The therapeutic value of adrenalectomy in case of solitary metastatic spread originating from primary renal cell cancer

SEOM SOGUG clinical guideline for treatment of kidney cancer (2022)

Renal cancer is the seventh most common cancer in men and the tenth in women. The aim of this article is to review the diagnosis, treatment, and follow-up of renal carcinoma accompanied by recommendations with new evidence and treatment algorithms. A new pathologic classification of RCC by the World Health Organization (WHO) was published in 2022 and this classification would be considered a "bridge" to a future molecular classification. For patients with localized disease, surgery is the treatment of choice with nephron-sparing surgery recommended when feasible. Adjuvant treatment with pembrolizumab is an option for intermediate-or high-risk cases, as well as patients after complete resection of metastatic disease. More data are needed in the future, including positive overall survival data. Clinical prognostic classification, preferably IMDC, should be used for treatment decision making in mRCC. Cytoreductive nephrectomy should not be deemed mandatory in individuals with intermediate-poor IMDC/MSKCC risk who require systemic therapy. Metastasectomy can be contemplated in selected subjects with a limited number of metastases or long metachronous disease-free interval. For the population of patients with metastatic ccRCC as a whole, the combination of pembrolizumab-axitinib, nivolumab-cabozantinib, or pembrolizumab-lenvatinib can be considered as the first option based on the benefit obtained in OS versus sunitinib. In cases that have an intermediate IMDC and poor prognosis, the combination of ipilimumab and nivolumab has demonstrated superior OS compared to sunitinib. As for individuals with advanced RCC previously treated with one or two antiangiogenic tyrosine-kinase inhibitors, nivolumab and cabozantinib are the options of choice. When there is progression following initial immunotherapy-based treatment, we recommend treatment with an antiangiogenic tyrosine-kinase inhibitor. While no clear sequence can be advocated, medical oncologists and patients should be aware of the recent advances and new strategies that improve survival and quality of life in the setting of metastatic RC.

Imaging Recommendations for Diagnosis, Staging, and Management of Adrenal Tumors

Adrenal glands are affected by a wide variety of tumors apart from infective and inflammatory lesions and their noninvasive characterization on imaging is important for the management of these patients. Incidentalomas form the major bulk of adrenal tumors and differentiation of benign adenomas from other malignant lesions, especially in patients with a known malignancy, guide further management. Imaging is an integral part of management along with clinical and biochemical features. The cornerstone of clinical and biochemical evaluation of adrenal tumors is to determine whether the lesion is functional or nonfunctional. Computed tomography (CT) is considered as the workhorse for imaging evaluation of adrenal lesions. CT densitometry and CT contrast washout characteristics are quite reliable in differentiating adenomas from malignant lesions. CT is also the modality of choice for the evaluation of resectability and staging of primary adrenal tumors. Magnetic resonance imaging (MRI) has superior contrast resolution compared to other morphological imaging modalities and is generally used as a problem-solving tool. MRI chemical shift imaging can also be used to reliably detect adrenal adenomas. Ultrasonography (USG) is used as a screening tool that is usually followed by either CT or MRI to better characterize the tumor and it is not routinely used for assessing the resectability, staging, and characterization of adrenal tumors. Another important role of USG is in image-guided sampling of tumors. Fluorodeoxyglucose positron emission tomography-computed tomography and other nuclear medicine modalities are a valuable addition to morphological imaging modalities. Image-guided interventions also play an important role in obtaining tissue samples where diagnostic imaging is not able to characterize adrenal tumors. In the functioning of adrenal tumors, adrenal venous sampling is widely used to accurately lateralize the secreting tumor.

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.

Renal cell cancer treatment: an expert panel recommendation from the Latin American cooperative group-genitourinary and the Latin American renal cancer group: focus on surgery

Background:

Renal cell cancer (RCC) is one of the 10 most common cancers in the world, and its incidence is increasing, whereas mortality is declining only in developed countries. Therefore, two collaborative groups, The Latin American Oncology Cooperative Group-Genitourinary Section (LACOG-GU) and the Latin American Renal Cancer Group (LARCG), held a consensus meeting to develop this guideline.

Methods:

Issues (134) related to the treatment of RCC were previously formulated by a panel of experts. The voting panel comprised 26 specialists (urologists and medical oncologists) from the LACOG-GU/LARCG. A consensus was reached if 75% agreement was achieved. If there was less concordance, a new discussion was undertaken, and a consensus was determined by the most votes after a second voting session.

