Surgical and ablative therapies for the management of adrenal ‘oligometastases’ – A systematic review

Cryoprobe Placement Using Electromagnetic Navigation System (IMACTIS® CT-Navigation™) for Cryoablation Treatment of Upper Kidney Pole Lesions and Adrenal Metastases: Experience from a Single-Center, 4-Year Study

The aim of this study is to evaluate the safety and efficacy of the use of the IMACTIS® CT-Navigation™-electromagnetic navigation system (EMNS) in cryoablation CT-guided procedures under local anesthesia for the treatment of upper kidney pole and adrenal lesions. We conducted a retrospective analysis of patients with upper kidney pole lesions and adrenal metastases who underwent cryoablation using the IMACTIS-CT®-EMNS between January 2019 and April 2023. The EMNS was used to guide the placement of the cryoprobes with CT guidance under local anesthesia. The primary outcome was technical success, defined as the successful placement of the cryoprobes in the target lesion. A total of 31 patients were studied, of whom, 25 patients were treated with cryoablation for upper pole kidney masses, and 6 patients underwent the cryoablation of adrenal metastases during the study period. The mean age was 60 years (range, 36-82 years), and 21 patients were male. All the upper kidney pole lesions were renal cell carcinomas, and regarding adrenal metastases, the primary cancer sites were the lungs (n = 3), breast (n = 2), and the colon (n = 1). The median size of the lesions was 3,8 cm (range, 1.5-5 cm). All procedures were technically successful, with the cryoprobes accurately placed in the target lesions under CT guidance using the EMNS, avoiding the penetration of any other organs using an oblique trajectory. No major complications were reported, and local tumor control was achieved in all cases. Our initial experience using the EMNS for cryoprobe placement during CT-guided interventional procedures under local anesthesia for the cryoablation treatment of upper pole kidney lesions and adrenal metastases showed that it is safe and effective.

Value of the three-dimensional visualization ablation planning system in ultrasound-guided percutaneous microwave ablation for malignant adrenal tumors: A clinical comparative study

OBJECTIVE

We aimed to assess the efficacy and safety of the three-dimensional visualization ablation planning system (3DVAPS) in ultrasound-guided percutaneous microwave ablation (US-PMWA) for malignant adrenal tumors (MATs).

METHODS

A retrospective analysis was conducted on a cohort of 62 unilateral MAT cases from March 2011 to November 2022. There were a total of 62 lesions, with a mean maximum diameter of 5.4 ± 2.7 cm (range, 1.4-15.7 cm). The patients were categorized into the following, based on the pre-operative planning method: 3D planning (n = 32) and 2D planning (n = 30) groups. A comparative analysis was performed on various parameters, including ablation techniques, tumor-related prognosis, and incidence of complications. This analysis encompassed indicators, such as overall survival (OS) rate and local tumor progression (LTP), among others.

RESULTS

The median follow-up period was 30 months (range, 3-84 months). Notably, compared with the 2D planning group, the 3D planning group exhibited significant disparities in the number of punctures (P = 0.035) and incidence of complications (P = 0.029) and had no significant difference in the OS ( P > 0.05) but had a significantly lower LTP rate (6.2% vs. 23.3%, P = 0.033). In the 3D planning group, the sub-group with a tumor diameter of < 5 cm exhibited a significantly less number of punctures ( P = 0.039), lower input energy ( P = 0.002), and a shorter ablation time ( P = 0.001), compared with the sub-group with a tumor diameter of ≥ 5 cm, but there was no significant difference in the LTP and OS rates between the two sub-groups ( P > 0.05).

CONCLUSIONS

The use of 3DVAPS in US-PMWA of MATs was advantageous, especially in lesions with a diameter of ≥ 5 cm. It can help in developing more rational surgical plans, reducing the incidence of complications, and extending the local recurrence-free survival time of patients and can add a certain value for precise treatment and expand the indications for ablation.

Factors influencing local control after MR-guided stereotactic body radiotherapy (MRgSBRT) for adrenal metastases

Purpose

Stereotactic body radiotherapy (SBRT) is an effective treatment for adrenal gland metastases, but it is technically challenging and there are concerns about toxicity. We performed a multi-institutional pooled retrospective analysis to study clinical outcomes and toxicities after MR-guided SBRT (MRgSBRT) using for adrenal gland metastases.

Methods and Materials

Clinical and dosimetric data of patients treated with MRgSBRT on a 0.35 T MR-Linac at 11 institutions between 2016 and 2022 were analyzed. Local control (LC), local progression-free survival (LPFS), distant progression-free survival (DPFS) and overall survival (OS) were estimated using Kaplan-Meier method and log-rank test.

Results

A total of 255 patients (269 adrenal metastases) were included. Metastatic pattern was solitary in 25.9 % and oligometastatic in 58.0 % of patients. Median total dose was 45 Gy (range, 16-60 Gy) in a median of 5 fractions, and the median BED10 was 100 Gy (range, 37.5-132.0 Gy). Adaptation was done in 87.4 % of delivered fractions based on the individual clinicians' judgement. The 1- and 2- year LPFS rates were 94.0 % (95 % CI: 90.7-97.3 %) and 88.3 % (95 % CI: 82.4-94.2 %), respectively and only 2 patients (0.8 %) experienced grade 3 + toxicity. No local recurrences were observed after treatment to a total dose of BED10 > 100 Gy, with single fraction or fractional dose of > 10 Gy.

Conclusions

This is a large retrospective multi-institutional study to evaluate the treatment outcomes and toxicities with MRgSBRT in over 250 patients, demonstrating the need for frequent adaptation in 87.4 % of delivered fractions to achieve a 1- year LPFS rate of 94 % and less than 1 % rate of grade 3 + toxicity. Outcomes analysis in 269 adrenal lesions revealed improved outcomes with delivery of a BED10 > 100 Gy, use of single fraction SBRT and with fraction doses > 10 Gy, providing benchmarks for future clinical trials.

Stereotactic body radiation therapy for adrenal gland metastases: A multi-institutional outcome analysis

Aim

The adrenal gland is a common site of metastasis with a rate of up to 27% in autopsy series. The incidence of these metastases is increasing due to greater use of Positron Emission Tomography scans and improved overall survival of patients with metastatic cancers. Stereotactic body radiation therapy (SBRT) is a non-invasive treatment option for metastasis. The aim of this study is to assess prognostic factors influencing local control, progression-free and overall survival in oligometastatic patients treated with SBRT for an adrenal metastasis.

Methods

In this multicentric retrospective study, we included patients with adrenal metastases treated with SBRT between 2010 and 2021 in eleven french centers. All primary tumors were included.

Results

A total of 110 patients treated for 121 adrenal lesions were included. Non-small-cell lung cancer was the predominant histologic type (55.4 %). Eighty-two percent of patients had at least 2 metastatic sites. The median Planning Target Volume was 70 cm3 with a median prescription dose of 40 Gray (Gy). The mean Biologically Effective Dose (BED) 10 dose was 74.2 Gy. Local control at 1 and 2 years was 85.9 % and 72.5 % respectively. The median overall survival and progression-free survival were 31.6 and 8.5 months respectively. Local control was significantly improved by systemic treatment one month before or after SBRT (p = 0.009) and by a BED10 greater than or equal to 50 Gy (p = 0.003).In multivariate analysis, oligometastatic presentation (p = 0.009) and a metachronous metastatic presentation (p = 0.008) were independent factors for progression-free survival.Tolerance was excellent, no grade 3 and 4 toxicities were described due to SBRT.

Conclusion

Stereotactic radiotherapy of adrenal metastases makes possible a local control of more than 85% at one year and was well tolerated. The factors influencing survival in oligometastatic patients still need to be found in order to better select those who benefit the most from this type of treatment.

