Incidence and outcome of patients with adrenal metastases of renal cell cancer

Long-term survival following adrenalectomy for secondary adrenal tumors: A systematic review and meta-analysis

BACKGROUND

Secondary adrenal tumors (SATs) are uncommon, and the benefits of adrenalectomy for SATs have not been well-established. A systematic review and meta-analysis were conducted to assess the survival benefits of adrenalectomy for SATs.

METHOD

ology: A systematic literature search was performed (1990-2022). The inclusion criteria included a known primary tumor with confirmed adrenal metastasis in patients who underwent adrenalectomy. The primary outcome was the overall survival (OS).

RESULTS

A total of 26 studies were included, with 2279 patients. The average age at the time of diagnosis was 61.1 years. Lung cancer was the most common primary tumor. The average time from primary tumor diagnosis to identification of adrenal metastasis was 17 months. The median OS was 35.2 months. One, three, and five-year OS were 79.7 ​%, 49.1 ​%, and 37.9 ​%, respectively.

CONCLUSION

The results of this review provide insight into the long-term survival of patients with SATs who underwent adrenalectomy. The study highlights the need for further research to identify the risk factors that play a role in the outcome of adrenalectomy in patients with SATs.

Role of metastasectomy in the management of renal cell carcinoma

Treatment of metastatic renal cell carcinoma (mRCC) has evolved with the development of a variety of systemic agents; however, these therapies alone rarely lead to a complete response. Complete consolidative surgery with surgical metastasectomy has been associated with improved survival outcomes in well-selected patients in previous reports. No randomized control trial exists to determine the effectiveness of metastasectomy. Therefore, reviewing observational studies is important to best determine which patients are most appropriate for metastasectomy for mRCC and if such treatment continues to be effective with the development of new systemic therapies such as immunotherapy. In this narrative review, we discuss the indications for metastasectomies, outcomes, factors associated with improved survival, and special considerations such as location of metastasis, number of metastases, synchronous metastases, and use of systemic therapy. Additionally, alternative treatment options and trials involving metastasectomy will be reviewed.

Elective partial and radical nephrectomy in patients with renal cell carcinoma in CT1B stadium

Background/Aim. In renal cell carcinoma (RCC) the choice of surgical technique, radical (RN) or partial nephrectomy (PN) is still centre dependant because there still are no absolute recommendations for this approach. This study aims to analyze the oncological aspects, time until recurrent disease appears and cancer-specific survival in patients with RCC in T1bN0?0 depending on the type of surgical procedure partial or radical nephrectomy. Methods. A clinical observational study of a series of cases was conducted that analyzed data of 154 patients operated in our institution with a mean follow up a period not less than five years. The inclusion criteria included: renal tumours 4-7 cm, histopathological confirmation of RCC, absence of metastasis and normal serum creatinine. Exclusion criteria included: the presence of other malignancies, solitary functional kidney or comorbidities that can compromise renal function, bilateral tumours or unilateral multiple tumours. Results. The study analyzed data of 154 patients, 97 radical nephrectomies and 57 patients that underwent partial nephrectomy. Analyzing cancer-specific survival in four patients with RN there was a disease advancement that led to a lethal outcome, one PN patient died as a result of local relapse and distant metastasis. Conclusion. Based on our results PN is a good and safe treatment option for patients with RCC in T1b stadium. Partial nephrectomy offers a similar tumour control and better cancer-specific survival.

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.

Clinical and prognostic factors for renal parenchymal, pelvis, and ureter cancers in SEER registries: collaborative stage data collection system, version 2

BACKGROUND

The American Joint Committee on Cancer's (AJCC) 7th edition cancer staging manual reflects recent changes in cancer care practices. This report assesses changes from the AJCC 6th to the AJCC 7th edition stage distributions and the quality of site-specific factors (SSFs).

METHODS

Incidence data for renal parenchyma and pelvis and ureter cancers from 18 Surveillance, Epidemiology, and End Results (SEER) registries were examined, including staging trends during 2004-2010, stage distribution changes between the AJCC 6th and 7th editions, and SSF completeness for cases diagnosed in 2010.

