Surgical management of adrenal metastasis from bronchogenic carcinoma

Survival outcomes of patients with oligometastatic non-small cell lung cancer who were treated with radical therapy: a multicenter analysis

BACKGROUND

Oligometastatic disease for nonsmall cell lung cancer (NSCLC) patients is generally thought to represent a better prognosis with a quieter biology, limited number of disease sites and long-term disease control. In this study, we aimed to determine the efficacy of radical treatment options for patients with oligometastatic NSCLC.

METHODS

This retrospective trial included totally 134 patients with oligometastatic NSCLC. The presence of oncodriver mutation, tumor stages and nodal status, the number of metastases and involved metastatic site, treatment of primary tumor and oligometastasis, response rate, overall survival (OS) and progression-free survival (PFS) were evaluated.

RESULTS

Of 134 patients 66.4% were defined as adenocarcinoma, 26.1% were squamous cell carcinoma and 7.5% of patients were in other histology. Based on the treatment of primary tumor, in 36 patients (26.9%) curative surgery has undergone, in addition, 19 (14.2%) patients were received chemotherapy, 73 (54.5%) were treated with chemoradiotherapy, while immunotherapy and targeted therapy were used in 1 (0.7%) and 2 (1.4%), respectively. The preferred treatment for oligometastatic lesions were SBRT in 72.4% of patients, surgery in 10.5%, and both SBRT and surgery in 17.1% of patients. At the median follow up of 31.3 months (range: 9.5-48.5), the median PFS and OS times were 17 and 24.4 months, respectively. Moreover, OS-2 after progression was also 7.2 months.

DISCUSSION

Based on our real-life experience, we demonstrated a significant correlation between good response to first treatment and survival in oligometastatic disease, we also understand that local ablative treatment modalities prolong and also delay both OS and PFS in oligometastatic NSCLC patients OS-2.

Laparoscopic adrenalectomy for adrenal metastases of solid tumors

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Treatment outcomes in oligometastatic non-small-cell lung cancer: A single-centre experience

BACKGROUND

Even in oligometastatic stage 4 disease, survival rates are higher when curative approaches focus on both the primary tumour and metastasis. So, we aim to analyse our results of oligometastatic disease retrospectively.

METHODS

In total, data on 52 non-small-cell lung cancer (NSCLC) patients with limited metastasis (one to three synchronous/metachronous) were retrospectively analysed. All treatment modalities associated with various treatment modalities [surgery, chemoradiotherapy (CRT), supportive care and palliative chemotherapy] were compared in terms of survival. Curative treatment consisted of surgery or CRT (concurrent or sequential).

RESULTS

The median overall survival (OS) time was 35.2 ± 4.1 months. Surgery was superior to CRT in terms of OS (36.7 months vs 27.4 months, P > 0.05). Progression-free survival was 29.4 ± 3.9 months, and survival after first progression (SAFP) was 15.6 ± 2.8 months. Patients in whom a metastasectomy was performed had significantly higher rate of SAFP as compared with those who did not have a metastasectomy (20.07 ± 3.8 months vs 7.9 ± 1.7 months P = 0.046). According to pathological type, an adenocarcinoma was associated with better SAFP than a non-adenocarcinoma (23 ± 4.1 vs 6.4 ± 1.5, P = 0.002). The 1- and 2-years OS rates were 67% and 50.4%, respectively. Among the curative treatment group, the OS of patients younger than 65 years (n = 25) was 31 months, whereas that of patients older than 65 years (n = 13) was 22 months (P = 0.88).

CONCLUSION

In well-selected NSCLC patients with limited metastasis, survival rates can reach up to 3 years, even in a geriatric population. Clinical N staging and co-morbidity are important prognostic factors.

Results of adrenalectomy in lung cancer metastases

BACKGROUND

The aim of this study was to report our centre's experience over the past 15 years with patients with lung carcinoma and adrenal metastases treated sequentially with lung resection and adrenalectomy.

