Adrenal metastectomy is safe in selected patients

Perioperative Outcomes After Adrenalectomy for Secondary Adrenal Malignancy

INTRODUCTION

The risk of adverse outcomes after adrenal metastasectomy is not well defined. Knowledge of these risks is essential to guide patient counseling.

METHODS

The 2015-2020 National Surgical Quality Improvement Program datasets were combined. Patients who underwent adrenalectomy for secondary adrenal malignancy (SM) and benign nonfunctional (BNF) adrenal neoplasms were identified; BNF neoplasms were chosen as a comparison as functional neoplasms can contribute to comorbidity. Patients who had additional surgery at the time of adrenalectomy were excluded. Patient demographics, comorbidities, perioperative factors, and outcomes were compared between groups. Multivariable logistic regression analysis was performed.

RESULTS

Of 3496 adrenalectomy patients, 332 had SM and 3164 had BNF neoplasms. Patients with SM were older (65 versus 54 y) and more often had chronic obstructive pulmonary disease (7.5% versus 4.4%), chronic steroid use (10.5% versus 3.8%), and bleeding disorders (4.5% versus 2.2%) than patients with BNF, respectively (P < 0.01 for all). Laparoscopic adrenalectomy was the most common operative approach for both groups (74.7% versus 88.3%). Rates of mortality, morbidity, reoperation, readmission, and nonhome discharge did not differ significantly between groups. Patients with SM had higher rates of postoperative bleeding than patients with BNF (6.3% versus 2.6%, P < 0.001). This persisted on multivariable regression analysis that adjusted for demographics, comorbidities, and operative approach (odds ratio 2.34, 95% confidence interval 1.19-4.64).

CONCLUSIONS

Adrenalectomy for SM is associated with an increased risk of postoperative bleeding compared to adrenalectomy for BNF adrenal neoplasms. Patients with SM that meet criteria for adrenal metastasectomy should be counseled appropriately.

Surgery for adrenal metastasis: Surgical outcomes and prognostic factors for long-term survival

PURPOSE

To analyze surgical outcomes and predictive factors for long-term overall and disease-specific survival in patients undergoing surgical resection of adrenal metastasis.

METHODS

A multicenter retrospective study included patients who underwent adrenalectomy for adrenal metastasis in two Spanish hospitals between 2005 and 2021. Clinical variables associated with surgical complications and survival during follow-up were analyzed.

RESULTS

Thirty-three patients were included. Adrenalectomy was performed laparoscopically in 27 patients and by an open approach in 6. The most common primary tumor site was the lung (n=15), followed by the kidney (n=7). Most patients had metachronous lesions (n=28). Six patients (18.2%) had intra- and/or postoperative complications; synchronous metastasis was a risk factor (odds ratio 12.5 [1.45-107.6]) for their development. Progression-free survival and disease-specific survival were 7.5months (range 1-64) and 22.5months (6-120), respectively. Survival rates at 1, 2, 3 and 5years were 94%, 65%, 48% and 29%, respectively. Survival was significantly lower in patients with lung cancer than with other cancers (hazard ratio 4.23 [1.42-12.59]).

CONCLUSIONS

Adrenalectomy for solitary adrenal metastases was associated with intra- or postoperative complications in 18% of cases. Synchronous metastasis was a risk factor for complications.

Adrenalectomy for Metastasis: The Impact of Primary Histology on Survival Outcome

Adrenalectomy is commonly considered a curative treatment in case of adrenal gland as site of metastasis. In the present study, we evaluated the impact of primary tumor histology on survival outcomes after a minimally invasive adrenal mastectomy for a solitary metachronous metastasis. From May 2004 to August 2020, we prospectively collected data on minimally invasive adrenalectomies whose pathological examination showed a metastasis. All patients only received metastasectomies that were performed with curative intent, or to achieve non-evidence of disease status. Adjuvant systemic therapy was not administered in any case. Cancer-specific survival (CSS) was assessed using the Kaplan-Meier method. Univariable and multivariable Cox regression analyses were applied to identify independent predictors of CSS. Out of 235 laparoscopic and robotic adrenalectomies, the pathologic report showed metastases in 60 cases. The primary histologies included 36 (60%) renal cell carcinoma (RCC), 9 (15%) lung cancer, 6 (10%) colon cancer, 4 (6.7%) sarcoma, 3 (5%) melanoma and 2 (3.3%) bladder cancer. RCC displayed significantly longer survival rates with a 5-year CSS of 55.9%, versus 22.8% for other histologies (log-rank p = 0.01). At univariable analysis, disease-free interval (defined as the time from adrenalectomy to evidence of disease progression) < 12 months and histology were predictors of CSS (p = 0.003 and p < 0.001, respectively). At multivariable Cox analysis, the only independent predictor of CSS was primary tumor histology (p = 0.005); patients with adrenal metastasis from colon cancer and bladder cancer showed a 5.3- and 75.5-fold increased risk of cancer death, respectively, compared to patients who had RCC as primary tumor histology. Oncological outcomes of adrenal metastasectomies are strongly influenced by primary tumor histology. A proper discussion of the role of surgery in a multidisciplinary context could provide optimal treatment strategies.