Results:

The expert meeting provided recommendations that were in line with the global literature; 75.0% of the recommendations made by the panel of experts were evidence-based level A, 22.5% of the recommendations were level B, and 2.5% of the recommendations were level D.

Conclusions:

This review suggests recommendations for the surgical treatment of RCC according to the LACOG-GU/LARCG experts.

Laparoscopic adrenalectomy: lateral transperitoneal versus posterior retroperitoneal approach - prospective randomized trial

INTRODUCTION

Laparoscopic adrenalectomy has become the gold standard of surgical treatment for benign adrenal masses. Two alternative surgical approaches are currently advocated: the lateral transperitoneal approach (LTA) and the posterior retroperitoneal approach (PRA). Several randomized trials have compared LTA to PRA, but most of them included small numbers of patients or had stringent inclusion criteria.

AIM

To compare clinical results of LTA and PRA endoscopic adrenalectomies for tumors < 8 cm with wide inclusion criteria.

MATERIAL AND METHODS

We randomized 77 patients to either LTA (n = 33) or PRA (n = 44). The groups were comparable in terms of age, gender proportions, body mass index, tumor size, clinical and pathological diagnosis. We analyzed duration of surgery, intraoperative blood loss, postoperative pain, length of hospital stay and postoperative morbidity.

RESULTS

The follow-up concerned 98.8% of patients and was on average 28 (8-47) months long. There were no conversions. We identified significantly lower intensity of pain assessed 24 h after surgery in the PRA group (3.4 ±1), as compared to LTA (4.2 ±1), with lower prevalence of shoulder pain (2.3% vs. 30.3%, respectively). Postoperative hospital stay was shorter in the PRA (1.14 ±0.4) than in the LTA (1.36 ±0.5) group. Perioperative morbidity concerned 4 patients in each group with pain requiring oral analgesia > 7 days.

CONCLUSIONS

To our knowledge this is the largest prospective randomized study comparing LTA to PRA. We demonstrated safety, efficacy and very low morbidity of both techniques. The PRA proved superior to LTA in terms of lower intensity of postoperative pain and shorter hospital stay.

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma 2017

In this report, we update the previously published Saudi guidelines for the evaluation and medical and surgical management of renal cell carcinoma. It is categorized according to the stage of the disease using the tumor node metastasis staging system 7th edition. The recommendations are presented with supporting evidence level.

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma 2017

In this report, we update the previously published Saudi guidelines for the evaluation and medical and surgical management of renal cell carcinoma. It is categorized according to the stage of the disease using the tumor node metastasis staging system 7th edition. The recommendations are presented with supporting evidence level.

Clinical, Biochemical, and Radiological Characteristics of a Single-Center Retrospective Cohort of 705 Large Adrenal Tumors

OBJECTIVE

To characterize large adrenal tumors (≥4 cm in diameter) and to identify features associated with malignancy.

PATIENTS AND METHODS

We investigated the clinical, biochemical, and imaging characteristics in a large retrospective single-center cohort of patients with adrenal tumors of 4 cm or more in diameter during the period of January 1, 2000, through December 31, 2014.

RESULTS

Of 4085 patients with adrenal tumors, 705 (17%) had adrenal masses measuring 4 cm or more in diameter; of these, 373 (53%) were women, with a median age of 59 years (range, 18-91 years) and median tumor size of 5.2 cm (range, 4.0-24.4 cm). Underlying diagnoses were adrenocortical adenomas (n=216 [31%]), pheochromocytomas (n=158 [22%]), other benign adrenal tumors (n=116 [16%]), adrenocortical carcinomas (n=88 [13%]), and other malignant tumors (n=127 [18%]). Compared with benign tumors, malignant tumors were less frequently diagnosed incidentally (45.5% vs 86.7%), were larger (7 cm [range, 4-24.4 cm] vs 5 cm [range, 4-20 cm]), and had higher unenhanced computed tomographic (CT) attenuation (34.5 Hounsfield units [HU] [range, 14.1-75.5 HU] vs 11.5 HU [range, -110 to 71.3 HU]; P<.001). On multivariate analysis, older age at diagnosis, male sex, nonincidental mode of discovery, larger tumor size, and higher unenhanced CT attenuation were all found to be statistically significant predictors of malignancy.