RESULTS

From 2004 to 2010, the percentage of stage I renal parenchyma cancers increased from 50% to 58%, whereas stage IV and unknown stage cases decreased (18% to 15%, and 10% to 6%, respectively). During this period, the percentage of stage 0a renal pelvis and ureter cancers increased from 21% to 25%, and stage IV and unknown stage tumors decreased (20% to 18%, and 7% to 5%, respectively). Stage distributions under the AJCC 6th and 7th editions were about the same. For renal parenchymal cancers, 71%-90% of cases had known values for 6 required SSFs. For renal pelvis and ureter cancers, 74% of cases were coded as known for SSF1 (WHO/ISUP grade) and 47% as known for SSF2 (depth of renal parenchymal invasion). SSF values were known for larger proportions of cases with reported resections.

CONCLUSIONS

Stage distributions between the AJCC 6th and 7th editions were similar. SSFs were known for more than two-thirds of cases, providing more detail in the SEER database relevant to prognosis.

Should ipsilateral solitary adrenal involvement in renal cell carcinoma be staged as M1?

OBJECTIVE

In 2009, the TNM classification of malignant tumors was revised, and the renewal of the T2-4 stage in renal cell carcinoma was adopted. To date, however, the staging of ipsilateral solitary adrenal involvement in renal cell carcinoma has not been sufficiently evaluated.

METHODS

We retrospectively reviewed the adrenal involvement in renal cell carcinoma among 1033 patients admitted to the Department of Urology at Hamamatsu University Hospital, Japan, and affiliated hospitals between 1978 and 2007.

RESULTS

We identified 23 of the 1033 patients (2.2%) with adrenal involvement in renal cell carcinoma. In renal cell carcinoma patients with adrenal involvement, a tendency for a high histological grade of tumor and lower overall survival (P< 0.0001) was observed. Ipsilateral solitary adrenal involvement was detected in 4 of the 23 patients (15%), whereas 2 of the 23 (9%) had direct invasion of the adrenal gland. All tumors in the 14 patients without ipsilateral solitary adrenal involvement and recurrent adrenal tumors were classified as Stage IV. The TNM classification of the four renal cell carcinoma patients with ipsilateral solitary adrenal involvement was determined to be either pT3N0M0 or pT1-3N0M1. Among the four patients with ipsilateral solitary adrenal involvement, three patients had recurrent tumors, despite complete surgical resection. Two of these patients died of metastatic renal cell carcinoma after 2 and 10 years of radical nephrectomy, respectively, whereas one was still alive with cancer 3 years after the initial radical nephrectomy. The fourth had no recurrence of renal cell carcinoma, but did develop synchronous gall bladder cancer (pT2N0M0) and bile duct cancer (pT2N0M0).

CONCLUSIONS

Adrenal involvement in primary renal cell carcinoma was observed more frequently in patients with advanced tumor stages. In the TNM classification system, we propose that ipsilateral solitary adrenal involvement in renal cell carcinoma should be staged as M1.

[Significance of ipsilateral adrenalectomy in surgery for renal cell carcinoma]

PURPOSE

The aim of this study is to analyze the incidence of involvement of ipsilateral adrenal gland from renal cell carcinoma and assess the actual significance of ipsilateral adrenalectomy at nephrectomy.

PATIENTS AND METHODS

From 1981 to 2007, 588 patients were diagnosed as having renal cell carcinoma pathologically at our institution. Of those patients, we retrospectively reviewed the clinicopathologic data in the 426 renal cell carcinoma patients who were eligible for evaluation. Of the 426 patients, 193 (AD group) and the remaining 233 (AS group) underwent radical or partial nephrectomy with or without adrenalectomy, respectively.