PATIENTS AND METHODS

We analysed a retrospective series of 19 patients who underwent adrenalectomy for lung carcinoma metastasis. All patients were operated on at the same centre, between October 2000 and October 2015. We performed a descriptive analysis and an overall survival and disease-free survival analysis.

RESULTS

The study included 13 men and 6 women. The most common primary lung tumour was adenocarcinoma, 87.5% of which were G3. In 7 patients, the adrenal metastasis was detected synchronously, and in 12 patients it was detected metachronously. The median size of the metastasis was 63mm. Twenty-one percent of the cases presented local recurrence, and 79% presented distant metastasis. The median DFS was 21.5 months, while the DFS at 5 years was calculated at 58.33%. The median overall survival was 37.3 months, while survival at 5 years was calculated at 42.86%. None of the prognostic factors evaluated were statistically significant.

CONCLUSIONS

Adrenalectomy in cases of isolated lung carcinoma metastasis can offer increased overall survival. Age and the degree of differentiation of the primary lung carcinoma are the factors that most influence poorer survival.

The role of laparoscopic resection of metastases to adrenal glands

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adrenalectomy for solid tumor metastases: results of a multicenter European study

BACKGROUND

We assessed the results of adrenalectomy for solid tumor metastases in 317 patients recruited from 30 European centers.

METHODS

Patients with histologically proven adrenal metastatic disease and undergoing complete removal(s) of the affected gland(s) were eligible.

RESULTS

Non-small cell lung cancer (NSCLC) was the most frequent tumor type followed by colorectal and renal cell carcinoma. Adrenal metastases were synchronous (≤6 months) in 73 (23%) patients and isolated in 213 (67%). The median disease-free interval was 18.5 months. Laparoscopic resection was used in 46% of patients. Surgery was limited to the adrenal gland in 73% of patients and R0 resection was achieved in 86% of cases. The median overall survival was 29 months (95% confidence interval, 24.69-33.30). The survival rates at 1, 2, 3, and 5 years were 80%, 61%, 42%, and 35%, respectively. Patients with renal cancer showed a median survival of 84 months, patients with NSCLC 26 months, and patients with colorectal cancer 29 months (P = .017). Differences in survival between metachronous and synchronous lesions were also significant (30 vs. 23 months; P = .038).

CONCLUSION

Surgical removal of adrenal metastasis is associated with long-term survival in selected patients.

Surgical management of adrenal metastases

In the presence of a history of cancer, adrenal masses are commonly, but not exclusively, metastases. Depending upon the status of the patient's ongoing cancer therapy, overall tumor burden, and performance score, adrenalectomy is a viable treatment option. Herein we review the prevalence, diagnostic evaluation, and selection for surgical treatment of adrenal metastases. Additional attention is paid to recent data supporting the safety and oncologic efficacy of laparoscopic adrenalectomy.

Laparoscopic adrenalectomy for cancer

Laparoscopic procedures are preferred by surgeons and patients alike because of decreased pain, reduced perioperative morbidity, and an earlier return to self-reliance. During the last decade, laparoscopic adrenalectomy has become the technique most commonly used for the removal of benign adrenal tumors. The indications for laparoscopy in malignant adrenal tumors remains controversial, because oncologic resections have not been reproducible compared with open techniques.

Long-term survival of a patient with pulmonary artery intimal sarcoma after sequential metastasectomies of the thyroid and adrenal glands