CONCLUSION

The prevalence of malignancy in patients with adrenal tumors of 4 cm or more in diameter was 31%. Older age, male sex, nonincidental mode of discovery, larger tumor size, and higher unenhanced CT attenuation were associated with an increased risk for malignancy. Clinical context should guide management in patients with adrenal tumors of 4 cm or more in diameter.

An isolated metachronous metastasis to the adrenal gland from a pancreatic neuroendocrine tumor: A case report

INTRODUCTION

Pancreatic neuroendocrine tumors are rare. Treatment includes aggressive local management of the primary lesion and metastases, and systemic somatostatin. This is the first report of an isolated metachronous metastasis to the adrenal gland from a pancreatic neuroendocrine tumor that presented 90 months after the primary tumor.

PRESENTATION OF CASE

The patient presented as a 53yo man with a left upper quadrant mass and synchronous metastases to the spleen and liver (pancreatic neuroendocrine tumor T4N0M1, Stage IV), which were resected (CD56-, synaptophysin+, chromogranin+, Ki-67<1%). Over the next 90 months, he underwent five procedures to treat hepatic recurrences (2 liver resections and 3 percutaneous radiofrequency ablations). Serum PIVKA levels were elevated prior to treatment of four of six lesions and returned to baseline after therapy. He presents now, asymptomatic, with a right adrenal mass found on routine imaging and no other lesions. Serum PIVKA was elevated to 44mg/dL. The adrenal gland was resected and shown to be a metastasis (CD56+, synaptophysin+, chromogranin+, Ki-67 15-20%).

DISCUSSION

This patient's clinical course reflects aggressive local therapy of the primary lesion and multiple metastatic lesions to three organs (liver, spleen, adrenal) over nearly eight years. The utility of serum PIVKA levels in patients with pancreatic neuroendocrine tumors is not previously reported and needs further investigation.

CONCLUSION

This patient has a pancreatic neuroendocrine tumor with metastases to the spleen, liver and adrenal gland and elevated PIVKA levels with recurrent disease. These unique clinical features add to the diversity of clinical presentation of these rare tumors.

Saudi Oncology Society and Saudi Urology Association combined clinical management guidelines for renal cell carcinoma

This is an update to the previously published Saudi guidelines for the evaluation, medical, and surgical management of patients diagnosed with renal cell carcinoma (RCC). It is categorized according to the stage of the disease using the tumor node metastasis staging system 7(th) edition. The guidelines are presented with supporting evidence level, they are based on comprehensive literature review, several internationally recognized guidelines, and the collective expertise of the guidelines committee members (authors) who were selected by the Saudi Oncology Society and Saudi Urological Association. Considerations to the local availability of drugs, technology, and expertise have been regarded. These guidelines should serve as a roadmap for the urologists, oncologists, general physicians, support groups, and healthcare policy makers in the management of patients diagnosed with RCC.

The Role of Adrenalectomy in Renal Cancer

CONTEXT

Since the 1960s, routine ipsilateral adrenalectomy (IA) has been considered an integral step in the removal of renal tumors as a part of a radical nephrectomy. However, recent data from the past decade have narrowed the indications for adrenalectomy and called into question the need for adrenalectomy at all in the treatment of renal cell carcinoma (RCC).

OBJECTIVE

We sought to identify the role of adrenalectomy in the treatment of RCC. Specifically, we wanted to answer the following questions: What is the incidence of ipsilateral adrenal involvement by cancer? How reliable is preoperative imaging? What is the rate of ipsilateral and contralateral metachronous recurrence? And finally, what are the potential noncancer sequelae from unnecessary removal of the adrenal gland?

EVIDENCE ACQUISITION

A systematic literature search of Embase, PubMed, Cochrane, and Ovid Medline was performed to identify studies evaluating the role of adrenalectomy during RCC surgery. Only articles published in English from the years 2000-2015 were included. Case reports, articles about primary adrenal tumors, letters to the editor, and surgical technique papers were excluded.

