Laparoscopic adrenalectomy for metachronous metastasis from renal cell carcinoma

Bilateral adrenal metastases from renal cell carcinoma after robot-assisted partial nephrectomy

Renal cell carcinoma often metastasizes to the adrenals; however, bilateral adrenal metastases are rare. We here report a patient with bilateral adrenal metastases from renal cell carcinoma after robot-assisted partial nephrectomy and review relevant published reports. A 64-year-old man underwent robot-assisted partial nephrectomy for a left renal tumor. During follow-up, he was diagnosed with bilateral adrenal metastases. He underwent left adrenalectomy followed by right partial adrenalectomy to preserve adrenal function. The renal tumor later metastasized to other parts of the body. He continues to receive systemic treatment and remains in partial remission. Patients with pT1aN0M0 renal cell carcinoma generally have a favorable prognosis. However, occasional such patients develop multiple metastases. To the best of our knowledge, this is the first reported case of bilateral adrenal metastases after partial nephrectomy. Clinicians should keep this rare scenario in mind.

The role of laparoscopic resection of metastases to adrenal glands

BACKGROUND

The potential role of the laparoscopic approach for metastases to the adrenal gland is debated. We review here a series of patients consecutively submitted to laparoscopic adrenalectomy (LA) for suspected adrenal metastasis (AM).

METHODS

Retrospective study (consecutive series) of LA for AM. We measured parameters associated to primary tumor and metastasis. Statistical analysis: stepwise regression model.

RESULTS

Thirty-seven LA were performed on 36 patients. The mean age was 62.1 yrs. The side was right in 13 cases. Primary tumor was in the lung (n=22), breast (n=4), colon-rectum (n=4), kidney (n=3), thyroid, melanoma and ovary (n=1 each). Thirty-three out of 37 were confirmed to be AM (mean diameter 50 mm). Twenty-five were single metastasis. One LA was converted due to cava vein infiltration. Mean operative time was 142 min', median p.o. hospital stay was 3 days. After a mean follow-up of 33 months, 9 patients (25%) were alive free of disease, 6 (17%) were alive with disease. Mean post-adrenalectomy DFI was 19 months (range, 0-97 months), and it was the most predictive variable for survival (P<0.001).

CONCLUSIONS

The dimensions and absence of invasion on imaging, the evolutive status of the disease and the performance status of the patient are key factors for LA, which is associated with adequate oncologic results, a quicker postoperative recovery, and potential survival benefits.

Prognostic factors for recurrence-free and overall survival after adrenalectomy for metastatic carcinoma: a retrospective cohort pilot study

BACKGROUND

The survival benefits of adrenalectomy (ADx) in the setting of metastatic cancer and prognostic factors for recurrence-free (RFS) and overall survival (OS) after adrenalectomy for metastatic carcinoma are still under debate. We evaluated the impact of clinicopathological variables on RFS and OS after ADx for metastatic carcinoma in patients with primary cancer.

METHODS

A total of 32 patients undergoing ADx for metastatic cancer between 2004 and 2012 at two tertiary medical centers. Metastases were regarded as synchronous (<6 months) or metachronous (≥6 months) depending on the interval after primary surgery. Associations of perioperative clinicopathologic variables with RFS and OS were analyzed using Cox regression models.

RESULTS

In total, 32 patients received ADx for metastatic primary tumors located in the lung (n = 11), colon (n = 4), liver (n = 5), stomach (n = 3), kidney (n = 4), pancreas (n = 2), glottis, esophagus, cervix, and ovary (n = 1 each). The overall recurrence rate after adrenalectomy was 62.5% (n = 20). By univariate analysis, C-reactive protein, inflammation-based prognosis score, and adrenalectomy for curative intent were associated with RFS and OS. Independent prognostic factors for shorter RFS were operative method (laparoscopy HR 4.68, 95% CI 1.61-13.61, p = 0.005) and inflammation-based prognostic score (HR 11.8, 95% CI 2.50-55.7, p = 0.002). For shorter OS, synchronous metastasis (HR 3.05, 95% CI 1.07-11.94, p = 0.048) and inflammation-based prognostic score (HR 6.65, 95% CI 1.25-35.23, p = 0.026) were identified as independent prognostic factors.

CONCLUSIONS

Our pilot study suggests that synchronous disease and inflammation-based prognostic score are significant prognostic factors for survival and should be considered when performing ADx for metastatic diseases.

Adrenalectomy improves outcomes of selected patients with metastatic carcinoma

BACKGROUND

Indications and survival benefit for adrenalectomy (ADX) in the setting of metastasis are not clearly defined. We aimed to determine which patients with primary malignancies may benefit from ADX performed for metastasis. Mayo Clinic institutional outcomes in patients with metastatic disease to the adrenal(s) treated by adrenalectomy were compared to stage-matched historical controls from the Surveillance Epidemiology and End Results (SEER) database.

METHODS

A retrospective review (1992-2010) was conducted to identify patients treated with ADX for metastatic cancer at Mayo Clinic, Rochester. Associations of clinical, surgical, and pathologic features with overall survival (OS) were evaluated using Cox proportional regression models. OS for those treated with ADX was compared with that for SEER database stage-matched patients who underwent primary resection without resection of distant disease using log-rank tests.