RESULTS

Five patients (2.6%) of AD group had adrenal involvement and all of them presented T4 and/or M1 disease. The three patients presented direct involvement of adrenal gland, while metastasis in the remaining 2. All the 5 patients had disease progression after surgery and 4 of them died of disease. The remaining one patient, in whom interferon showed a remarkable response, has been alive with disease for 31 months. The ipsilateral adrenal gland was abnormal on preoperative computed tomography (CT) in 8 patients (1.8%), of whom, 4 had adrenal involvement. One of the five adrenal involvements was overlooked by CT. Thus, in this study, CT showed 80% sensitivity, 98% specificity, 99% negative predictive value and 50% positive predictive value. The 18 patients (7.7%) in AS group later developed nodal and/or visceral metastasis, while no solitary ipsilateral adrenal recurrence was observed in this group.

CONCLUSIONS

Ipsilateral adrenal involvement from renal cell carcinoma is rare, especially after the adrenal-sparing surgery. It is concluded that concomitant adrenalectomy appears to give a very limited therapeutic benefit in this

Renal cell carcinoma with bilateral synchronous adrenal gland metastases: a case report

Introduction

Renal cell carcinoma is characterized by its potential of metastasizing widely and to unusual sites, with the metastases occasionally preceding clinical recognition of the primary tumor. Synchronous bilateral adrenal metastases from renal cell carcinoma, without other metastases, are rare and, to our knowledge, only 17 cases have been published in the literature to date. In general, patients with synchronous bilateral adrenal metastases from renal cell carcinoma have a poor prognosis.

Case presentation

We report a case of right-sided renal cell carcinoma with simultaneous bilateral adrenal metastases in a 58-year-old woman. The primary tumor was localized in the upper and mid pole of the kidney. The diagnosis was established preoperatively by abdominal ultrasound and computed tomography. Surgical treatment consisted of a right radical nephrectomy and bilateral adrenalectomy. Postoperative cortisone acetate replacement was instituted. The pathological findings of the right renal tumor showed clear cell carcinoma and both adrenal tumors showed the same pathology as the right renal tumor. There was no evidence of recurrence after 6 months of follow-up.

Conclusion

Patients with bilateral synchronous adrenal metastases should be considered to have disseminated metastatic disease. However, good performance status, the presence of paraneoplastic syndrome and the alleviation of refractory pain are important reasons make an urologist to consider radical nephrectomy in renal cell carcinoma patient with metastases.

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.

Staging of Renal Cell Carcinoma: Past, Present, and Future

Tumor stage, which describes the anatomic extent of disease, is a powerful determinant of prognosis and survival for patients with renal cell carcinoma (RCC). Stratification of patients based on prognostic outcomes derived from staging systems facilitates therapeutic decision-making, disease surveillance, and clinical research. Staging for RCC has evolved from the Robson classification into the TNM system, developed by the International Union Against Cancer and the American Joint Committee on Cancer. The most recent revisions of the TNM system for RCC introduced in 1997 and 2002 further subdivided organ-confined tumors, reclassified tumors with venous involvement, and clarified the staging of tumors that invade the perisinus fat. Most studies suggest that these revisions have substantially improved prognostication for RCC. Nevertheless, additional modifications have been proposed that would alter the subclassification of organ-confined disease, integrate various levels of venous involvement with other aspects of local tumor aggressiveness, and upgrade the classification of adrenal involvement. The data in support of each of these proposals will be discussed, and the current limitations of clinical and radiographic staging for RCC will be reviewed. Finally, a glimpse into the future of staging of RCC will be offered with a discussion of integrated staging and prognostic systems.

Surgical treatment of adrenal metastasis from renal cell carcinoma: a single-centre experience of 45 patients

OBJECTIVE

To report, in a retrospective study, the diagnostic problems and oncological results of surgery in patients with either synchronous or metachronous adrenal metastasis, which are uncommon in renal cancer, at 2-10% of patients.

PATIENTS AND METHODS

Of 1179 patients treated for renal cancer between 1987 and 2003, 914 had renal surgery with concomitant ipsilateral adrenalectomy (routinely in 875 and for abnormal findings on computed tomography, CT, in 39) and 15 contralateral adrenalectomy (all after suspicious findings on CT). During the follow-up after renal surgery, another 14 patients had adrenalectomy for CT evidence of an abnormal adrenal gland, contralateral to the previous renal tumour in 12 and bilaterally in two.