Percutaneous Image Guided Cryoablation of Adrenal Metastases From Renal Cell Carcinoma: A Single Institution Review

OBJECTIVES

To assess the safety, technical success, disease progression, and survival associated with percutaneous image-guided cryoablation of renal cell carcinoma metastasis (mRCC) in the adrenal gland.

METHODS

Retrospective, single-institution review of adult patients undergoing percutaneous cryoablation for adrenal mRCC between the years of 2007-2021. Technical parameters, technical success, safety, and survival were analyzed according to standard criteria.

RESULTS

Forty-six patients (39 male; mean age 66 ± 8.8 years) with 57 tumors ablated over 51 sessions with a median hospital length of stay of 1 day (range 0-3 days). Forty-four (96%) had primary of clear cell histology. Aim of ablation was curative intent in 39 of 57 tumors (72%) with local tumor control in the remainder. There were 2 (4%) technical failures and technique efficacy was achieved in 52 out of the remaining 55 (95%). There were no Common Terminology Criteria for Adverse Events' immediate complications and 4 of 51 (8%) delayed complications. Twenty-five of 57 (44%) had disease progression anywhere, away from ablation site. One-, 3-, and 5-year recurrence free survival rates were 100%, 89%, and 89% and overall survival was 98%, 85%, and 71%. Fifty-one of 57 (89%) underwent preprocedural alpha blockade with hypertensive crisis in 27 of 56 (54%) available records, of which there were no adverse outcomes.

CONCLUSION

Percutaneous cryoablation of mRCC to the adrenal glands is safe with robust local control, leading to advocacy for its ongoing use in this patient population. Multi-disciplinary management is recommended for successful treatment.

[Metastatic lesions of the adrenal glands. The experience of Endocrinology Research Center.]

Differentiation between benign, primary and secondary malignant tumors is a critical problem in the clinical treatment of adrenal tumors, especially in patients with isolated adrenal lesions. In most cases, the correct diagnosis can be established microscopically with standard staining with hematoxylin and eosin. However, there are cases when it is almost impossible to distinguish metastasis from primary adrenal cancer, so an accurate diagnosis requires an immunohistochemical examination.This article presents five unique observations of secondary adrenal tumors that were diagnosed by us in the current surgical material: metastasis of clear cell renal cell carcinoma, follicular variant of papillary thyroid cancer, metastasis of keratinizing squamous cell carcinoma of the cervix, lymphoepithelioma-like carcinoma of the bladder, as well as malignant mesothelioma. Taking into account the extreme rarity of the presented observations, we present an analysis of the literature data.

The efficacy and outcomes of stereotactic body radiotherapy in adrenal gland metastases

Aim

This retrospective study presents our single-institutional experience with stereotactic body radiotherapy for adrenal gland metastases.

Materials and Methods

We evaluated patients with adrenal metastases treated by stereotactic body radiotherapy (SBRT) from 2014 to 2020. We performed an analysis of 35 patients. The median age of the patients was 62.2. Dosimetric parameters and treatment outcomes were evaluated.

Results

The primary diagnosis of the majority of patients was non-small cell lung cancer (94.3%). Treatment was performed in a median of 3 fractions, and the median prescribed dose was 24 Gy (range 22,5-27). The median follow-up was 17 months. Treatment response according to Response Evaluation Criteria in Solid Tumours was categorized as complete response in 11 patients, partial response in nine patients, stable disease in 7, and progressive disease in eight patients. Twenty seven patients had oligometastatic disease and treatment response. Patients with oligometastatic disease had a significantly higher rate of complete response and partial response to treatment than patients with common disease (P = 0,011). The 6-month and 1-year local control rates were 68.4% and 43%, respectively. In general, SBRT was well tolerated and no acute toxicities were observed.

Conclusion

Our retrospective study shows that SBRT can be applied safely in adrenal metastases with good results especially in patients with oligometastatic disease.

Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions

Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.

Risk of malignancy in adrenal tumors in patients with a history of cancer

Purpose

Adrenal gland is a common site of metastasis and on the other hand, metastases are the most frequent malignant adrenal tumors. The aim of this study was to estimate the risk of malignancy in suspicious adrenal mass in patients with a history of cancer.

Methods

This is a single-center retrospective analysis of patients with adrenal tumors treated previously for different types of cancers. Between 2004 and 2021 a hundred and six such patients were identified. Mean age of patients was 62.6 years (30-78), and mean time from oncologic treatment was 55.8 months (0-274). The most common primary cancer was kidney (RCC): 29 (27.4%), colon/rectum (CRC): 20 (18.9%) and lung (NSCLC): 20 (18.9%).

Results

Of 106 patients, 12 had hormonally active (HA) (11,3%) and 94 (88,7%) non active (HNA) tumors In group of patients with HA tumours 4 had hypercortisolaemia and 8 had elevation of urinary metanephrines. In the first group of HA patients pathology confirmed preoperative diagnosis of adrenocortical cancer and no metastasis was found. In all patients from the second group pheochromocytomas were confirmed. Primary (PM) and secondary (SM) malignancies were found in 50 patients (47.2%). In hormone inactive group only SM - 46/94 (48.9%) were diagnosed. The odds that adrenal lesion was a metastasis were higher if primary cancer was RCC (OR 4.29) and NSCLC (OR 12.3). Metastases were also more likely with high native tumor density, and bigger size in CT. The cut-off values for tumor size and native density calculated from receiver operating characteristic (ROC) curves were 37mm and 24, respectively.

Conclusion

Risk of malignancy of adrenal mass in a patient with a history of cancer is high (47,2%), regardless of hormonal status. 47,2% risk of malignancy. In preoperative assessment type of primary cancer, adrenal tumour size and native density on CT should be taken into consideration as predictive factors of malignancy. Native density exceeding 24 HU was the strongest risk factor of adrenal malignancy (RR 3.23), followed by history of lung or renal cancer (RR 2.82) and maximum tumor diameter over 37 mm (RR 2.14).

Efficacy and Safety of Ultrasound-Guided Percutaneous Ablation for Adrenal Metastases: A Meta-Analysis

OBJECTIVES

To assess the efficacy and safety of ultrasound-guided percutaneous ablation (US-PA) for adrenal metastases (AMs) using a meta-analysis.

METHODS

A systematic search of PubMed, Cochrane, Web of Science, and Embase electronic databases was performed to identify studies on US-PA for AM. Seven studies published between January 2000 and August 2022 were analyzed, which resulted in a sample size of 140 patients. Both random effects and common effects meta-analysis models were used to analyze the following efficacy and safety outcomes: the first and secondary technical success rate, 1-year overall survival rates, 1-year local tumor control rate, incidence rate of intraoperative hypertensive crises, and major complications. The subgroup analysis was performed to explore the origin of heterogeneity.

RESULTS

Among 140 patients from 7 studies included in this meta-analysis: 51 (36.43%) underwent radiofrequency ablation (RFA), and 89 (63.57%) underwent microwave ablation (MWA). Pooled data analysis revealed that the first and secondary technical success rates were 85% (95% confidence interval [CI], 73-96) and 99% (95% CI, 96-100), the 1-year overall survival rate was 83% (95% CI, 71-93), the 1-year local tumor control rate was 83% (95% CI, 75-90), and the incidence rate of intraoperative hypertensive crises was 14% (95% CI, 8-20). The overall rate of major complications was 3.6%. In the subgroup analysis, lower heterogeneity was indicated to be associated with mean tumor size and ablation type.

CONCLUSIONS

This meta-analysis showed that US-PA can be both effective and safe for AM in terms of overall survival, technical success rate, and local control for AM.

