Autologous Islet Transplantation After Total Pancreatectomy for Renal Cell Carcinoma Metastases

Pancreatic metastases from renal cell carcinoma (RCC) may have a chronic and highly indolent course, and may be resected for cure after considerable delay following treatment of the primary tumor, in contrast to other more common pancreatic tumors. Surgical resection is the treatment of choice, which may lead to postpancreatectomy diabetes mellitus in the case of extensive resection. We present a 70‐year‐old patient with multifocal pancreatic metastases from RCC causing obstructive jaundice. A total pancreatectomy was required to excise two distant tumors in the head and tail of the pancreas, together with a segment VI liver resection. An autologous islet transplant (AIT) prepared from the central, uninvolved pancreas was carried out to prevent postpancreatectomy diabetes. The patient was rendered insulin‐free and remains so with excellent glycemic control for 1 year of follow‐up, and there is no evidence of tumor recurrence. The patient has been treated with adjuvant sunitinib to minimize risk of further recurrence. In conclusion, AIT after pancreatectomy may represent a useful option to treat patients with metastatic RCC. A critical component of this approach was dependent upon elaborate additional testing to exclude contamination of the islet preparation by cancerous cells.     

Scrotal Skin Metastases of Renal Cell Carcinoma A Case Report

A 52-year old male, with a history of radical nephrectomy due to renal cell carcinoma ten years ago, presented with a lesion on the scrotum which was diagnosed as a metastasis of renal cell carcinoma.     

双侧异时性肾癌

病例摘要:患者男,78岁,因右肾肿瘤切除术后9月余,全程无痛性肉眼血尿半月入院,于2009年6月29日再次收入我院泌尿微创科.     

Retroperitoneal Laparoscopic Adrenalectomy for Functioning Adrenal Tumors: Comparison With Conventional Transperitoneal Laparoscopic Adrenalectomy

Purpose

We attempted to confirm the possibility and feasibility of laparoscopic adrenalectomy via the retroperitoneal approach, and to compare results of the transperitoneal and retroperitoneal approaches.

Materials and Methods

Three men and 8 women (mean age 39.6 years) with functioning adrenocortical tumors (primary aldosteronism in 5 and Cushing's syndrome in 6) underwent laparoscopic adrenalectomy via the retroperitoneal approach using a balloon dissection technique and a newly developed ultrasonic aspirator. Results were compared to those of 27 cases of transperitoneal laparoscopic adrenalectomy.

Results

Although the retroperitoneal approach was successful in all 5 patients with primary aldosteronism, it succeeded in only 2 of the 6 cases of Cushing's syndrome. In 3 Cushing's syndrome cases the retroperitoneal approach was changed to the transperitoneal laparoscopic approach due to difficulty in exploration. Open laparotomy was required in 1 case of left Cushing's syndrome because of an inadvertent pancreatic injury. Subcutaneous emphysema developed in 6 patients without hypercapnia or prolonged postoperative symptoms. Mean operative time and blood loss, and time to oral intake and ambulation were 248.3 minutes, 151.4 ml., and 1.55 and 2 days, respectively. There was no difference between retroperitoneal and conventional transperitoneal laparoscopic adrenalectomy in regard to these factors or to convalescence.

Conclusions

Retroperitoneal laparoscopic adrenalectomy is feasible for primary aldosteronism. However, Cushing's syndrome is presently a much more difficult indication than primary aldosteronism for this new operative technique.     

Ectopic Adrenal Tissue as Radiographic Lymphadenopathy in Renal Cell Carcinoma

In the presence of solid, contrast-enhancing renal mass, concomitant contrast-enhancing retroperitoneal mass is usually viewed as regional lymph node metastasis unless proven otherwise. The present report of ectopic adrenal tissue demonstrates that the presence of retroperitoneal contrast-enhancing mass may be a benign finding in patients with renal malignancy. Pathology remains the definitive method for diagnosis in such situation.     

Bilateral Chromophobe Cell Renal Carcinoma in Tuberous Sclerosis Comple

We report on a patient with tuberous sclerosis complex and polycystic kidney disease who developed bilateral chromophobe cell renal carcinoma. We discuss the tuberous sclerosis complex, associated bilateral renal cell carcinoma, polycystic kidney disease and chromophobe cell renal carcinoma; a recently established subtype with a rather favorable prognosis.
In a patient with tuberous sclerosis complex and multiple space-occupying lesions, a diagnosis of angiomyolipoma should be considered first but bilateral and/or multifocal renal cell carcinoma is a likely diagnosis.     

Aldosterone-Producing Adrenocortical Carcinoma Metastases Found Seven Years After Adrenalectomy

We report a case of metastatic adrenocortical carcinoma detected 7 years after adrenalectomy. A 52-year-old woman, who. had undergone adrenalectomy for an aldosterone-producing adrenocortical carcinoma at age 45, was found on examination by computerized tomography to have enlarged paraaortic lymph nodes. These nodes were surgically resected, and the histological diagnosis from the resected tissue was metastatic adrenocortical carcinoma. The patient has now survived for more than 9 years following the original adrenalectomy. Evidence suggests that this was a slow-growing tumor, because the primary tumor was sharply demarcated and the metastases were found 7 years after the original operation. We believe that aggressive surgical resection of metastatic lesions could lead to prolonged survival in patients with adrenocortical carcinomas of this type.