Adrenal Metastasectomy in the Era of Immuno- and Targeted Therapy

Adrenal metastasectomy has an increasing role in multimodality oncologic care for diverse primary cancer types. In this review, we discuss the epidemiology, evaluation, and contemporary best practices in the management of adrenal metastases from various primaries. Initial evaluation of suspected adrenal metastases should include diagnostic imaging to assess the extent of tumor involvement and determine surgical resectability, as well as biochemical evaluation for hormone secretion. Biopsy has a minimal role and should only be performed in tumors that are established to be non-hormone secreting and when the biopsy results would change clinical management. Adrenal metastasectomy is associated with survival benefit in selected patients. We suggest that adrenal metastasectomy has the greatest benefit in four clinical scenarios: (1) disease limited to the adrenal gland in which adrenalectomy renders the patient disease-free; (2) isolated progression in the adrenal gland in the setting of otherwise controlled metastatic extra-adrenal disease; (3) need for palliation of symptoms related to adrenal metastases; or (4) in the context of tissue-based clinical trials. Both minimally invasive and open adrenalectomy techniques are safe and appear to have equivalent oncologic outcomes. Minimally invasive approaches are favored when technically feasible while maintaining oncologic principles. A multidisciplinary evaluation including clinicians with expertise in the primary cancer type is essential to the successful management of adrenal metastases.

Laparoscopic adrenalectomy for adrenal metastases of solid tumors

INTRODUCTION

In patients with history of cancer adrenal metastases can be found in up to 70% of adrenal tumors detected during follow-up. Currently, laparoscopic adrenalectomy (LA) is considered the gold standard approach for benign adrenal tumors but is still controversial in malignant disease. Depending on the patient's oncological status, adrenalectomy might be a possible treatment option. Our objective was to analyze the results of LA for adrenal metastasis from solid tumors in two referral centers.

METHODS

Retrospective analysis of 17 patients with non-primary adrenal malignancy treated with LA between 2007 and 2019 was performed. Demographic and primary tumor data, type of metastasis, morbidity, disease recurrence and evolution were evaluated. Patients were compared according to type of metastases: synchronous (< 6 months) vs metachronous (≥ 6 months).

RESULTS

17 patients were included. Median metastatic adrenal tumor size was 4 cm (IQR, 3-5.4). We had one conversion to open surgery. Recurrence was found in 6 patients with one recurring in the adrenal bed. The median OS was 24 (IQR, 10.5-60.5) months and 5-year OS was 61.4% (95%CI: 36.7%-81.4%). Patients with metachronous metastases had better overall survival vs. patients with synchronous metastases (87% vs. 14%, p = 0.0037).

CONCLUSION

LA for adrenal metastases is a procedure associated with low morbidity and acceptable oncologic outcomes. Based on our results, seems reasonable to offer this procedure to carefully selected patients, mainly those with metachronous presentation. Indication of LA must be done on a case by case evaluation in the context of a multidisciplinary tumor board.

Advances in Endocrine Surgery

Recent changes in the landscape of endocrine surgery include a shift from total thyroidectomy for almost all patients with papillary thyroid cancer to the incorporation of thyroid lobectomy for well-selected patients with low-risk disease; minimally invasive parathyroidectomy with, and potentially without, intraoperative parathyroid hormone monitoring for patients with well-localized primary hyperparathyroidism; improvement in the management of parathyroid cancer with the incorporation of immune checkpoint blockade and/or targeted therapies; and the incorporation of minimally invasive techniques in the management of patients with benign tumors and selected secondary malignancies of the adrenal gland.

Unexpected deaths after endocrine surgery: learning from rare events using a national audit of surgical mortality

BACKGROUND

The mortality rate is low in endocrine surgery, making it a difficult outcome to use for quality improvement in individual units. Lessons from population data sets are of value in improving outcomes. Data from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) were used here to understand and elucidate potential systems issues that may contribute to preventable deaths.

METHODS

ANZASM data relating to 30-day mortality after thyroidectomy, parathyroidectomy, and adrenalectomy from 2009 to 2020 were reviewed. Mortality rates were calculated using billing data. Thematic analysis of independent assessor reports was conducted to produce a coding framework.

RESULTS

A total of 67 deaths were reported, with an estimated mortality rate of 0.03-0.07 per cent (38 for thyroidectomy (0.03-0.06 per cent), 16 for parathyroidectomy (0.03-0.06 per cent), 13 for adrenalectomy (0.15-0.33 per cent)). Twenty-seven deaths (40 per cent) were precipitated by clinically significant adverse events, and 18 (27 per cent) were judged to be preventable by independent ANZASM assessors. Recurrent themes included inadequate preoperative assessment, lack of anticipation of intraoperative pitfalls, and failure to recognize and effectively address postoperative complications. Several novel themes were reiterated, such as occult ischaemic heart disease associated with death after parathyroid surgery, unexpected intraoperative difficulties from adrenal metastasis, and complications due to anticoagulation therapy after thyroid surgery.