Adjuvant Therapy for High-Risk Localized Renal Cell Carcinoma: Current Landscape and Future Direction

Locally and regionally advanced renal cell carcinoma (RCC) can recur at high rates even after visually complete resection of primary disease. Both targeted therapies and immunotherapies represent potential agents that might help reduce recurrence of RCC in these patients. This paper reviews the current body of evidence defining their potential impact and examines the large Phase III randomized clinical trials that have been performed to assess the safety and efficacy of these systemic therapies in the adjuvant setting. Given that the findings from these trials have been predominantly negative, this paper also explores the role of other potential adjuvant agents, including single and combination agent targeted therapies and immunotherapies, whose use is currently limited to metastatic RCC. Finally, the use of radiation therapy and the use of advanced imaging modalities in RCC are also considered.

Stereotactic MR-Guided Radiotherapy for Adrenal Gland Metastases: First Clinical Results

Stereotactic MR-guided Radiotherapy (MRgRT) is an interesting treatment option for adrenal gland metastases (AGM). We reviewed data from 12 consecutive patients treated with MRgRT for an AGM in our center between 14 November 2019 and 17 August 2021. Endpoints were tolerance assessment, the impact of adaptive treatment on target volume coverage and organs at risk (OAR) sparing, local control (LC), and overall survival (OS). The majority of patients were oligometastatic (58.3%), with 6 right AGM, 5 left AGM and 1 left and right AGM. The prescribed dose was 35 to 50 Gy in 3 to 5 fractions. The median PTV V95% on the initial plan was 95.74%. The median V95% of the PTVoptimized (PTVopt) on the initial plan was 95.26%. Thirty-eight (69%) fractions were adapted. The PTV coverage was significantly improved for adapted plans compared to predicted plans (median PTV V95% increased from 89.85% to 91.17%, p = 0.0478). The plan adaptation also significantly reduced Dmax for the stomach and small intestine. The treatment was well tolerated with no grade > 2 toxicities. With a median follow-up of 15.5 months, the 1−year LC and OS rate were 100% and 91.7%. Six patients (50%) presented a metastatic progression, and one patient (8.3%) died of metastatic evolution during the follow-up. Adaptation of the treatment plan improved the overall dosimetric quality of MRI-guided radiotherapy. A longer follow-up is required to assess late toxicities and clinical results.

Long-term control of melanoma adrenal metastasis treated with radiotherapy

Melanoma remains a large global burden with a significant proportion of patients succumbing to metastatic disease. The adrenal gland is a common area for metastasis with surgical treatment as the main modality. Radiotherapy is less utilised in this setting with uncertainty over deliverability and efficacy. Here, we present the details and outcomes of 20 patients treated with radiotherapy, with or without systemic therapy, for melanoma adrenal metastasis in a single institute. Twenty patients were identified from radiation treatment and medical records from between 2015 and 2019 at our institution. Three patients had bilateral radiotherapy treatments and therefore 23 adrenal lesions were analysed. Demographics, indications for treatment, radiotherapy methodology and outcomes were recorded. Outcomes were based on serial 18F FDG PET/computerized tomography scans reporting using the PERCIST criteria. The most common indication for radiotherapy was oligo-progressive disease (70%) followed by symptom palliation. Eight (35%) of the treatments were delivered by stereotactic ablative body radiotherapy. Twelve (60%) patients had concurrent immunotherapy. Twenty of twenty-three (87%) adrenal lesions had an initial response to treatment with 12 (60%) maintaining local control until death or end of follow-up. Median adrenal-specific progression-free survival was 13 months. Four patients (17%) required salvage adrenalectomy. Symptom palliation was achieved in the majority of patients for which it was indicated and there were no grade three toxicities. The median time from radiotherapy to change of immunotherapy treatment was 4 months. Radiotherapy for melanoma adrenal metastasis is effective and deliverable. With the majority of patients achieving a palliative and clinically relevant durable response, adrenalectomy can be reserved as a salvage option.

Stereotactic radiotherapy for adrenal oligometastases

Approximately 50% of melanomas, 30–40% of lung and breast cancers and 10–20% of renal and gastrointestinal tumors metastasize to the adrenal gland.

Metastatic adrenal involvement is diagnosed by computed tomography (CT ) with contrast medium, ultrasound (which does not explore the left adrenal gland well), magnetic resonance imaging (MRI) with contrast medium and 18F-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDGPET-CT ) which also evaluates lesion uptake. The simulation CT should be performed with contrast medium; an oral bolus of contrast medium is useful, given adrenal gland proximity to the duodenum. The simulation CT may be merged with PET-CT images with ¹⁸FDG in order to evaluate uptaking areas. In contouring, the radiologically visible and/or uptaking lesion provides the gross tumor volume (GTV ). Appropriate techniques are needed to overcome target motion. Single fraction stereotactic radiotherapy (SRT ) with median doses of 16–23 Gy is rarely used. More common are doses of 25–48 Gy in 3–10 fractions although 3 or 5 fractions are preferred. Local control at 1 and 2 years ranges from 44 to 100% and from 27 to 100%, respectively. The local control rate is as high as 90%, remaining stable during follow-up when BED_10Gy is equal to or greater than 100 Gy. SRT-related toxicity is mild, consisting mainly of gastrointestinal disorders, local pain and fatigue. Adrenal insufficiency is rare.

Management of an Unusual Metastasis of Cervical Cancer in the Adrenal Bed With Stereotactic Ablative Body Radiation Therapy

Uterine cervical carcinoma is an important type of cancer among Ecuadorian women, especially in adult women. Survival rates have improved with the development of radiotherapy, surgical techniques, and chemotherapy. However, recurrence and/or metastasis are not unusual phenomena. Frequent sites of metastasis are the lungs, regional lymph nodes, and bones. Atypical locations can also occur on solid organs, such as adrenal glands. Treatment for the rare complication that is adrenal metastasis is individualized, it can include surgical resection, chemotherapy, local ablation, or different types of radiotherapy.

We aimed to report a case of an Ecuadorian woman from Quito city with a diagnosis of cervical carcinoma diagnosed in 2009, treated surgically and with adjuvant chemotherapy. Her progression was monitored with medical controls with no recurrence until 2018, when she relapsed with a metastatic invasion of the pelvic ganglia and the surroundings of the abdominal aorta, with a histopathologic diagnosis of adenocarcinoma. She was then treated with chemotherapy and radiotherapy until June 2019. In 2020, she went through a splenectomy and left adrenalectomy to treat vascular thrombosis. In 2021, 37 x 15 mm mass was discovered in the surgical bed of the previously removed adrenal gland. It was treated as an oligometastatic carcinoma with stereotactic body radiotherapy (SBRT) by a linear accelerator.

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.

Stereotactic body radiation therapy for adrenal gland metastases: outcome and predictive factors from a multicenter analysis

Adrenal metastases occur in 15-35% of oncological patients. Surgery is the first treatment option. Stereotactic body radiotherapy (SBRT) has been largely explored in oligometastatic patients unfit for surgery, representing an effective and non-invasive local treatment. The results of a multi-institutional experience of SBRT on adrenal metastases in the oligorecurrent or oligoprogressive setting are herein reported. We collected data of adrenal gland metastases treated with SBRT in three Italian centers from 2010 to 2020. End-points of the present study were: Overall survival (OS), Local control of treated metastases (LC), Progression free survival (PFS), and toxicity. 149 adrenal gland metastases were treated with SBRT in 142 patients. The most common primary tumor was lung cancer (58.4%), followed by kidney cancer (9.4%). Median lesion's volume was 28.5 cm³ (2.5-323.4). The median SBRT dose was 40 Gy (10-60). Median follow-up was 14.4 months. One- and two-year OS were 72.3% and 53.5%. At univariate analysis performance status correlated with survival (HR 1.57, p = 0.006). One- and two-year LC were 85.4% and 79.2%, with lung primary tumor (HR 0.33, p = 0.021) and BED10 (HR 0.97, p = 0.036) significant independent factors. One- and two-year PFS were 37.7% and 24.8%. Median time to polymetastatic disease was 11.3 months. Grade 1 and 2 toxicity occurred in 21 (14.7%) and 3 (2.1%) patients. The results from this large multi-center study confirm the efficacy and safety of SBRT in the management of adrenal gland metastases, as a valid alternative to other more invasive local approaches.