RESULTS

Of 914 ipsilateral adrenal glands removed during renal surgery, 854 (93.5%) were normal on pathological examination, 28 (3%) had a benign pathology, six (0.8%) were directly infiltrated by the tumour and 26 (2.7%) were metastatic. For both benign and metastatic ipsilateral adrenal pathology, CT had sensitivity, specificity and positive/negative predictive values of 47%, 99%, 73% and 96%, respectively. Of 29 contralateral glands removed because of suspicious CT findings (15 at diagnosis of renal cancer, 14 during the follow-up) there was no abnormality in one (3.4%), a benign pathology in seven (24%) and a metastasis in 21 (72%). Thus there were 32 synchronous (incidence 2.7%; ipsilateral to the renal tumour in 24, contralateral in six and bilateral in two), and 13 metachronous adrenal metastases (incidence 1.0%; contralateral in 11 and bilateral in two). The metachronous metastases were diagnosed at a mean (range) interval of 30.6 (8-73) months after renal surgery. No ipsilateral adrenal metastases were discovered at diagnosis or during the follow-up in the 382 patients with an organ-confined renal tumour of <4 cm in diameter. Twenty-seven patients with an isolated adrenal metastasis (synchronous in 14, metachronous in 13) had statistically significantly (P < 0.001) better survival than the 18 (all synchronous) with multiple sites of metastatic disease. In particular, there was long-term survival (mean 83 months) in 10 patients with an isolated adrenal metastasis.

CONCLUSION

Sparing the ipsilateral adrenal is advisable only for organ-confined renal tumours of <4 cm in diameter; clinical local staging of renal cancer is the best predictor of the risk of adrenal metastasis. Conversely, CT had good diagnostic ability for the contralateral adrenal gland, especially during the follow-up. Some patients with isolated adrenal metastasis could be treated by metastasectomy, with long-term survival free of disease and confirming that, even if in a few and unselectable patients, removing all the neoplastic bulk can be curative. Nevertheless, the high rate of relapse underlines the need for an effective systemic therapy, and more so for widespread metastatic disease that currently cannot be cured.

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

INTRODUCTION

Solitary adrenal metastases occur in about 1.2-10% of renal cell cancer patients. Since the vast majority of intraadrenal lesions can be detected preoperatively, we and others have recently recommended to renounce a routine adrenalectomy during surgery of renal cell cancer. However, the impact of adrenalectomy on the patients' clinical prognosis in case of a solitary metastatic lesion within the adrenal gland remains an issue of controversial discussion. Whereas some authors suggest adrenalectomy as a potentially curative treatment option in these cases, others compare its clinical value with that of a mere lymphadenectomy.

PATIENTS AND METHOD

Between 1981 and 2000, 648 patients (440 males and 208 females) underwent nephrectomy in combination with adrenalectomy in our clinic for the diagnosis of renal cell cancer. The median age at first diagnosis was 59 (range 33-84) and 60 (range 20-85) years for male and female patients, respectively. The median postoperative follow - up was 2.4 years (0.2-18 years). According to the TNM - classification system (2003) tumor stages were classified as follows: T1, 228 pat. (37%); T2, 70 pat. (11%); T3, 287 pat. (46%); T4, 37 pat. (6%). In total, 339 patients revealed regional lymph node or distant metastases at the time of the surgical treatment. Although metastases of the adrenal gland were diagnosed in 48 patients, solitary intraadrenal metastases without further systemic spread were observed in only 13 cases. Several patients' and tumor characteristics (age, tumor stage and size, the presence of regional lymph node metastases, the presence of metastatic lesions at different organ sites as well as the detection of solitary intraadrenal metastases) were correlated with the patients' overall survival by univariate and multivariate statistical analysis (logistic Cox regression analysis).