Cancer metastases to the thyroid or adrenal gland are uncommon. Furthermore, cases showing long-term survival after surgical resection of those metastatic tumors are rare. We report a case of pulmonary artery intimal sarcoma with metastases to the thyroid and adrenal glands sequentially that was successfully treated with sequential metastasectomies. A 62-year-old woman presented with a 4-week history of dyspnea on exertion and facial edema in November 1999. Echocardiography and chest computed tomography (CT) revealed an embolism-like mass in the pulmonary trunk. Pulmonary artery endarterectomy with pulmonary valve replacement was performed, and histopathology revealed pulmonary artery intimal sarcoma. A thyroid nodule was found by chest CT in November 2001 (2 years after initial surgery). During follow-up, this lesion showed no change, but we decided to obtain fine needle aspiration cytology (FNAC) in August 2004 (4.7 years after initial surgery). FNAC revealed atypical spindle cells suggestive of metastatic intimal sarcoma. She underwent total thyroidectomy. During follow-up, a right adrenal gland mass was detected by chest CT in March 2006 (6.3 years after initial surgery), and adrenalectomy was done, which also revealed metastatic sarcoma. She has been followed up without any evidence of recurrent disease until May 2012 (12.5 years after initial surgery).

Surgical treatment of oligometastatic non-small cell lung cancer

Patients with stage IV metastatic non-small cell lung cancer (NSCLC) are generally believed to have an incurable disease. Patients with oligometastatic disease represent a distinct subset of patients among those with metastatic disease. There is evidence that these patients have synchronous or metachronous satellite nodules in different pulmonary lobes or have solitary extrapulmonary metastases. In these cases, evidence has shown that surgical resection may provide patients with survival benefit. This article discusses the biology of the oligometastatic state in patients with lung cancer and the selection of patients for surgery, as well as the prognostic factors that influence survival of the patient. To properly select patients for an aggressive local treatment regime, accurate clinical staging is of prime importance. The use of FDG-PET should be considered for restaging if oligometastatic disease is suspected based on a patient's CT scan. A limitation of retrospective clinical studies for oligometastatic disease is that it is difficult to summarize and evaluate the available evidence for the effectiveness of surgical resection due to selection bias, and to a high degree of variability among different clinical studies. Nevertheless, we can certainly learn from the clinical experience acquired from retrospective case series to identify prognostic factors. Following surgical resection, the overall 5-year actuarial survival rate is about 28% for patients with satellite nodules and 21% for patients with ipsilateral nodules. Patients with resected brain metastasis achieve 5-year survival rates between 11% and 30%, and those with adrenalectomy for adrenal metastasis achieve 5-year survival rates of 26%.

Metastatic non-small-cell lung carcinoma successfully treated with pre-operative chemotherapy and bilateral adrenalectomy

Metastatic non-small-cell lung cancer is a common condition with a dismal prognosis. Although palliative chemotherapy improves survival and quality of life, nearly all patients die of progressive disease. Metastatic involvement of adrenal glands is not rare, but usually reflects widespread dissemination. Selected patients with single adrenal metastasis may be cured with surgery, although the level of evidence comes from single cases reports and short retrospective series. Here we report a patient with bilateral adrenal metastases from previously resected non-small-cell lung cancer, who remains free of disease four years after pre-operative chemotherapy and bilateral adrenalectomy.

Laparoscopic adrenalectomy for malignant neoplasm: Our experience in 15 cases

BACKGROUND

We report our experience with laparoscopic adrenalectomy (LA) for malignant pathologies that in some cases required a multiorgan resection.

METHODS

In this study, we retrospectively reviewed a group of 15 patients (10 men, and five women) who underwent an operation for primitive or metastatic adrenal malignant tumors.

RESULTS

The sizes of the lesions ranged from 3.5 to 8.5 cm (average 3.6). We performed 11 adrenalectomies (four right and seven left), two left adrenalectomies with distal spleno-pancreatectomy, one right adrenalectomy with nephrectomy, and one laparoscopic exploration that showed a peritoneal spreading. Six patients, with a follow-up ranging from 3 to 24 months (mean 13.6 months), are disease free; the others developed metastatic repetitions or local recurrences.

CONCLUSIONS

LA could be performed always respecting the oncological principles of radical excisions. This approach in our patients has been associated with low morbidity, low intraoperative blood loss, short hospital stay, and fast functional recovery.