Modeling of Tumor Control Probability in Stereotactic Body Radiation Therapy for Adrenal Tumors

PURPOSE

Stereotactic body radiation therapy (SBRT) in the management of adrenal metastases is emerging as a well-tolerated, effective method of treatment for patients with limited metastatic disease. SBRT planning and treatment utilization are widely variable, and publications report heterogeneous radiation dose fractionation schemes and treatment outcomes. The objective of this analysis was to review the current literature on SBRT for adrenal metastases and to develop treatment guidelines and a model for tumor control probability of SBRT for adrenal metastases based on these publications.

METHODS AND MATERIALS

A literature search of all studies on SBRT for adrenal metastases published from 2008 to 2017 was performed, and outcomes in these studies were reviewed. Local control (LC) rates were fit to a statistically significant Poisson model using maximum likelihood estimation techniques.

RESULTS

One-year LC greater than 95% was achieved at an approximated biological equivalent dose with α/β = 10 Gy of 116.4 Gy.

CONCLUSIONS

While respecting normal tissue tolerances, tumor doses greater than or equal to a biological equivalent dose with α/β = 10 Gy of 116.4 Gy are recommended to achieve high LC. Further studies following unified reporting standards are needed for more robust prediction.

Computed Tomography-Guided Cryoablation for Adrenal Metastasis Secondary to Non-small-cell Lung Cancer

Background: Computed tomography (CT)-guided ablation has been used to treat adrenal metastasis (AM). However, the incidence of AM secondary to non-small-cell lung cancer (NSCLC) has not been investigated. Objectives: To assess the clinical efficacy of CT-guided cryoablation for treating AM secondary to NSCLC. Patients and Methods: This retrospective study was performed among patients with AM secondary to NSCLC, undergoing CT-guided cryoablation in our hospital. The rates of complete ablation, local recurrence, local recurrence-free survival (RFS), systematic RFS, and overall survival (OS) were also analyzed. Results: Thirty-four consecutive patients with AM secondary to NSCLC (16 cases of squamous cell carcinoma [SCC] and 18 cases of adenocarcinoma) underwent cryoablation in our hospital. The primary complete ablation rates were 93.8% and 88.9% in the SCC and adenocarcinoma groups, respectively (P = 1.000). Moderate blood pressure increases were observed in 7/34 (20.6%) patients during cryoablation. The local recurrence of AM was observed in five and three patients in the SCC and adenocarcinoma groups, respectively (P = 0.551). The median local RFS was 22 months in all patients, and there was no significant difference in terms of the local RFS between the SCC and adenocarcinoma groups (38 vs. 17 months) (P = 0.093). The median systematic RFS was 28 months in all patients, and the systematic RFS was significantly longer in the SCC group as compared to the adenocarcinoma group (56 vs. 19 months) (P = 0.001). The median OS was 34 months in all patients; it was significantly higher in the SCC group as compared to the adenocarcinoma group (56 vs. 22 months) (P = 0.009). Conclusion: CT-guided cryoablation can be a safe and effective treatment to control AM secondary to NSCLC.

Image-Guided Percutaneous Ablation of Adrenal Metastases: A Meta-Analysis of Efficacy and Safety

PURPOSE

To evaluate the efficacy and safety of percutaneous ablation of adrenal metastases through a meta-analysis of various image-guided percutaneous ablation techniques.

MATERIALS AND METHODS

A comprehensive literature search of PubMed and Embase databases was performed for studies evaluating the efficacy and/or safety of image-guided percutaneous ablation of adrenal metastases. A total of 37 studies published between 2009 and 2020 were analyzed, comprising a sample size of 959 patients. Proportion estimates of overall survival, local control, and toxicity were analyzed in a pooled meta-analysis. The pooled prevalence of adverse events after ablation was calculated based on common terminology criteria for adverse events (CTCAE) grading.

RESULTS

Of the 959 included patients, 320 (33.3%) underwent radiofrequency ablation, 72 (7.5%) microwave ablation, 95 (9.9%) cryoablation, and 46 (4.8%) ethanol injections for treatment of adrenal metastases. The remaining 426 (44.4%) patients were from studies involving a mixture of the 4 listed percutaneous ablation techniques. The pooled 1-year local control rate was 80% (95% confidence interval [CI], 76%-83%). The pooled 1-year overall survival rate was 77% (95% CI, 70%-83%). The overall rate of severe adverse events after ablation (CTCAE grade 3 or higher) was 16.1%. The overall rate of low-grade adverse events after ablation (CTCAE grade 2 or lower) was 32.6%. Approximately 21.9% (n = 203) of patients experienced intraprocedural hypertensive crises, the majority of which were reversed with antihypertensive medications.

CONCLUSIONS

This study demonstrates that image-guided percutaneous ablation can be effective in achieving acceptable short- to mid-term local tumor control and overall survival with a moderate safety profile.

Presentation, disease progression and outcomes of adrenal gland metastases

OBJECTIVE

Data on the presentations and outcomes of patients with adrenal gland metastases are limited. Our objectives were to characterize the prevalence of adrenal metastases subtypes and investigate how varying clinical presentations affect disease progression, development of primary adrenal insufficiency (PAI) and mortality.

DESIGN

Single institution tertiary centre, retrospective cohort study from 1997 to 2020.

PATIENTS AND MEASUREMENTS

Adult patients with adrenal metastases. Clinical, radiologic and biochemical presentations and outcomes were reviewed.

RESULTS

Of 579 patients (62.3% men, median age 67 years [range 25-92]) with adrenal metastases (median tumour size of 30 mm [range 5-200]), 339 (58.5%) were discovered during cancer staging, 210 (36.3%) were found incidentally, and 29 (5.0%) based on symptoms. Tumours originated from the lung (226, 39.0%), genitourinary (GU) (160, 27.6%), gastrointestinal (GI) (79, 13.6%) and other (114, 19.7%) organ systems. Bilateral metastases were found in 140 (24.2%) patients at the time of initial diagnosis, and 249 (43.0%) had bilateral disease throughout the study course. PAI developed in 12.4% of patients with bilateral disease and was associated with larger tumour size. Median follow-up time was 14 months (range 0-232), and 442 (76.3%) patients died. Higher mortality was independently associated with older age, adrenal metastases originating from the lung, bilateral disease, and the absence of adrenalectomy.

CONCLUSIONS

Adrenal gland metastases originated most commonly from lung, GU and GI malignancies. Bilateral adrenal metastases occurred in 43% of patients, and PAI occurred in 12.4% of those with bilateral disease, warranting further case detection strategies.

Percutaneous Bilateral Adrenal Radiofrequency Ablation in Severe Adrenocorticotropic Hormone-dependent Cushing Syndrome

Objectives:

The objectives of the study were to evaluate adrenal radiofrequency ablation (RFA) as a method of treatment in patients with severe adrenocorticotropic hormone (ACTH)-dependent Cushing syndrome, among whom bilateral adrenalectomy is not a suitable option.

Material and Methods:

Five patients with ACTH-dependent Cushing syndrome underwent RFA of both adrenal glands. Four of them presented with Cushing disease unsuccessfully treated with pituitary surgery and medical therapy, while one patient had ACTH-dependent Cushing syndrome due to pancreatic endocrine tumor with liver metastases. All patients were disqualified from adrenalectomy due to morbid obesity or lack of consent.