CONCLUSION

This study represents a large-scale national report of deaths after endocrine surgery and provides insights into these rare events. Although the overall mortality rate is low, 27 per cent of deaths involved systems issues that were preventable following independent peer review.

Survival After Adrenalectomy for Metastatic Lung Cancer

BACKGROUND

Adrenal metastasectomy is associated with increased survival in non-small cell lung cancer (NSCLC) with isolated adrenal metastases. Although clinical use of adrenal metastasectomy has expanded, indications remain poorly defined. The aim of this study was to evaluate the clinical benefit of adrenal metastasectomy for all lung cancer subtypes.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients who underwent adrenal metastasectomy for metastatic lung cancer at six institutions between 2001 and 2015. The primary outcomes were disease-free survival (DFS) and overall survival (OS). Cox proportional hazards regressions and Kaplan-Meier survival analysis were performed.

RESULTS

For 122 patients, the mean age was 60.5 years and 49.2% were female. Median time to detection of the metastasis was 11 months, and 41.8% were ipsilateral to the primary lung cancer. Median DFS was 40 months (1 year: 64.8%; 5 year: 42.9%). Factors associated with longer DFS included primary tumor resection [hazard ratio (HR): 0.001; p = 0.005], longer time to adrenal metastasis (HR: 0.94; p = 0.005), and ipsilateral metastases (HR: 0.13; p = 0.004). Shorter DFS corresponded with older age (HR: 1.11; p = 0.01), R1 resection (HR: 8.94; p = 0.01), adjuvant radiation (HR: 9.45; p = 0.02), and open adrenal metastasectomy (HR: 10.0; p = 0.03). Median OS was 47 months (1 year: 80.2%; 5 year: 35.2%). Longer OS was associated with ipsilateral metastasis (HR: 0.55; p = 0.02) and adjuvant chemotherapy (HR: 0.35; p = 0.02). Shorter OS was associated with extra-adrenal metastases at adrenalectomy (HR: 3.52; p = 0.007), small cell histology (HR: 15.0; p = 0.04), and lung radiation (HR: 3.37; p = 0.002).

DISCUSSION

Durable survival was observed in patients undergoing adrenal metastasectomy and should be considered for isolated adrenal metastases of NSCLC. Small cell histology and extra-adrenal metastases are relative contraindications to adrenal metastasectomy.

Outcomes after Surgical Treatment of Metastatic Disease in the Adrenal Gland; Valuable for the Patient?

Simple Summary

Adrenal glands are common dissemination sites for metastases of various solid tumors. The rapid development of new treatment strategies, such as targeted therapy and immunotherapy for different cancer types, has led to increased metastatic adrenalectomies. Therefore, clear communication between oncologists and adrenal gland specialists has become increasingly important to outweigh surgical risks versus oncological advantages of adrenalectomies in these patients. This study assesses trends in diagnosis, type of surgery, and short-term and long-term surgical outcomes of patients who underwent metastatic adrenalectomy. We included a total of 95 patients with an adrenal metastasis of non-adrenal primary tumors, most often colorectal or lung cancer, who underwent (minimal invasive) adrenalectomy. 37.9% of the patients experienced one or more complications after adrenalectomy. Within our patient cohort, an increased demand for metastatic adrenalectomy was observed over the past years, which might be associated with the rise of targeted- and immunotherapy. Our data aims to assist multidisciplinary teams with weighing the pros and cons of resection of the metastasized adrenal gland of cancer patients.

Abstract

The adrenal glands are common dissemination sites for metastasis of various solid tumors. Surgical treatment is often recommended because targeted therapies and immunotherapy are frequently ineffective for adrenal metastasis. We report the experience with short-term and long-term surgical outcomes of patients undergoing surgery for adrenal metastasis in two hospitals. A retrospective, multicenter study was performed to analyze patient characteristics, tumor-related data, perioperative outcomes, and oncological outcomes. Postoperative complications that occurred within 30 days were scored according to the Clavien Dindo classification. Metastatic adrenalectomy was performed in 95 patients. We observed an increase from an average of 3 metastatic adrenalectomies per year between 2001–2005 to 10 between 2015–2019. The most frequent underlying malignancies were colorectal and lung cancer. In 55.8%, minimal invasive adrenalectomy was performed, including six conversions to open surgery. A total of 37.9% of patients had postoperative complications, of which ileus or gastroparesis, wound problems, pneumonia, and heart arrhythmias were the most occurring complications. Improved cancer care has led to an increased demand for metastatic adrenalectomy over the past years. Complication rates of 37.9% are significant and cannot be neglected. Therefore, multidisciplinary teams should weigh the decision to perform metastatic adrenalectomy for each patient individually, taking into account the drawbacks of the described morbidity versus the potential benefits.

Adrenalectomy for Secondary Malignancy: Patients, Outcomes, and Indications

OBJECTIVE

The goal of this study was to examine a multi-institutional experience with adrenal metastases to describe survival outcomes and identify subpopulations who benefit from adrenal metastasectomy.