EVIDENCE SYNTHESIS

We found little evidence to suggest that routine IA is associated with a higher risk of short-term surgical or medical complications. We did not find evidence that IA is associated with improved cancer control. Tomographic preoperative imaging of the adrenal gland demonstrating no cancer involvement is rarely wrong (<1% of the time), and the few adrenal lesions missed on imaging can often be identified intraoperatively. Some evidence indicates that IA may be associated with worse long-term survival. Adrenalectomy rates have been decreasing in recent years, reflecting a changing practice pattern.

CONCLUSIONS

IA at the time of kidney surgery for a renal mass should be performed only if radiographic or intraoperative evidence indicates adrenal gland involvement.

PATIENT SUMMARY

We sought to define the role of adrenalectomy in patients with kidney cancer. Although there are not high-quality studies to answer this question definitively, we conclude that the adrenal gland should be spared unless there is clinical evidence of adrenal involvement.

Surgical resection of metastases to the adrenal gland: a single center experience

BACKGROUND

Only limited data exist on the treatment and outcome of adrenal metastases that derive from different primary tumor entities. Due to the lack of evidence, it is difficult to determine the indication for surgical resection.

METHODS

We assessed the outcome of 45 patients (28 men, 17 women) with adrenal metastases who underwent surgery (1990-2014). The median age at the time of adrenal surgery was 62 years (range 44-77 years). We were able to evaluate follow-up data of 41 patients.

RESULTS

Primary tumor types were liver n = 12 (hepatocellular carcinoma n = 9, cholangiocellular carcinoma n = 2, sarcoma n = 1), upper GI tract n = 5 (esophagus n = 2, stomach n = 3), lung n = 9, kidney n = 6, neuroendocrine tumors n = 3, colon n = 2, ovarial n = 2, melanoma n = 2, others n = 4. The overall median survival time was 14 months (95 % CI 8.375-19.625). The survival rates at 1, 2, 5, and 10 years were 60, 31, 21, and 11 %, respectively. There were statistically significant differences in the survival time according to the resection status (R0 vs. R1/R2) (p < 0.001) and the type of the primary tumor (p = 0.009), while the metachronous or synchronous occurrence of adrenal metastases did not affect the prognosis.

CONCLUSIONS

Resection of adrenal metastases can improve the survival if patients are carefully selected, the tumor is completely resected, and the intervention is integrated into a multidisciplinary oncologic treatment strategy.

Saudi oncology society and Saudi urology association combined clinical management guidelines for renal cell carcinoma

In this report, updated guidelines for the evaluation, medical and surgical management of renal cell carcinoma are presented. They are categorized according the stage of the disease using the tumor node metastasis staging system 7(th) edition. The recommendations are presented with supporting evidence level.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Incidence of synchronous and metachronous adrenal metastases following tumor nephrectomy in renal cell cancer patients: a retrospective bi-center analysis

INTRODUCTION

Synchronous adrenalectomy has become dispensable since retrospective studies have demonstrated no survival benefit when preoperative imaging was normal. The aim of this large bi-institutional study was to determine the appearance of synchronous and metachronous metastases to the adrenal gland as detected by computed tomography and positron emission tomography or magnetic resonance imaging with consecutive surgical removal of suspicious lesions.

MATERIALS AND METHODS

We retrospectively reviewed the clinico-pathological records of 2720 patients from two urological centers who underwent radical or partial nephrectomy due to kidney cancer disease. Synchronous adrenalectomy was carried out in 548 of all cases (20.2%). Metachronous adrenalectomy was performed in 24 cases due to suspicious imaging in follow-up.

RESULTS

Metastatic spread in patients with synchronous adrenalectomy was found in 29/548 cases (5.3%), as suspected. In metachronous procedures positive pathological results were found in 24 of 24 cases. Among them 54% of all tumor recurrences were detected in the contralateral adrenal gland.

CONCLUSIONS

In case of preoperative suspicious imaging an intraoperative frozen section should be performed. Radiological investigations are of high diagnostic value for detecting metachronous tumor growth into the adrenal gland. Surgery in this scenario should be recommended due to the high malignancy rate reported here.

Adrenalectomy improves outcomes of selected patients with metastatic carcinoma

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Operative treatment of renal cell carcinoma]

Renal cell carcinoma represents the fifth most frequent malignant tumor in humans. At the time of diagnosis, 20% of the patients already manifest metastases. A further 20-30% of the patients develop systemic metastases in the postoperative course. Despite continued advances in pharmacological treatment options, cancer surgery tailored to the individual tumor findings constitutes the only curative treatment option.