Results:

A technical success was obtained in all cases, with only one re-intervention necessitated by a cooling effect of the inferior vena cava. Despite pre-procedural adrenergic blockade, severe hypertension was noted during the procedure in three cases, this being treated immediately using direct-acting vasodilators. No complications occurred otherwise. In all cases, significant improvement of clinical symptoms was observed, as well as marked decreases in levels of serum cortisol, free urine cortisol, and dehydroepiandrosterone sulfate.

Conclusion:

Bilateral RFA under CT-guidance is technically feasible and clinical improvement can be achieved using the method. In patients disqualified from adrenal surgery, RFA might be considered as an alternative method of ACTH-dependent Cushing syndrome treatment.

Stereotactic body radiotherapy for adrenal oligometastasis in lung cancer patients

OBJECTIVE

To report our experience on stereotactic body radiotherapy (SBRT) in adrenal metastases from lung cancer.

METHODS

37 oligometastatic lung cancer patients with 38 adrenal metastases submitted to SBRT were retrospectively analyzed. SBRT was delivered by volumetric modulated arc therapy (VMAT) or helical tomotherapy (HT). Primary study end point was local recurrence-free survival (LR-FS) and secondary end points were distant-progression free survival (d-PFS) and overall survival (OS).

RESULTS

Median age was 67 years and primary tumor was non-small-cell lung cancer in 27 (73%) and small-cell lung cancer in 10 (27%) patients. Adrenal metastases were in the left side in 66% cases. Median prescribed dose was 30 Gy in 5 fractions for a median biologically equivalent dose (α/β ratio 10  Gy, BED10) of 48 Gy. Most patients (62%) were submitted to SBRT alone, while the others (38%) received chemo-, immune- or target- therapies. Median follow-up was 10.5 months, median OS 16 months and median d-PFS 3 months. 27 (70%) patients obtained a local control with a median LR-FS of 32 months. LR-FS was significantly related to BED10 with a better LC with BED10 ≥72 Gy, 1- and 2 year LR-FS rates were 54.1±11.6% and 45±12.7% vs 100 and 100% for BED ≤59.5 Gy and BED ≥72 Gy, respectively (p = 0.05). There was no severe toxicity.

CONCLUSION

SBRT was effective and safe in lung cancer adrenal metastases. A dose-response relationship was found between BED10 >72 Gy and better local control. No significant toxicity was registered thanks to the respect of dose constraints and suspension of chemo- and target-therapies.

ADVANCES IN KNOWLEDGE

SBRT with a BED10 >72 Gy is an effective treatment for adrenal oligometastatic lung cancer patients.

Outcomes following minimally invasive imagine-guided percutaneous ablation of adrenal glands

Whilst surgery represents the gold standard for the treatment of adrenal primary malignant tumors, metastatic involvement of the adrenal glands is generally approached conservatively; however, surgery for local control has been controversial, and several reports have described the utility of surgical removal in terms of prolonged survival in selected patients. Different techniques, including radiofrequency ablation (RFA), microwave ablation (MWA), laser induced thermal therapy (LITT), cryoablation (CRA), and chemical ablation, are employed in percutaneous image-guided ablation for primary and metastatic malignancies of the adrenal glands, in case of patients with multiple comorbidities or who refuse surgery. Technical success, clinical success and safety were analysed and discussed in this systematic review. Tumor size was found a significant determinant for local disease control; histology of the primary malignancy and coexistence of tumor elsewhere were correlated with prognosis. These procedures resulted to be feasible and safe, with hypertensive crisis representing the most common complication. Although there is lack of evidence in the literature concerning outcomes compared with surgery, percutaneous ablation may represent a useful therapeutic option for controlling unresectable adrenal metastases, offering patients opportunities for improved survival.

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.

Novel Dose Escalation Approaches for Stereotactic Body Radiotherapy to Adrenal Oligometastases: A Single-Institution Experience

OBJECTIVES

The role of local disease control in the oligometastatic setting is evolving. Stereotactic body radiation therapy (SBRT) is a noninvasive treatment option for oligometastases; however, using ablative radiation doses for adrenal metastases raises concern given the proximity to radiosensitive organs. Novel treatment techniques may allow for selective dose escalation to improve local control (LC) while minimizing dose to nearby critical structures.

MATERIALS AND METHODS

We retrospectively reviewed patients with adrenal oligometastases treated with SBRT from 2013 to 2018. LC, disease-free survival, and overall survival were estimated using Kaplan-Meier methods. Predictors of outcomes were evaluated by log-rank and Cox proportional hazard analyses.

RESULTS

We identified 45 adrenal oligometastases in 41 patients treated with SBRT. The median age at treatment was 67 years (range, 40 to 80). The most common primary histologies were non-small cell lung cancer (51%), renal cell carcinoma (24%), and small cell lung cancer (10%). The median prescription dose was 50 Gy (range, 25 to 60 Gy), with 30 (67%) lesions receiving ≥50 Gy and 14 (31%) receiving 60 Gy. In total, 26 (58%) lesions received a simultaneous-integrated boost. Of the 42 treatment simulations, 26 (62%) were supine, 5 (12%) prone, and 11 (26%) in the left lateral decubitus position. At a median follow-up of 10.5 months, there were 3 local failures with a 12-month LC rate of 96%.

CONCLUSIONS

Adrenal SBRT for oligometastatic disease is a feasible, noninvasive option with excellent LC and minimal toxicity. Lesions in close proximity to radiosensitive organs may benefit from dynamic patient positioning and selective simultaneous-integrated boost techniques to allow for dose escalation, while also limiting toxicity risks.

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.

The financial impact of SBRT for oligometastatic disease: A population-level analysis in Belgium

INTRODUCTION

There is a steady rise in Stereotactic Body RadioTherapy (SBRT) utilization in oligometastatic disease (OMD). This may generate important financial consequences for radiotherapy budgets. The National Institute for Health and Disability Insurance of Belgium (NIHDI) initiated a coverage with evidence development (CED) project for innovative radiotherapy, including SBRT, in 2011. A cost calculation and budget estimation for SBRT in the OMD setting was carried out.

MATERIALS AND METHODS

Predictive growth scenarios for future uptake of SBRT for OMD in Belgium were developed using demographics and CED data. The provider cost of SBRT for OMD in Belgium was calculated using the Time-Driven Activity-Based Costing (TD-ABC) model developed by ESTRO-HERO, alimented with national data on resources, treatments and operational parameters, and compared to the new reimbursement. Combining these, the future financial impact of this novel treatment indication for healthcare providers and payers in Belgium was evaluated.

RESULTS

The number of 428 OMDs treated with SBRT in Belgium in 2017 is expected to increase between 484 and 2073 courses annually by 2025. A provider cost of €4360 per SBRT was calculated (range: €3488-€5654), whereas the reimbursement covers between €4139 and €4654. Large variations in potential extra provider costs by 2025 ensue from the different scenarios, ranging between €1,765,993 and €9,038,754. Provider costs and reimbursement show good agreement.

CONCLUSION

Although the financial impact of SBRT for OMD in Belgium is forecasted to remain acceptable, even in extreme scenarios, further clinical trials and real-life clinical and financial monitoring with prospective data gathering are necessary to refine the data.

Stereotactic body radiotherapy (SBRT) for adrenal metastases of oligometastatic or oligoprogressive tumor patients

INTRODUCTION

Local ablative treatment strategies are frequently offered to patients diagnosed with oligometastatic disease. Stereotactic body radiotherapy (SBRT), as ablative treatment option, is well established for lung and liver metastases, whereas for isolated adrenal gland metastases the level of evidence is scarce.