BACKGROUND

Adrenalectomy for metastatic disease is well-described, although indications and outcomes are incompletely defined.

METHODS

A retrospective cohort study was performed of patients undergoing adrenalectomy for secondary malignancy (2002-2015) at 6 institutions. The primary outcomes were disease free survival (DFS) and overall survival (OS). Analysis methods included Kaplan-Meier and Cox proportional hazards.

RESULTS

Of 269 patients, mean age was 60.1 years; 50% were male. The most common primary malignancies were lung (n = 125, 47%), renal cell (n = 38, 14%), melanoma (n = 33, 12%), sarcoma (n = 18, 7%), and colorectal (n = 12, 5%). The median time to detection of adrenal metastasis after initial diagnosis of the primary tumor was 17 months (interquartile range: 6-41). Post-adrenalectomy, the median DFS was 18 months (1-year DFS: 54%, 5-year DFS: 31%). On multivariable analysis, lung primary was associated with longer DFS [hazard ratio (HR): 0.49, P = 0.008). Extra-adrenal oligometastatic disease at initial presentation (HR: 1.84, P = 0.016), larger tumor size (HR: 1.07, P = 0.013), chemotherapy as treatment of the primary tumor (HR: 2.07 P = 0.027) and adjuvant chemotherapy (HR: 1.95, P = 0.009) were associated with shorter DFS. Median OS was 53 months (1-year OS: 83%, 5-year OS: 43%). On multivariable analysis, extra-adrenal oligometastatic disease at adrenalectomy (HR: 1.74, P = 0.031), and incomplete resection of adrenal metastasis (R1 margins; HR: 1.62, P = 0.034; R2 margins; HR: 5.45, P = 0.002) were associated with shorter OS.

CONCLUSIONS

Durable survival is observed in patients undergoing adrenal metastasectomy and should be considered for subjects with isolated adrenal metastases.

Phase II trial of stereotactic body radiation therapy on adrenal gland metastases: evaluation of efficacy and impact on hormonal production

PURPOSE

The purpose of this study was to assess prospectively the efficacy and safety of stereotactic body radiation therapy (SBRT) for adrenal gland metastasis, with a focus on the assessment of the irradiated subjects' endocrinological function.

MATERIALS AND METHODS

A total of 36 patients were enrolled from 2017 to 2020 in this prospective phase II trial. Patients were treated with Linac-based SBRT, with a dose of 45 Gy in 3 consecutive fractions. Primary end-point was local control (LC) of the treated lesions and secondary end-points included evaluation of acute and late toxicity, progression free survival (PFS), overall survival (OS) and the impact on the hormonal production of adrenal glands.

RESULTS

With a median follow-up of 9.5 months, LC rates at 1 and 2 years were 94.7% and 88.4%, respectively. Rates of PFS at 1 and 2 years were 50.5% and 29.8%, with a median PFS of 14.7 months. Rates of OS at 1 and 2 years were 62.9% and 44.1%. At univariate analysis, oligorecurrence was associated with better OS compared to oligoprogressive or synchronous metastatic disease. No grade 3 or greater toxicities were registered and only a minority of patients (22.2%) reported mild treatment-related side effects. Hormonal and electrolytes production was assessed before and after treatment, showing only a slight and transient variation within the reference ranges.

CONCLUSION

SBRT on adrenal metastases has been confirmed to be a feasible and effective treatment. With an excellent disease control and the preservation of the endocrine function, SBRT with ablative dose can be considered a viable alternative to more invasive approaches.

[Surgery of adrenal diseases]

Incidentally discovered adrenal alterations should be separated into those without any clinical importance and adrenal diseases that have to be surgically or conservatively treated. Before operative treatment, in addition to the possible different functional activity of tumors, a differentiation must be made between sporadically arising singular or multiple adrenal tumors or nodular adrenal hyperplasia, adrenal tumors as part of a familial syndrome and metastases of other primary malignant tumors into the adrenal glands. Benign hormonally active adrenal tumors as well as questionable malignant tumors of the adrenal cortex are resected by minimally invasive techniques. For large malignant tumors infiltrating into surrounding tissues and tumors with proven lymph node metastases, the primarily open approach is indicated. Patients with adrenal diseases should always undergo an interdisciplinary assessment and in cases with clear indications for surgery, sometimes transferred to a center with experience in surgery and postoperative management of these patients.

Prognostic factors after adrenalectomy for adrenal metastasis

PURPOSE

Very few studies have sought prognostic factors after adrenalectomy for metastasis. The aim of this study was to assess prognostic factors for oncological outcomes after adrenalectomy for adrenal metastasis.

METHODS

All adrenalectomies for metastases performed in seven centers between 2006 and 2016 were included in a retrospective study. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Prognostic factors for CSS and RFS were sought by Cox regression analyses.