Laparoscopic adrenalectomy for malignancy

The superiority of the minimally invasive approach to adrenal resections has been well documented for benign pathology. With technical advances and increased experience, surgeons have successfully performed laparoscopic adrenalectomies for metastatic and primary malignancies of the adrenal gland. The technique of laparoscopic adrenalectomy as it pertains to malignant lesions is presented. A review of the literature demonstrates the safety and efficacy of laparoscopic adrenalectomy for metastatic colorectal, lung, and renal tumors. For primary adrenal malignancies, radical resections can be effectively performed laparoscopically; however, continued long-term follow-up is needed to establish the minimally invasive technique as the preferred approach.

Ten Years of Laparoscopic Adrenalectomy: Lesson Learned from 104 Procedures

The purpose of this study was to evaluate the short- and long-term results of 104 consecutive laparoscopic adrenalectomies performed during a period of 10 years in two specialist centers. One hundred four patients underwent laparoscopic adrenalectomy in two specialist centers in Italy between 1994 and 2003. Indications to laparoscopic adrenalectomy were aldosterone-secreting adenoma (20%), pheochromocytoma (24%), cortisol-secreting adenoma (11.5%), incidentaloma (26.9%), multiple endocrine neoplasia (MEN) type 2A (2.8%), adrenal metastases from lung cancer (3.8%), adrenal cyst (6.7%), and angiomyolipoma (3.8%). Transperitoneal anterior and lateral approaches were adopted in 17 and 84 patients, respectively. Retroperitoneal approach was adopted in three patients. Mean operative time was 108 ± 39.1 minutes (range, 40–300 minutes). There was no correlation between adrenal tumor diameter and operative time. Mean intraoperative blood loss was 106 mL (range, 40–600 mL). Intraoperative complication rate and conversion rate were 4.8 per cent (5 cases). Laparoscopic adrenalectomy is a safe procedure. After a relatively short learning curve, it can be performed successfully by any surgeon with low operative morbidity and mortality. The size of the adrenal tumor should not be considered a contraindication to this procedure.

Laparoscopic adrenalectomy for malignant disease

Malignant tumours of the adrenal gland are uncommon but are associated with substantial mortality. For most tumours resection is the only opportunity for cure. Advances in diagnostic and surgical techniques have improved the detection and treatment of these tumours. Further advances need new ways to make decisions about the use of laparoscopic resection for malignant, or potentially malignant, adrenal tumours. We review studies on the outcome of laparoscopic adrenalectomy for primary adrenal cancer as well as studies on metastatic disease to the adrenal glands. There are few prospective data because of the rarity of this condition. Careful individual judgment by the surgeon remains the cornerstone of safe and complete resection for adrenal malignant disease.

Laparoscopic adrenalectomy for malignancy

Laparoscopic adrenalectomy for primary malignancies and tumors metastatic to the adrenal is controversial. Most studies demonstrate that results of laparoscopic adrenalectomy for malignant lesions are similar to those of open adrenalectomy, without its morbidity. The results of laparoscopic adrenalectomy for tumor metastases suggest that it may benefit patients who have a metachronous metastasis from any of a variety of primary tumors. Selective laparoscopic adrenalectomy for potentially malignant tumors requires seeking signs of local invasion, lymphadenopathy, or distant metastasis; there are no other reliable preoperative criteria of malignancy. Diagnostic laparoscopy may be useful, and in some cases, may establish a diagnosis. Laparoscopic adrenalectomy should be cautiously performed, with the goals of achieving complete tumor resection without disruption of the adrenal capsule.

Three-dimensional Volume-rendered Helical CT before Laparoscopic Adrenalectomy

Use of three-dimensional (3D) volume-rendered helical computed tomography (CT) in surgical planning before laparoscopic adrenalectomy was evaluated in a retrospective study. In 35 consecutive patients before laparoscopic adrenalectomy, 3D volume-rendered CT scans were created from helical CT scans. Videotapes that showed anterior, lateral, posterior, and posterocephalic approaches were assessed retrospectively. The relationship (not contacting, abutting, displacing, or invading) of adrenal masses to adjacent organs (diaphragm, liver, spleen, kidneys, stomach, pancreas, and vessels) was recorded and compared with findings in surgery reports. When such findings were available, they corresponded to those in the videotape. Three-dimensional volume-rendered CT successfully displayed the relationship of adrenal masses to adjacent anatomic structures and organs before laparoscopic adrenalectomy.