MATERIAL AND METHODS

This single-institution analysis of oligometastatic or oligoprogressive disease was limited to patients who received SBRT to adrenal metastasis between 2012 and 2019. Patient, tumor, treatment characteristics, and dosimetric parameters were analyzed for evaluation of their effect on survival outcomes.

RESULTS

During the period of review 28 patients received ablative SBRT to their adrenal gland metastases. Most common primary tumors were non-small cell lung cancers (46%) with most patients diagnosed with a single adrenal gland metastasis (61%), which occurred after a median time of 14 months. SBRT was delivered to a median biological effective dose at α/β of 10 (BED₁₀) of 75 Gy (range: 58-151 Gy). Median gross tumor volume (GTV) and median planning target volume (PTV) were 42 and 111 mL, respectively. The homogeneity and conformity indices were 1.17 (range: 1.04-1.64) and 0.5 (range: 0.4.0.99), respectively, with the conformity index being affected by dose restrictions to organs at risk (OARs) in 50% of the patients. Overall response rate based on RECIST criteria was 86% (CR = 29%, PR = 57%) with 2-year local control (LC) of 84.8%, 2-year progression-free survival (PFS) of 26.3%, and 1-and 2-year overall survival (OS) of 46.6 and 32.0%, respectively. During follow up, only two local recurrences occurred. A trend for superior LC was seen if BED₁₀ was ≥75Gy (p = 0.101) or if the PTV was < 100 ml (p = 0.072). SBRT was tolerated well with only mild toxicity.

CONCLUSION

SBRT for adrenal metastases resulted in promising LC with low toxicity. Treatment response appeared to be superior, if SBRT was applied with higher BED. As the close proximity of OARs often limits the application of sufficiently high doses, further dose escalations strategies and techniques should be investigated in future.

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.

Usefulness of Stereotactic Body Radiation Therapy for Treatment of Adrenal Gland Metastases

Purpose: This study aimed to describe our institutional experience in the use of stereotactic body radiation therapy (SBRT) for the management of adrenal gland metastases from multiple primary cancers. Materials and Methods: We retrospectively reviewed 31 patients who underwent SBRT as treatment for 33 adrenal gland lesions in the academic radiotherapy department of Oscar Lambret cancer center between May 2011 and September 2018. The primary study endpoints were 1- and 2-year local control rates, defined as the absence of progression at the treatment site based on the response evaluation criteria in solid tumors (RECIST). Toxicities were graded in accordance with the Common Terminology Criteria for Adverse Events version 4.03. Results: The average tumor volume was 33.5 cm³ (standard deviation: 51.7 cm³), and the prescribed dose ranged from 30 to 55 Gy given in 3-9 fractions. The median biological effective dose was 112.5 Gy (range: 45-115.5 Gy), assuming α/β = 10. Considering progression at distant sites or death as competing events, the 1- and 2-year actuarial local control rates were 96.5% (95% confidence interval: 84.9-99.7) and 92.6% (95% confidence interval: 79.2-98.7), respectively. According to RECIST, a complete response was achieved in 10 (32.3%) lesions, a partial response in 10 (32.3%) lesions, and stability in 8 (25.8%) lesions. Three patients presented with local relapse at 8.8, 14, and 49.4 months. After a median follow-up of 18 months (range: 4.4-66.4), the median overall survival was 33.5 months (95% confidence interval: 17-not reached), while the median progression-free survival was 7.4 months (95% confidence interval: 3.8-14.1). Treatment-related toxicity was grade 1 or 2 in 42.4% of patients, including nausea (27.3%), abdominal pain (18.2%), vomiting (15.2%), and asthenia (9.1%). None of the patients developed acute grade ≥3 or late toxicity. Conclusion: SBRT seems to be a safe and effective treatment for adrenal gland metastases in patients whose primary tumor and metastatic spread are controlled by systemic treatment. With a 2-year local control rate of 92.6%, SBRT may be considered as one of the first-line treatments in oligometastatic patients with adrenal metastases.

Percutaneous radiofrequency ablation of adrenal metastases from hepatocellular carcinoma: a single-center experience

BACKGROUND

The prognosis of adrenal metastases (AM) from hepatocellular carcinoma (HCC) with surgical contraindication was poor. This study evaluated the feasibility, safety and treatment efficacy of percutaneous ultrasound (US)-guided radiofrequency ablation (RFA) for the local treatment of AM originated from HCC.

METHODS

A retrospective study was carried out on 22 patients (21 male and 1 female, mean age, 53.0 ± 13.0 years) who had single AM (mean diameter, 4.0 ± 1.8 cm, range, 1.7-8.0 cm) originated from HCC and received US-guided percutaneous RFA at our institution. The diagnosis was established on typical radiologic findings. The primary technical success was defined as the tumour being completely ablated in the first RFA session. The secondary technical success was defined as tumour residual left from the first ablation was completely ablated by a second ablation session. Local tumour progression (LTP) and overall survival (OS) were estimated by using Kaplan-Meier analysis.

RESULTS

A total of 25 ablation sessions were performed. The primary technical success and the secondary technical success were 77.3% (17 of 22) and 86.4% (19 of 22), respectively, with the major complication rate at 4.5% (1 of 22). The median follow-up period after RFA was 10 months (3-55 months). During the follow-up period, five patients were detected LTP. The LTP at 3, 6, and 12 months were 15.8, 26.3, and 26.3%, respectively. Nine patients died of distant extra-adrenal metastases and another five of liver failure due to HCC. The OS at 6, 12, 24 months after RFA for AM were at 79.7, 52.6, and 32.9%, respectively.

CONCLUSION

Percutaneous US-guided RFA in the treatment of AM originated from HCC is feasible, safe and effective.

Real-Time Tumor-Tracking Radiotherapy and General Stereotactic Body Radiotherapy for Adrenal Metastasis in Patients With Oligometastasis

Background:

Precise local radiotherapy for adrenal metastasis can prolong the useful life of patients with oligometastasis. The aim of this retrospective, 2-center study was to establish the safety and effectiveness of real-time tumor-tracking radiotherapy and general stereotactic body radiotherapy in treating patients with adrenal metastatic tumors.

Materials and Methods:

Thirteen lesions in 12 patients were treated with real-time tumor-tracking radiotherapy (48 Gy in 8 fractions over 2 weeks) and 8 lesions in 8 patients were treated with general stereotactic body radiotherapy (40-50 Gy in 5-8 fractions over 2 weeks or 60-70 Gy in 10 fractions over 2 weeks). Overall survival rates, local control rates, and adverse effects were analyzed.

Results:

The actuarial overall survival rates for all patients at 1 and 2 years were 78.5% and 45.8%, respectively, with a median follow-up of 17.5 months, and the actuarial local control rates for all tumors at 1 and 2 years were 91.7% and 53.0%, respectively, with a median follow-up of 9 months. A complete local tumor response was obtained in 3 tumors treated by real-time tumor-tracking radiotherapy (lung adenocarcinomas with diameters of 35, 40, and 60 mm). There was a statistically significant difference in the local control between the groups treated by real-time tumor-tracking radiotherapy (100% at 1 year) and general stereotactic body radiotherapy (50% at 1 year; P < .001). No late adverse reactions at Grade 2 or higher were reported for either treatment group.

Conclusions:

This study showed that although both treatments are safe and effective, the real-time tumor-tracking radiotherapy is more effective than general stereotactic body radiotherapy in local control for adrenal metastasis.

The case for radiotherapy in a Value based environment

AIM

Describe the Value proposition for radiotherapy (RT) in the United States.

BACKGROUND

In the United States since 2005, two forces have worked to decrease RT cost per patient: Federal changes in reimbursement and hypofractionation of treatment courses. We theorize that these have driven stable reimbursement in the context of increasing technology of intensity modulation (IMRT) and image guidance (IGRT). This phenomenon provides increasing Value of the discipline to patients and systems.