RESULTS

106 patients were included. The primary tumors were mostly renal (47.7%) and pulmonary (32.3%). RFS and CSS estimated rates at 5 years were 20.7% and 63.7%, respectively. In univariate analysis, tumor size (HR 3.83; p = 0.04) and the metastasis timing (synchronous vs. metachronous; HR 0.47; p = 0.02) were associated with RFS. In multivariate analysis, tumor size (HR 8.28; p = 0.01) and metastasis timing (HR 18.60; p = 0.002) were significant factors for RFS. In univariate analysis, the renal origin of the primary tumor (HR 0.1; p < 0.001) and the disease-free interval (DFI; HR 0.12; p = 0.02) were associated with better CSS, positive surgical margins with poorer CSS (HR 3.4; p = 0.01). In multivariate analysis, the renal origin of the primary tumor vs. pulmonary (HR 0.13; p = 0.03) and vs. other origins (HR 0.10; p = 00.4) and the DFI (HR 0.01; p = 0.009) were prognostic factors for CSS.

CONCLUSION

In this study, tumor size and synchronous occurrence of the adrenal metastasis were associated with poorer RFS. Renal origin of the primary tumor and longer DFI were associated with better CSS. These prognostic factors might help for treatment decision in the management of adrenal metastasis.

Adrenal metastases - long-term results of surgical treatment, single-centre experience

Introduction

The adrenal gland is a frequent site of metastases in different types of cancer. The aim of this study was to assess the results of metastatic adrenalectomy in a single institution and to identify factors for survival.

Material and methods

A retrospective, single-centre analysis of outcomes of 39 patients (22 male, 17 female) with adrenal metastases who underwent surgery within 14 years (2004–2017) was performed. The median age at the time of adrenal surgery was 64.8 years (range 49–79 years).

Results

In our study group non-small cell lung cancer (NSCLC) was the most frequent primary tumour type (15 pts), followed by renal cell carcinoma (RCC) (14 pts) and colon cancer (6 pts). Most of the metastases – 36 (92%) – were metachronous (> 6 months). All synchronous metastases were NSCLC. The mean time from primary cancer to adrenalectomy was 42.3 months (range 1–176) and was statistically longer for RCC. In 3 patients (8%) metastases were bilateral and both adrenal glands were removed. In all patients, surgery was limited to the adrenal gland, and no major complications of surgery were observed. The median overall survival after metastasectomy was 18 months (3–81) and was statistically longer for colon cancer – 29.5 months (p = 0.012). In patients who died, tumours were significantly bigger than in survivors, 76.5 mm vs. 52.5 mm (p = 0.026).

Conclusions

Surgery for adrenal metastasis is safe and indications for this procedure should be individualized. In selected patients, surgical removal of adrenal metastasis was associated with longer survival.

Feasibility of laparoscopic adrenalectomy for metastatic adrenal tumors in selected patients: a retrospective multicenter study of Japanese populations

BACKGROUND

Because of the small numbers of cases in single centers, the indications for and survival benefits of adrenalectomy for adrenal metastasis remain unclear. We evaluated the outcomes of laparoscopic adrenalectomy for patients with adrenal metastasis.

METHODS

We retrospectively analyzed the records of 67 patients who underwent laparoscopic adrenalectomy for metastatic disease from 2003 to 2017 at 11 hospitals. Associations of clinical, surgical, and pathologic features with overall survival (OS) and positive surgical margins were evaluated using univariate and multivariate Cox regression analyses and univariate logistic regression analysis.

RESULTS

Lung cancer (30%) and renal cell carcinoma (30%) were the most common primary tumor types. Intraoperative complications were observed in seven patients (10%) and postoperative complications in seven (10%). The surgical margin was positive in 10 patients (15%). The median OS was 3.8 years. Univariate analysis showed that the tumor size, episodes of extra-adrenal metastasis before adrenalectomy, extra-adrenal metastasis at the time of adrenalectomy, and positive surgical margins were significantly associated with shorter OS (p = 0.022, p = 0.005, p < 0.001, and p = 0.022, respectively). Multivariate analysis showed that extra-adrenal metastasis at the time of adrenalectomy and positive surgical margins remained statistically significant (p = 0.022 and p = 0.049, respectively). In the univariate analysis, the tumor size was significantly associated with positive surgical margins (p = 0.039).

CONCLUSIONS

Laparoscopic adrenalectomy for adrenal metastasis can be safely performed in selected patients, and patients with isolated adrenal metastasis and negative surgical margins seem to have more favorable outcomes.

Outcomes of surgery for benign and malignant adrenal disease from the British Association of Endocrine and Thyroid Surgeons' national registry

BACKGROUND

This study investigated the indications, procedures and outcomes for adrenal surgery from the UK Registry of Endocrine and Thyroid Surgery database from 2005 to 2017, and compared outcomes between benign and malignant disease.

METHODS

Data on adrenalectomies were extracted from a national surgeon-reported registry. Preoperative diagnosis, surgical technique, length of hospital stay, morbidity and in-hospital mortality were examined.