Contrast-enhanced endoscopic ultrasonography (CE-EUS) findings in adrenal metastasis from renal cell carcinoma

Solitary adrenal metastasis is often difficult to distinguish from benign adrenal tumor using only plain computed tomography (CT) scanning. We describe a solitary left adrenal gland mass in a patient who had undergone simultaneous gastrectomy and right nephrectomy for advanced gastric cancer and renal cell carcinoma (RCC), respectively. Contrast-enhanced endoscopic ultrasonography (CE-EUS) findings indicated a hypervascular adrenal mass, and EUS-guided fine needle aspiration (EUS-FNA) revealed clear cell carcinoma. Adrenalectomy confirmed metastatic clear cell carcinoma of the kidney.

[What is the importance of kidney cancer surgery in contrast with targeted therapies?]

Despite the extraordinary development of the medical treatment of kidney cancer, its treatment remains very surgical in localized and metastatic stage. Advances in surgery have accompanied the advent of targeted therapies. The laparoscopy has become the reference procedure for radical nephrectomy in the case of T1-T2 tumors. Partial nephrectomy, currently widespread, should be the first surgical procedure to consider in cases of tumors less than 4 cm. Partial nephrectomy for tumors between 4 and 7 cm is feasible for selected patients with favorable tumor localization. In the future, the use of neo-adjuvant anti-angiogenesis agents could broaden the scope of partial nephrectomy. Laparoscopic partial nephrectomy is spreading but is still considered as a therapeutic option, conducted in reference centres. In case of metastatic disease, pending the results of randomized trials including patients on anti-angiogenesis agents, cytoreductive nephrectomy remains indicated for patients in good general condition with kidney cancer metastatic immediately.

Management of the adrenal gland during partial nephrectomy

PURPOSE

Nephron sparing surgery is an increasingly used alternative to Robson's radical nephroadrenalectomy. The indications for adrenalectomy in patients undergoing partial nephrectomy are not clearly defined and some surgeons perform it routinely for large and/or upper pole renal tumors. We analyzed initial management and oncological outcomes of adrenal glands after open partial nephrectomy.

MATERIALS AND METHODS

Institutional review board approval was obtained for this study. During partial nephrectomy the ipsilateral adrenal gland was resected if a suspicious adrenal nodule was noted on radiographic imaging, or if intraoperative findings indicated direct extension or metastasis.

RESULTS

Concomitant adrenalectomy was performed in 48 of 2,065 partial nephrectomies (2.3%). Pathological analysis revealed direct invasion of the adrenal gland by renal cell carcinoma (1), renal cell carcinoma metastasis (2), other adrenal neoplasms (3) or benign tissue (42, 87%). During a median followup of 5.5 years only 15 patients underwent subsequent adrenalectomy (0.74%). Metachronous adrenalectomy was ipsilateral (10), contralateral (2) or bilateral (3), revealing metastatic renal cell carcinoma in 11 patients. Overall survival at 5 years in patients undergoing partial nephrectomy with or without adrenalectomy was 82% and 85%, respectively (p = 0.56).

CONCLUSIONS

Adrenalectomy should not be routinely performed during partial nephrectomy, even for upper pole tumors. We propose concomitant adrenalectomy only if a suspicious adrenal lesion is identified radiographically or invasion of the adrenal gland is suspected intraoperatively. Using these criteria adrenalectomy was avoided in more than 97% of patients undergoing partial nephrectomy. Even using such strict criteria only 13% of these suspicious adrenal nodules contained cancer. The rarity of metachronous adrenal metastasis and the lack of an observable benefit to concomitant adrenalectomy support adrenal preservation during partial nephrectomy except as previously outlined.

Solitary adrenal metastasis in a patient with sigmoid colon cancer; report of a case

A 73-year-old man had sigmoidectomy for sigmoid colon cancer in December 2001. Although he was followed regularly with chemotherapy, his serum carcinoembryonic antigen (CEA) increased on August 2002. Abdominal computed tomography and magnetic resonance imaging showed a right adrenal mass and no other abnormality. The preoperative diagnosis was a solitary adrenal metastasis from sigmoid colon cancer; the lesion was removed in September 2002. On pathology, adrenal metastasis was confirmed. Although the patient's serum CEA normalized soon thereafter, 12 months after adrenalectomy, the CEA again increased; the patient had local recurrence of the resected adrenal lesion and liver metastasis. Therefore, the patient was given systemic chemotherapy, but his condition deteriorated, and he died 38 months after adrenalectomy. Adrenal metastasis from colorectal cancer is not unusual; however, a solitary metastasis is rarely found and resected surgically. As surgical treatment of the metastatic lesion could improve patients' prognosis to some extent if it is detected early, the possibility of adrenal metastasis should be kept in mind when colorectal cancer patients are followed.