MATERIALS AND METHODS

We searched the Medicare Physician/Supplier data for Program Payments per Person with Utilization for 2000 through 2016. This involves two databases: Enrollment Database (EDB) for 2000-2012 and Common Medicare Enrollment (CME) since 2013. RT payments to individual patients accessing services were retrieved.

RESULTS

Taking into account the change of calculation algorithm used by CMS in 2013, costs per patient were similar in 2012 and 2003, and 2016 and 2013.

CONCLUSIONS

In the United States, stabilizing costs in the face of increasing work, better outcomes, and decreased toxicity contributes to increasing RT value over the past 10 years.

Computed tomography-guided cryoablation for adrenal metastases: local control and survival

To evaluate the feasibility, local control, and survival after computed tomography (CT)-guided cryoablation for adrenal metastases.This study included 31 consecutive patients with adrenal metastases who were treated by CT-guided cryoablation in our center from July 2011 to October 2017. The technical success rate, local progression rate, local progression-free survival (LPFS), systemic progression-free survival (SPFS), and overall survival were assessed. The predictors of survival were determined using univariate and multivariate Cox regression analyses.The primary and secondary technical success rates were 90.3% and 100%, respectively. None of the patients experienced a hypertensive crisis. The local progression rate during follow-up was 19.4%. Systemic progression was found in 9 patients. The cumulative 1-, 3-, and 5-year LPFS rates were 80.6%, 37.8%, and 18.4%, respectively. The cumulative 1-, 3-, and 5-year SPFS rates were 77.4%, 31.9%, and 14.6%, respectively. The cumulative 1-, 3-, and 5-year overall survival rates were 83.9%, 45.0%, and 30.0%, respectively. The existence of an extra-adrenal tumor was a significant independent predictor of worse overall survival (P = .012). The mean overall survival durations were significantly different between patients with and without an extra-adrenal tumor (16.6 ± 2.4 vs 50.9 ± 4.5 months, P <.001).Our findings support that CT-guided cryoablation is a safe and effective method for controlling adrenal metastases and imply that this approach may improve the survival of patients with adrenal metastases.

Role of Daily Plan Adaptation in MR-Guided Stereotactic Ablative Radiation Therapy for Adrenal Metastases

PURPOSE

To study interfractional organ changes during magnetic resonance (MR)-guided stereotactic ablative radiation therapy for adrenal metastases and to evaluate the dosimetric advantages of online plan adaptation.

METHODS AND MATERIALS

Seventeen patients underwent a total of 84 fractions of video-assisted, respiration-gated, MR-guided adaptive radiation therapy to deliver either 50 Gy (5 fractions), 60 Gy (8 fractions), or 24 Gy (3 fractions). An MR scan was repeated before each fraction, followed by rigid coregistration to the gross tumor volume (GTV) on the pretreatment MR scan. Contour deformation, planning target volume (PTV) (GTV + 3 mm) expansion, and online plan reoptimization were then performed. Reoptimized plans were compared with baseline treatment plans recalculated on the anatomy-of-the-day ("predicted plans"). Interfractional changes in organs at risk (OARs) were quantified according to OAR volume changes within a 3 cm distance from the PTV surface, center of mass displacements, and the Dice similarity coefficient. Plan quality evaluation was based on target coverage (GTV and PTV) and high dose sparing of all OARs (V_36Gy, V_33Gy, and V_25Gy).

RESULTS

Substantial center of mass displacements were observed for stomach, bowel, and duodenum, 17, 27 and 36 mm, respectively. Maximum volume changes for the stomach, bowel, and duodenum within 3 cm of PTV were 23.8, 20.5, and 20.9 cm³, respectively. Dice similarity coefficient values for OARs ranged from 0.0 to 0.9 for all fractions. Baseline plans recalculated on anatomy-of-the-day revealed underdosage of target volumes and variable OAR sparing, leading to a failure to meet institutional constraints in a third of fractions. Online reoptimization improved target coverage in 63% of fractions and reduced the number of fractions not meeting the V_95% objective for GTV and PTV. Reoptimized plans exhibited significantly better sparing of OARs.

CONCLUSIONS

Significant interfractional changes in OAR positions were observed despite breath-hold stereotactic ablative radiation therapy delivery under MR-guidance. Online reoptimization of treatment plans led to significant improvements in target coverage and OAR sparing.

Thermal Ablation in the Management of Adrenal Metastasis Originating from Non-small Cell Lung Cancer: A 5-year Single-center Experience

Background:

Treatment of adrenal metastasis from lung carcinoma may prolong survival in the selected patients. However, not all patients can undergo surgery; thus, minimally invasive ablation procedures such as radiofrequency ablation (RFA) and microwave ablation (MWA) have gained acceptance as alternative treatment methods. This study summarized a 5-year single-center experience regarding the evaluation of safety and efficacy of computed tomography (CT)-guided thermal ablation in the management of adrenal metastasis originating from non-small cell lung cancer (NSCLC).

Methods:

The data of NSCLC patients ablated for adrenal metastasis at the Department of Diagnostic Imaging and Interventional Radiology, General Hospital Sotiria, were retrospectively analyzed. Patients were divided into two groups: RFA group and MWA group according to the therapeutic approaches. Preprocedural blood tests included measurement of international normalized ratio, partial thromboplastin time, and platelet enumeration. A dual-phase contrast-enhanced spiral CT was performed immediately after the procedure to assess the immediate response after ablation and to screen for related complications. Follow-up was performed with CT or magnetic resonance imaging at 1, 3, 6 months and 1 year after ablation and every 6 months thereafter.

Results:

A total of 99 ablation sessions in 71 patients with adrenal metastasis originating from NSCLC were included in the final analysis. Self-limited, postablation syndrome occurred in 16/99 (16.1%) of ablation sessions. All procedures were technically successful. Immediate postablation imaging showed no contrast enhancement of the ablated tumor in all patients. Follow-up imaging at 3 months revealed local tumor progression in 8 (22.8%) patients of the RFA group and 7 (19.4%) patients of MWA group, all of them underwent a second session successfully. The 1-year assessment revealed local recurrence of the ablated tumor in six patients (17.1%) of RFA group and seven patients (19.4%) of MWA group. Among these 71 patients, those with tumor size >3.5 cm had a higher local recurrence rate (65.2%, 15/23) than those with tumors ≤3.5 cm (16.7%, 8/48; P = 0.012). There was no significant difference in the median survival time between RFA (14.0 months) and MWA (14.6 months) groups (P > 0.05).

Conclusions:

RFA and MWA showed comparable efficacy and safety in adrenal metastasis treatment.

Progress in the Management of Primary Aldosteronism

Primary aldosteronism (PA) is now considered as one of leading causes of secondary hypertension, accounting for 5-10% of all hypertensive patients and more strikingly 20% of those with resistant hypertension. Importantly, those with the unilateral disease could be surgically cured when diagnosed appropriately. On the other hand, only a very limited portion of those suspected to have PA has been screened, diagnosed, or treated to date. With current advancement in medical technologies and genetic research, expanding knowledge of PA has been accumulated and recent achievements have also been documented in the care of those with PA. This review is aimed to have focused description on updated topics of the following; importance of PA screening both in the general and specialized settings and careful interpretation of screening data, recent achievements in hormone assays and sampling methods and their clinical relevance, and expanding knowledge on PA genetics. Improvement in workup processes and novel treatment options, as well as better understanding of the PA pathogenesis based on genetic research, might be expected to result in increased cure and better care of the patients.