RESULTS

The median long - term survival was 4.8 years for the entire cohort of patients investigated. The median long - term survival was 13.8 years and 11.7 years for patients with no evidence of metastatic spread as well as for patients with a solitary intraadrenal metastatic lesion, respectively. Accordingly, the long - term survival rates at 5 and 10 years after surgery were 66%/50% and 51%/51% for patients with no evidence of metastatic spread or isolated intraadrenal metastases. This difference was not statistically significant. In contrast, for patients revealing lymph node or distant metastases at other organ sites, the median long - term survival was significantly decreased (lymph node metastases: 0.7 years; distant metastases: 1.2 years).

DISCUSSION

For patients with a solitary intraadrenal metastatic lesion, adrenalectomy is a potentially curative treatment option. The observation that the long - term survival of the latter patients is comparable to that of patients with organ - confined disease might suggest the establishment of a separate TNM - category for patients revealing a solitary metastasis within the adrenal gland and no hint at further systemic metastatic spread.

ADRENAL METASTASES IN 1,635 PATIENTS WITH RENAL CELL CARCINOMA: OUTCOME AND INDICATION FOR ADRENALECTOMY

PURPOSE

Routine removal of the ipsilateral adrenal gland in patients with renal cell carcinoma who undergo nephrectomy has been a matter of dispute. In a retrospective study we screened for subgroups of patients with renal cell carcinoma from a large single center patient population who may have benefited from ipsilateral adrenalectomy.

MATERIALS AND METHODS

Radical nephrectomy was performed in 1635 patients at a single institution between 1980 and 2000. A total of 1010 patients underwent radical nephrectomy plus ipsilateral adrenalectomy, whereas in 625 no simultaneous adrenalectomy was performed. Numerous clinical and histopathological parameters were investigated by univariate and multivariate statistical methods for their predictive value in regard to cancer specific survival.

RESULTS

Metastases in the adrenal gland were found in 5.5% of patients (56 of 1010) undergoing nephrectomy with adrenalectomy. Of 30 patients with adrenal metastasis and preoperative computerized tomography/magnetic resonance imaging 23 were found to have histological evidence of cancer, approaching a false-negative rate of 23.3%. All patients with false-negative computerized tomography/magnetic resonance imaging had a primary tumor of greater than 4 cm. Patients with adrenal metastases predominately had pT3 or greater tumor stage (82%). Cancer specific survival rates (75% vs 73% for adrenalectomy vs no adrenalectomy) and postoperative complications rates (7% vs 8%) did not differ significantly between the 2 groups. The prognosis in patients with a solitary adrenal metastasis (18 of 56) was more favorable than in patients with additional metastatic sites (38 of 56).

CONCLUSIONS

Adrenal metastases from primary renal cell carcinoma were found significantly more often in patients with advanced tumor stages. Ipsilateral adrenalectomy should be recommended for all resectable renal cell carcinoma with a primary tumor of greater than 4 cm or with nonorgan confined tumor stages (T3 or greater) since a false-negative rate of about 20% can be expected with current imaging techniques.

Adrenalectomy: Defining Its Role in the Surgical Treatment of Renal Cell Carcinoma

OBJECTIVES

With the recent widespread use of modern imaging techniques, the frequency of small low-stage renal cell carcinomas (RCC) has grown considerably, giving rise to more conservative surgical approaches. We evaluated the characteristics of adrenal involvement and the accuracy of computerized tomography (CT) in the diagnosis of RCC, defining the real need for adrenalectomy during surgical treatment.

METHODS

The medical records of 201 patients undergoing radical nephrectomy and ipsilateral adrenalectomy for localized or advanced RCC, from 1996 to 2002, were analyzed, retrospectively. We considered 76 with stage T1-2 disease and 125 with T3-4N0-1M0-1 disease. In all cases a blinded review of the preoperative abdominal CT was performed. Histopathology records of the surgical specimens were examined to determine the accuracy of the CT in identifying adrenal involvement by RCC.

RESULTS

The overall incidence of adrenal metastasis was 4.4%. The mean renal tumor size in patients with adrenal involvement was 7.8 cm. The tumor stage correlated with a probability of adrenal spread (p < 0.05), with T1-2 tumors accounting for 1.3% of cases only. The adrenal gland was diagnosed as abnormal on preoperative CT in 21 patients (10.4%). CT scan demonstrated 88.8% sensitivity, 92.1% specificity, 99.4% negative predictive value and 34.7% positive predictive value for adrenal involvement by RCC.