RESULTS

A total of 166 patients underwent ADX for metastatic primaries involving the kidney 60, lung 24, sarcoma 19, colon 15, pancreas 13, and other-35. Patients with sarcoma and kidney, lung, and pancreatic tumors who underwent ADX had better OS at 1, 2, and 3 years than did the SEER-matched controls. Respectively, the rates were for sarcoma (100, 93, 86% vs. 57, 36, 30%), kidney (86, 80, 72% vs. 55, 37, 27%), lung (91, 69, 52% vs. 52, 34, 25%), and pancreas (79, 56, 45% vs. 33, 20, 12%). Univariate analysis identified primary diagnosis <2 years before ADX, other distant site, pancreatic primary, palliative operation, and persistent disease as risk factors for death.

CONCLUSIONS

An aggressive surgical approach results in improved OS in patients with metastatic disease arising from soft tissues, kidney, lung, and pancreas. Other tumors may benefit, but larger study cohorts are needed for a meaningful comparison.

Metachronous metastasis to the spermatic cord from renal cell carcinoma presenting as a high scrotal mass: a case report

Primary malignant lesions and metastatic carcinomas of the spermatic cord are extremely rare. We present the case of a 57-year-old man, who presented with a painless palpable mass in the left high scrotal area 36 months after radical nephrectomy. The patient had received chemotherapy because of disseminated metastases. There was no sign of local recurrence after 3-month follow-up.

Metachronous contralateral testicular and bilateral adrenal metastasis of chromophobe renal cell carcinoma: a case report and review of the literature

Chromophobe renal cell carcinoma (ChRCC) metastatic to the testis has not, to the best of our knowledge, been reported in the literature. Nor have there been reports of delayed bilateral adrenal metastasis of ChRCC. Here we report a case of metachronous contralateral testicular and bilateral adrenal metastasis of ChRCC in a 70-year-old man who underwent right radical nephrectomy for RCC six years ago. He was admitted to the hospital because of left intrascrotal enlargement of two-month duration. Ultrasonography revealed a mass in the upper pole of the left testis. Computed tomography (CT) showed irregular masses in the bilateral adrenal area. Left radical orchiectomy and laparoscopic bilateral adrenalectomy were performed. The pathologic examination showed metastatic ChRCC in the left testis and bilateral adrenal gland. Postoperative follow-up showed that the patient had survived for at least 56 months without recurrence. The case highlights the unique behavior of RCC with an unusual site of metastasis and favorable survival after multiple metastasectomy.

[Laparoscopic adrenalectomy for metachronous metastasis. Experience in 12 cases]

OBJECTIVE

To assess the peroperative and oncological results of laparoscopic adrenalectomy for an isolated metastasis.

MATERIAL AND METHODS

A retrospective, descriptive study was conducted of 12 laparoscopic adrenalectomies performed for metastases out of a total of 40 adrenalectomies performed from May 1998 to April 2009. The primary tumor was pulmonary in 7 patients, renal in 3, and colonic in 2. Demographic data collected included median age, operating time, blood loss, complications, tumor size, and length of hospital stay. The Kaplan-Meier method was used to analyze survival.

RESULTS

Operating time was 150 min (range, 90-206). Peroperative bleeding was 60 ml (range, 15-150). Peroperative complications occurred in 3% of patients. Tumor size was 4.5 cm (range, 1.3-8.5). No positive margins were seen in the resected specimens. Hospital stay was 3 days (range 3-5). Actuarial survival was 55.6% at 23 months (range, 2-38) with mean and median follow-up times of 20.9 and 23 months.

CONCLUSIONS

In selected patients, laparoscopic adrenalectomy for metastasis is a safe procedure with oncological results superimposable to those of open surgery.

Should we use laparoscopic adrenalectomy for metastases? Scandinavian multicenter study

INTRODUCTION

Laparoscopic adrenalectomy for metastases is considered controversial. Multicenter retrospective study was performed to gain new knowledge in this issue.

MATERIALS AND METHODS

From January 1997 till November 2008, 41 adrenalectomies were performed during follow-up of the patients operated for malignant tumors. The median age was 64 (52-77) years. Metastases were confirmed in 31/41 cases. Metastatic lesions were further studied and to define factors influencing on survival, patients were divided to sub-groups of metachronous/synchronous, tumor origin and tumor size.

RESULTS

The median operative time was 104 (50-230) min, the median blood loss was 100 (0-500) ml. One procedure (3.2%) was converted. There were 3 (10.7%) intraoperative and 2 (7.4%) postoperative complications. The median tumor size was 6 (1.5-16) cm. Pathohistological analysis revealed 12 colorectal, 9 renal cell carcinoma, 5 lung carcinoma, 4 melanoma, and 1 hepatocellular metastases. The resection margin was not free in one case (3.7%). The median hospital stay was 2 (1-21) days. The median length of survival was 29 +/- 2.1 months for all patients.

CONCLUSION

Laparoscopic adrenalectomy for metastases is feasible regardless of their sizes. However these procedures should be performed by highly skilled laparoscopic surgeon in a fully equipped operating room and with a coordinated operation team.

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.