RESULTS

Some 3994 adrenalectomies were registered among patients with a median age of 54 (i.q.r. 43-65) years (55·9 per cent female). Surgery was performed for benign disease in 81·5 per cent. Tumour size was significantly greater in malignant disease: 60 (i.q.r. 34-100) versus 40 (24-55) mm (P < 0·001). A minimally invasive approach was employed in 90·2 per cent of operations for benign disease and 48·2 per cent for cancer (P < 0·001). The conversion rate was 3·5-fold higher in malignant disease (17·3 versus 4·7 per cent; P < 0·001). The length of hospital stay was 3 (i.q.r. 2-5) days for benign disease and 5 (3-8) days for malignant disease (P < 0·050). In multivariable analysis, risk factors for morbidity were malignant disease (odds ratio (OR) 1·69, 1·22 to 2·36; P = 0·002), tumour size larger than 60 mm (OR 1·43, 1·04 to 1·98; P = 0·028) and conversion to open surgery (OR 3·48, 2·16 to 5·61; P < 0·001). The in-hospital mortality rate was below 0·5 per cent overall, but significantly higher in the setting of malignant disease (1·2 versus 0·2 per cent; P < 0·001). Malignant disease (OR 4·88, 1·17 to 20·34; P = 0·029) and tumour size (OR 7·47, 1·52 to 39·61; P = 0·014) were independently associated with mortality in multivariable analysis.

CONCLUSION

Adrenalectomy is a safe procedure but the higher incidence of open surgery for malignant disease appears to influence postoperative outcomes.

Minimally Invasive Surgery for Primary and Metastatic Adrenal Malignancy

Since the first description of laparoscopic adrenalectomy (LA) for pheochromocytoma and Cushing syndrome in 1992, the utilization of and indications for a minimally invasive approach to the adrenal gland have vastly expanded. Although minimally invasive adrenalectomy has been established as the preferred approach for patients with benign tumors of the adrenal gland, minimally invasive adrenalectomy for cancer remains controversial. In this article, the authors review the indications for minimally invasive adrenalectomy for adrenal nodules suspicious for, or established to represent, a primary malignancy or a site of metastatic cancer.

Laparoscopic adrenalectomy for metastatic disease: Retrospective cohort with long-term, comprehensive follow-up

BACKGROUND

Several malignancies metastasize to the adrenal gland, especially non-small cell lung cancer, renal cell carcinoma, and melanoma. Adrenalectomy is associated with prolonged survival, but laparoscopic adrenalectomy for this indication is controversial. Our objective was to characterize and quantify outcomes after laparoscopic adrenalectomy for metastases to the adrenal gland.

METHODS

A prospectively maintained surgical database and institutional cancer registry were queried for patients who underwent adrenalectomy for metastases. From 1995 to 2016, a total of 62 patients underwent adrenalectomy for metastases, with 59 (95.%) having been performed laparoscopically. Primary end points were cumulative probability of 5-year survival and median survival. Patients in the institutional series were compared with Surveillance, Epidemiology, and End Results patients with metastatic non-small cell lung cancer, renal cell carcinoma, and melanoma.

RESULTS

There were no deaths within a 30-day period, 6 complications, and 2 conversions to open adrenalectomy. Non-small cell lung cancer (N = 20), renal cell carcinoma (N = 14), and melanoma (N = 8) were the 3 most common adrenal metastases. Overall, cumulative probability of 5-year survival was 37% and median survival was 34 months (95% CI 26-53 months). Median survival for non-small cell lung cancer was 26 months, for renal cell carcinoma was 67 months, and for melanoma was 30 months (P = NS). There was no demonstrable survival benefit for metachronous versus synchronous presentations, no association with size or disease-free interval, nor the presence/history of other metastases.

CONCLUSION

Laparoscopic adrenalectomy for metastases is safe when performed by experienced surgeons. Outcomes are similar or improved compared with series with predominantly open adrenalectomies. Patients selected for laparoscopic adrenalectomy to treat metastatic disease also have prolonged survival compared with Surveillance, Epidemiology, and End Results patients with metastatic non-small cell lung cancer, renal cell carcinoma, or melanoma who do not undergo resection of metastatic disease.

The outcomes of adrenalectomy for solitary adrenal metastasis: A 17-year single-center experience

AIM

We aimed to analyze surgical outcomes of open or laparoscopic adrenalectomy for solitary adrenal metastasis and assess the factors influencing survival.

METHODS

We retrospectively reviewed our institutional clinicopathological database for cases of adrenalectomy for solitary adrenal metastasis from solid tumors between 2000 and 2017.

RESULTS

Twenty-five patients underwent open adrenalectomy (n = 11) or laparoscopic adrenalectomy (n = 14). The most common primary site was the lung (n = 7), followed by the kidney (n = 5), liver (n = 3), ovary (n = 2), soft tissue (n = 2), and six other sites. The majority of the patients (n = 19) had metachronous metastasis. The median tumor size was 3.1 cm (1-9 cm). With the median follow-up of 32 months (2-144 months), the median progression-free and overall survivals were 14 and 63 months, respectively. Multivariate analysis revealed that synchronous metastasis (hazard ratio [HR] = 7.5) and tumor size ≥ 4 cm (HR = 17.7) were significant prognostic factors for shorter overall survival. There was no significant difference for survival between the laparoscopic and open groups.