CONCLUSIONS

Adrenal involvement is not likely in patients with localized early stage RCC and adrenalectomy can be omitted in such cases, particularly when CT is negative. However, in selected patients with large high-risk tumors, radical nephrectomy, including removal of the ipsilateral adrenal gland, should be performed.

Adrenal sparing surgery in the treatment of renal cell carcinoma: when is it possible?

Despite the fairly low incidence of adrenal involvement, adrenalectomy continues to be performed routinely as part of radical nephrectomy. With the recent development of modern imaging techniques and their widespread use, the frequency of small, low stage renal cell carcinomas (RCC) has grown considerably, giving rise to more conservative surgical approaches. We conducted a retrospective study in order to evaluate the incidence and characteristics of adrenal metastasis in RCC, trying to clarify the accuracy of computerized tomography (CT) in the diagnosis and the real need for adrenalectomy during surgery for RCC. The medical records of 192 patients undergoing radical nephrectomy and ipsilateral adrenalectomy for localized or advanced RCC, from 1996 to 2001, were analyzed retrospectively. We considered two subgroups of patients, 73 with stage T1-2 disease (group 1) and 119 with T3-4N0-1M0-1 disease (group 2) according to the 1997 TNM classification. In all cases, a blinded review of the preoperative abdominal CT was performed and an adrenal gland was considered to be abnormal if there was any aberration. Histopathology records of the surgical specimens were examined to determine the accuracy of the CT in identifying adrenal involvement by RCC. Descriptive statistics were used to evaluate the collected data. The overall incidence of adrenal metastasis was 4.1%. Mean renal tumor size in patients with adrenal involvement was 7.8 cm. The tumor stage correlated with the probability of adrenal spread ( P<0.05), with T1-2 tumors accounting for 1.3% of cases only. An adrenal gland was diagnosed as abnormal on preoperative CT in 20 patients (10.4%). CT scans had 87.5% sensitivity, 92.9% specificity, 99.4% negative predictive value and 35% positive predictive value for adrenal involvement by RCC. Adrenal involvement is not likely in patients with localized early stage RCC, and adrenalectomy is unnecessary in such cases, particularly when the CT is negative. However, radical nephrectomy, including removal of the ipsilateral adrenal gland, should be performed in patients with large, high risk tumors.

TNM T3a renal cell carcinoma: adrenal gland involvement is not the same as renal fat invasion

PURPOSE

Upper pole tumors with direct extension into the adrenal gland are currently staged as pT3a tumors in the 1997 TNM staging system. To determine whether the clinical behavior of pT3a adrenal tumors differs from that of tumors with perinephric fat invasion (also stage pT3a) a retrospective analysis was performed.

MATERIALS AND METHODS

Of 1,087 patients who underwent nephrectomy 27 were identified with direct adrenal involvement and 187 were identified with perinephric fat or renal sinus involvement. Variables and outcomes analyzed in each group included the percent of patients with metastatic disease at presentation, lymph node involvement, Eastern Cooperative Oncology Group score, response to immunotherapy, and median and overall survival using Kaplan-Meier curves.

RESULTS

Median survival for patients with pT3a disease and perinephric or renal sinus fat involvement was 36 months with a 36% 5-year cancer specific survival rate. In contrast, patients with adrenal gland invasion had significantly worse survival at a median of 12.5 months and a 0% 5-year cancer specific survival rate (p <0.001), which was similar to median survival of those with stage pT4 disease (11 months).

CONCLUSIONS

Upper pole tumors with direct extension into the adrenal gland predict significantly worse survival than similarly staged tumors with fat invasion and they have a prognosis similar to that of stage pT4 disease. While these data await external validation, consideration should be given to re-categorizing tumors with direct adrenal gland involvement as stage pT4 or in a subcategory such as pT4a.