Renal cell carcinoma guideline

OBJECTIVES

The European Association of Urology (EAU) Guideline Group for renal cell carcinoma (RCC) prepared this guideline to help urologists assess the evidence-based management of RCC and to incorporate the guideline recommendations into their clinical practice.

METHODS

The recommendations provided in the current guideline are based on a systematic literature search using MedLine, the Cochrane Central Register of Controlled Trials, and publications and review articles.

RESULTS

A limited number of prospective randomised studies are available with high-level evidence. Most publications concerning RCC are based on retrospective analyses, including some larger multicentre validation studies and well-designed controlled studies.

CONCLUSIONS

It must be stressed that the current guideline contains information for the treatment of an individual patient according to a standardised general approach. Updated recommendations concerning diagnosis, treatment, and follow-up can improve the clinical handling of patients with RCC.

Equal oncologic results for laparoscopic and open resection of adrenal metastases

BACKGROUND

While open adrenalectomy is often performed for malignant adrenal tumors, increasing numbers of surgeons have adopted the laparoscopic approach. The postoperative benefits of laparoscopic adrenalectomy are well established, but questions persist about long-term oncologic outcomes when used for malignant lesions. The current study was undertaken to compare laparoscopic with open adrenalectomy for isolated adrenal metastases.

METHODS

From March 1993 to April 2006, 20 adults underwent adrenalectomy for isolated metastases to the adrenal gland. Three patients were excluded because of a concomitant nephrectomy (2) and an unresectable tumor (1). Patient demographics, tumor characteristics, and oncologic outcomes of the remaining patients were reviewed and analyzed.

RESULTS

Of the 17 patients who received adrenalectomy for an isolated metastasis, there were 11 men and 6 women with a mean age of 58 +/- 3 y. Nine patients underwent laparoscopic adrenalectomy, and 8 patients had open adrenalectomy. Laparoscopic adrenalectomy was associated with less blood loss (63 +/- 8 mL versus 2207 +/- 1067 mL, P=0.05), a lower complication rate (0% versus 63%, P=0.009), and a shorter length of stay (2.4 +/- 0.6 d versus 5.4 +/- 0.7 d, P=0.02). With a follow-up of up to 97 mo, there were no port site metastases, no tumor recurrences, and no difference in survival between laparoscopic and open adrenalectomy (median 19 months versus 17 months, 5-year survival 34% versus 54%, P=0.96).

CONCLUSIONS

When not limited by tumor size or invasion of surrounding tissue, laparoscopic adrenalectomy is a safe alternative to open adrenalectomy with equivalent oncologic outcomes and clear postoperative benefit for patients with isolated metastases to the adrenal gland.

Tumor size improves the accuracy of TNM predictions in patients with renal cancer

OBJECTIVES

Current staging for renal cancer (RC) does not directly rely on tumor size. We examined the increment in accuracy related to inclusion of pathologically determined tumor size in prediction of nodal metastases (N+), distant metastases (M+), and cancer-specific survival (CSS).

METHODS

Partial or radical nephrectomy was performed in 2245 patients with clear cell histology. Pathologic stages were T1a in 566, T1b in 490, T2 in 303, T3 in 831, and T4 in 55 patients. Tumor size was 0.5-25 cm (mean, 6.8). Multivariate models relied on 1997 and 2002 TNM variables and addressed N+, M+ disease, and CCS. Their accuracy was compared according to either the presence or absence of tumor size.

RESULTS

In all univariate and multivariate models, tumor size was a statistically significant predictor of all outcomes (p< or =0.001). In all multivariate models, tumor size added between 3.7% and 0.8% to predictive accuracy of either 1997 or 2002 TNM categories.

CONCLUSIONS

Tumor size represents a highly significant, multivariate, and informative predictor of RC outcomes and may warrant inclusion in future TNM revisions.