CONCLUSIONS

Adrenalectomy for solitary adrenal metastasis can be applied for selected patients with various types of malignancy. However, synchronous metastasis and tumor size ≥ 4 cm were prognostic factors for shorter overall survival.

[Hypofractionated stereotactic body radiation therapy for adrenal metastases]

Adrenal glands are a common site for metastatic spread since they represent the fourth metastatic site of solid tumors. Interest in local ablative treatments of oligometastases is growing since literature suggests better progression-free survival, quality of life and potentially overall survival in selected patients. Surgery remains the first treatment of adrenal oligometastases because results are good, with a long enough follow-up. However, stereotactic radiotherapy appears to be comparable to surgery and could be proposed to elderly, unfit, inoperable patients, or even to patients whose systemic treatment should not be suspended for too long. This article aims to present a review of published studies to date on stereotactic radiotherapy of adrenal metastases and to propose a treatment protocol.

Surgery in late melanoma adrenal metastasis

Metastatic melanoma to adrenal gland are very infrequent, being generally associated with additional evidence of systemic disease and, consequently, with short-term survival. However, the prognosis and the therapeutic management vary depending on some important oncological features. Long-term survival rates have been described after complete resection of metastatic disease. Here, we report the case of a woman aged 41 years diagnosed with a cutaneous melanoma on the right side of her paravertebral region, level III of Clark, in 2002, who underwent surgical excision of the tumour with negative margins and a negative sentinel node. She posteriorly developed pulmonary metastasis in 2006 and 2009, both resected with curative intention and in 2013, she was diagnosed with an adrenal metastasis. Therefore, she was submitted to an uneventful right laparoscopic adrenalectomy. The pathology report described metastasis of a cutaneous melanoma, negative for BRAF mutation. The patient is actually disease-free after 30 months of follow-up.

Minimally Invasive Stereotactical Radio-ablation of Adrenal Metastases as an Alternative to Surgery

Purpose

The purpose of this study was to study the clinical outcome for patients with metastases of the adrenal gland treated with stereotactic body radiation therapy.

Materials and Methods

Forty-six patients were studied retrospectively. The dose prescription was 40 Gy in four fractions. Dosimetric analysis was performed using the dose volume histograms while clinical outcome was assessed using actuarial analysis with determination of the overall survival (OS) and local control (LC) rates.

Results

The planning objectives were met for all patients. With a median follow-up period of 7.6 months, at the last follow-up 42 patients (91.3%) were alive and four had died because of distant progression. The actuarial mean OS was 28.5±1.6 months, the median was not reached. One-year and 2-year OS were 87.6±6.1%. None of the risk factors was significant in univariate analysis. Actuarial mean LC was 14.6±1.8 months (95% confidence interval [CI], 11.0 to 18.2) and median LC was 14.5±2.0 months (95% CI, 10.5 to 18.5). One-year and 2-year LC were 65.5±11.9% and 40.7±15.8%, respectively. A mild profile of toxicity was observed in the cohort of patients. Forty patients (86.9%) showed no complication (grade 0); two patients reported asthenia, six patients (13.1%) reported either pain, nausea, or vomiting. Of these six patients, five patients (10.9%) were scored as grade 1 toxicity while one patient (2.2%) was scored as grade 2.

Conclusion

Stereotactic body radiation therapy treatment provided an adequate clinical response in the management of adrenal gland metastases.

Management of suspected adrenal metastases at 2 academic medical centers

BACKGROUND

The optimal management of suspected adrenal metastases remains controversial.

METHODS

This is a retrospective bi-institutional review of 37 patients who underwent adrenalectomy for suspected adrenal metastasis between 2001 and 2014.

RESULTS

Three (8%) patients had benign adenomas on final pathology. At a median follow-up of 21 months, 7 (32%) patients were alive with no evidence of disease and 7 (32%) were alive with recurrent disease. Recurrence-free survival (RFS) was 8 months; decreased RFS was associated with positive margins and size ≥6 cm. Overall survival (OS) was 29 months; decreased OS was associated with capsular disruption. There were no differences in RFS or OS by surgical approach.

CONCLUSIONS

The favorable OS supports adrenalectomy in select patients with suspected adrenal metastases. Minimally invasive adrenalectomy is safe and effective, but the surgical approach should be based on the ability to achieve a margin-negative resection with avoidance of capsular disruption.

Patient selection for laparoscopic excision of adrenal metastases: A multicenter cohort study

INTRODUCTION

The use of laparoscopy for the excision of adrenal metastasis remains controversial. We aimed to report oncological and perioperative outcomes of laparoscopic excision of adrenal metastases and to seek for predictive factors of unfavorable oncological outcomes.