Effectiveness and safety of CT-guided percutaneous radiofrequency ablation of adrenal metastases

OBJECTIVE

The imaging-guided percutaneous radiofrequency (RF) ablation of adrenal metastases is a relatively new treatment procedure, compared to the more widespread application of the technique for the treatment of liver and renal cancers. The present study aims to evaluate the safety and efficacy of the CT-guided percutaneous RF ablation of adrenal metastases in a cohort of patients.

METHODS

33 patients with 38 adrenal metastases who received percutaneous CT-guided RF ablation between 2012 to 2015 were retrospectively reviewed. The average diameter of the treated adrenal metastases was 3.0 ± 1.6 cm. The treatment outcomes, including presence of residual tumours, technical success rate, recurrence rate, and complications, were evaluated. Patients were followed up for every 3 months to monitor the progression of the disease.

RESULTS

Postoperative CT images showed the lack of tumour enhancement in 30 tumours (30/38 tumours, technical success rate = 78.9%), and residual disease was found in 7 tumours (7/37 tumours, 18.9%). The rate of residual disease was significantly lower in the group with tumour size <3 cm than the group with tumour size ≥3 cm (p = 0.025). The severe complication rate was 4.3%, and the mild complication rate was 48%, with intraoperative hypertensive crisis as the most frequently observed complication (27.3%). The follow-up data showed that 76.3% of patients had recurrence-free survival in 27.4 months.

CONCLUSION

The current study demonstrated that radiofrequency ablation is a relatively safe and effective treatment for controlling adrenal metastases, especially for patients with tumour size <3 cm. Advances in knowledge: Surgical resection of the adrenal metastases was advocated as one of the treatment options for patients. The present study showed that radiofrequency ablation is a relatively safe and effective treatment for controlling adrenal metastases.

Stereotactic Body Radiotherapy for Oligometastasis: Opportunities for Biology to Guide Clinical Management

Oligometastasis refers to a state of limited metastatic disease burden, in which surgical or ablative treatment to all known visible metastases holds promise to extend survival or even effect cure. Stereotactic body radiotherapy is a form of radiation treatment capable of delivering a high biologically effective dose of radiation in a highly conformal manner, with a favorable toxicity profile. Enthusiasm for oligometastasis ablation, however, should be counterbalanced against the limited supporting evidence. It remains unknown to what extent (if any) ablation influences survival or quality of life. Rising clinical equipoise necessitates the completion of randomized controlled trials to assess this, several of which are underway. However, a lack of clear identification criteria or biomarkers to define the oligometastatic state hampers optimal patient selection.This narrative review explores the evolutionary origins of oligometastasis, the steps of the metastatic process at which oligometastases may arise, and the biomolecular mediators of this state. It discusses clinical outcomes with treatment of oligometastases, ongoing trials, and areas of basic and translational research that may lead to novel biomarkers. These efforts should provide a clearer, biomolecular definition of oligometastatic disease and aid in the accurate selection of patients for ablative therapies.

[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.

Radiotherapy for renal cell carcinoma: renaissance of an overlooked approach

Conventional radiotherapy previously had a limited role in the definitive treatment of renal cell carcinoma (RCC), owing to the disappointing outcomes of several trials and the perceived radioresistance of this type of cancer. In this context, radiotherapy has been relegated largely to the palliation of symptoms in patients with metastatic disease, with variable rates of response. Following the availability of newer technologies that enable safe delivery of high-dose radiotherapy, stereotactic ablative radiotherapy (SABR) has become increasingly used in patients with RCC. Preclinical evidence demonstrates that RCC cells are sensitive to ablative doses of radiotherapy (≥8-10 Gy). Trials in the setting of intracranial and extracranial oligometastases, as well as primary RCC, have demonstrated excellent tumour control using this approach. Additionally, an awareness of the capacity of high-dose radiation to stimulate antitumour immunity has resulted in novel combinations of SABR with immunotherapies. Here we describe the historical application of conventional radiotherapy, the current biological understanding of the effects of radiation, and the clinical evidence supporting the use of ablative radiotherapy in RCC. We also explore emerging opportunities to combine systemic targeted agents or immunotherapies with radiation. Radiotherapy, although once an overlooked approach, is moving towards the forefront of RCC treatment.

Unusual tumour ablations: report of difficult and interesting cases

Image-guided ablations are nowadays applied in the treatment of a wide group of diseases and in different organs and regions, and every day interventional radiologists have to face more difficult and unusual cases of tumour ablation. In the present case review, we report four difficult and unusual cases, reporting some tips and tricks for a successful image-guided treatment.

Radiofrequency ablation compared with laparoscopic adrenalectomy for aldosterone-producing adenoma

BACKGROUND

Radiofrequency ablation (RFA) is an emerging treatment for primary aldosteronism owing to aldosterone-producing adenoma. Whether RFA could be an alternative treatment to laparoscopic adrenalectomy is unknown.

METHODS

This was a retrospective comparative study in patients with aldosterone-producing adenoma undergoing either laparoscopic adrenalectomy or CT-guided percutaneous RFA between 2004 and 2012. Short-term outcomes and long-term resolution rates of primary aldosteronism (normalized aldosterone to renin ratio), hypokalaemia and hypertension (BP lower than 140/90 mmHg without antihypertensive medical therapy) were evaluated.

RESULTS

Some 63 patients were included, 27 in the laparoscopic adrenalectomy group and 36 in the RFA group. RFA was associated with shorter duration of operation (median 12 versus 124 min; P < 0·001), shorter hospital stay (2 versus 4 days; P < 0·001), lower analgesic requirements (13 of 36 versus 23 of 27 patients; P < 0·001) and earlier resumption of work (median 4 versus 14 days; P = 0·006). Morbidity rates were similar in the two groups. With median follow-up of 5·7 (range 1·9-10·6) years, resolution of primary aldosteronism was seen in 33 of 36 patients treated with RFA and all 27 patients who had laparoscopic adrenalectomy (P = 0·180). Hypertension was resolved less frequently after treatment with RFA compared with laparoscopic adrenalectomy (13 of 36 versus 19 of 27 patients; P = 0·007). Hypokalaemia was resolved in all patients.

CONCLUSION

For patients with aldosterone-producing adenoma the efficacy of resolution of primary aldosteronism and hypertension was inferior after treatment with RFA compared with laparoscopic adrenalectomy.

Percutaneous microwave ablation of adrenal tumours under ultrasound guidance in 33 patients with 35 tumours: A single-centre experience

PURPOSE

The aim of this study was to investigate the efficacy and safety of percutaneous microwave ablation (MWA) of adrenal tumours under ultrasound (US) guidance.

MATERIALS AND METHODS

A total of 33 consecutive patients with 35 tumours were enrolled. The term 'technical success' is used to indicate whether the tumour was treated according to protocol and was covered completely by the ablation zone. Technical success, local tumour progression (LTP) and complications were recorded. For seven patients with eight biochemically active tumours, biochemical markers were recorded prior to and after the ablation procedure.

RESULTS

In this study, technical success was achieved in all cases. Follow-up imaging was performed on 31 patients with 33 tumours (excluding two patients who were lost to follow-up). LTP occurred for five tumours (15.2%) at a mean of 24 months of follow-up (range 3-82 months). In the subgroup analysis of tumour size and LTP, a significant difference was noted between tumours with a diameter ≤5 cm compared with those >5 cm (p < 0.01). For seven cases of metabolically active adrenal tumours, technical success was confirmed in all patients, and LTP occurred in one case of recurrent pheochromocytoma. All patients demonstrated the normalisation of abnormal biochemical markers after ablation. No major complications were observed.

CONCLUSION

Percutaneous MWA under US guidance is effective in terms of good local control of adrenal tumours with a diameter of less than or equal to 5 cm and is capable of treating biochemically active tumours harbouring clinical syndromes.