METHODS

A retrospective chart review was conducted and all consecutive patients who underwent laparoscopic adrenalectomy (LA) in the setting of metastatic cancer in two academic urology departments from November 2006 through January 2014 were included. Primary tumors were categorized as pulmonary, renal or "other primary" tumors to allow statistical comparison. Unfavorable surgical outcomes were defined as the occurrence of either postoperative complications and/or positive surgical margins.

RESULTS

Forty-three patients who underwent a total of 45 LA were included for analysis. There were 8 complications (17.8%). Positive surgical margins were found in 12 specimens (26.7%). After a median follow-up of 37 months, estimated overall survival rates were 89.5% and 51.5% at 1 year and 5 years, respectively. In multivariable analysis the only predictor of unfavorable surgical outcomes was a tumor size >5 cm (OR = 20.5; p = 0.001). In multivariate analysis the pulmonary (OR = 0.3; p = 0.008) or "other" (OR = 0.1; p = 0.0006) origin of the primary tumor was the only prognostic factor of shorter cancer specific survival.

CONCLUSION

Laparoscopic resection of adrenal metastasis can be safely performed in most patients but is associated with an increased risk of positive surgical margins and postoperative complications in larger tumors (>5 cm). Adrenalectomy provides better oncological outcomes in metastases from renal cell carcinoma compared to other primary tumors.

Minimally Invasive Adrenalectomy

Minimally invasive adrenalectomy has become the gold standard for removal of benign adrenal tumors. The imaging characteristics, biochemical evaluation, and patient selection for laparoscopic transabdominal and posterior retroperitoneoscopic approaches are discussed with details of surgical technique for both procedures.

Laparoscopic transperitoneal lateral adrenalectomy for malignant and potentially malignant adrenal tumours

Background

Laparoscopic adrenalectomy is still controversial in cases where malignancy is suspected. However, many proponents of this technique argue that in the hands of an experienced surgeon, laparoscopy can be safely performed. The aim of this study is to present our own experience with the application of laparoscopic surgery for the treatment of malignant and potentially malignant adrenal tumours.

Methods

Our analysis included 52 patients who underwent laparoscopic adrenalectomy in 2003–2014 due to a malignant or potentially malignant adrenal tumour. Inclusion criteria were primary adrenal malignancy, adrenal metastasis or pheochromocytoma with a PASS score greater than 6. We analyzed the conversion rate, intra- and postoperative complications, intraoperative blood loss and R0 resection rate. Survival was estimated using the Kaplan-Meier method.

Results

Conversion was necessary in 5 (9.7 %) cases. Complications occurred in a total of 6 patients (11.5 %). R0 resection was achieved in 41 (78.8 %) patients and R1 resection in 9 (17.3 %) patients. In 2 (3.9 %) cases R2 resection was performed. The mean follow-up time was 32.9 months. Survival depended on the type of tumour and was comparable with survival after open adrenalectomy presented in other studies.

Conclusions

We consider that laparoscopic surgery for adrenal malignancy can be an equal alternative to open surgery and in the hand of an experienced surgeon it guarantees the possibility of noninferiority. Additionally, starting a procedure with laparoscopy allows for minimally invasive evaluation of peritoneal cavity. The key element in surgery for any malignancy is not the surgical access itself but the proper technique.

[Adrenalectomy for adrenal metastases: is the laparoscopic approach beneficial for all patients?]

INTRODUCTION

Laparoscopy has become the gold-standard approach for excision of benign adrenal tumors but the question of its safety for malignant lesions is still controversial. Our aim was to evaluate the oncologic outcome of laparoscopic adrenalectomy for adrenal metastasis and to look for predictors of a negative surgical outcome.

PATIENTS AND METHODS

We retrospectively reviewed the charts of all patients who underwent laparoscopic adrenalectomy for suspicion of adrenal metastasis between 2007 and 2013 at a single academic institution. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier method. Univariate analysis was performed to determine risk factors of negative surgical outcome (positive surgical margins, complications, conversion, significant blood loss) and predictors of RFS and CSS.

RESULTS

Thirteen patients underwent 14 laparoscopic adrenalectomies. All patients were operated by a single highly experienced surgeon. Complications occurred in 2 patients (15%): 2 blood transfusions (Clavien-score=2). There were 3 positive surgical margins (21%). Mean length of hospital stay was 4.3 days. Unadjusted RFS and CSS were respectively 48.4% and 83.3% at 1 year, 39.5% and 66.7% at 5 years. In univariate analysis, tumor size was the only risk factor of complication (P=.009) and conversion (P=0.009). Capsule invasion and tumor size were risk factors of positive surgical margins (P=0.01 and P<0.0001). One hundred percent of complications, conversion and positive surgical margins occurred in tumor>7.5 cm on preoperative CT-scan. No predictors of RFS and CSS was found in univariate analysis.

CONCLUSION

Laparoscopic adrenalectomy for adrenal metastasis achieves good surgical and oncologic outcomes. When performed by highly experienced surgeon, complications and positive surgical margins occur only in tumors>7.5 cm. These patients may benefit from an open surgical approach.