Late adrenal metastasis in operable non-small-cell lung carcinoma

Treatment of early-stage (I, II, and some IIIA) non-small-cell lung cancer (NSCLC) is curative resection. Simultaneous isolated adrenal metastasis represents a dilemma. Although many studies addressing the management of adrenal metastasis diagnosed simultaneously with NSCLC have been published, only very few reports of late adrenal metastasis can be found in the literature. Our purpose is to discuss the management of solitary late (metachronous) adrenal metastasis from operable NSCLC based on published experience. We describe a patient with a solitary metachronous adrenal metastasis diagnosed 3 years after resection of NSCLC. Adrenalectomy was done, followed by combination chemotherapy with paclitaxel and carboplatin. MEDLINE literature on similar cases was reviewed and updated. Only 18 cases have been reported from 1965 to 2000. The median interval between the diagnosis of NSCLC and development of adrenal metastasis was 11.5 months. All patients were male. Unilateral adrenal metastases were reported in 15 patients, whereas 3 had bilateral metastases. Five patients were treated with adrenalectomy, and eight patients were treated with adrenalectomy and postoperative adjunctive chemotherapy. Chemotherapy alone was used in two patients and two patients underwent palliative radiation therapy. One patient was treated with intraarterial chemotherapy followed by radiation therapy. Solitary metachronous adrenal metastases are rare. There are no standard treatment guidelines for this group of patients. Review of the literature showed that median survival after treatment was 19 months for the group treated with adrenalectomy followed by chemotherapy; 15 months for the chemotherapy group; 14 months for the adrenalectomy group; and 8 months for the group treated with palliative radiation.

Metastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital

OBJECTIVE

Adrenal metastases are frequently encountered during autopsy but uncommonly present clinically. The aim of this study was to evaluate the clinical and pathological impact of adrenal metastases in a large series of patients.

PATIENTS

Four hundred and sixty-four patients (288 men, 176 women) with metastatic disease in the adrenal glands over a 30-year period were included in the study.

MEASUREMENTS

The clinical records and pathological features were reviewed.

RESULTS

The frequencies of adrenal metastases at autopsies, adrenalectomies and fine-needle aspiration biopsies were 3.1%, 7.5% and 33%, respectively. The lesions were often seen in elderly patients (mean age, 62, SD = 13 years). Many of the metastatic lesions in the adrenal gland occurred shortly after the detection of a primary tumour (mean latent period = 7 months). Four per cent of the adrenal lesions (n = 20) were symptomatic. The symptomatic adrenal lesions, as compared with asymptomatic ones, were bigger and seen in younger patients. Five patients presented with adrenal insufficiency (Addison's disease) and one had massive peritoneal haemorrhage because of metastatic carcinoma. Ninety per cent (n = 421) of the metastatic adrenal tumours were carcinomas and 56% of these were adenocarcinoma. Lung was the most common primary tumour site (35%), followed by the stomach (14%), the oesophagus (12%) and the liver/bile ducts (10%). The adrenal metastases were bilateral in approximately half of the patients (49%, n = 229). The mean diameter of the adrenal metastases was 2 cm (SD = 1.9 cm). The mean weight of the right adrenal gland harbouring the metastasis was 19 g, while that of the left 20 g. The median survival of the 20 patients with symptomatic adrenal lesions was 3 months (range, 0-75 months) after the detection of adrenal metastases. Patients with surgically removed adrenal metastases had slightly better survival rates than those without surgical resection.

CONCLUSIONS

A variety of tumours may give rise to adrenal metastases. They are often asymptomatic and detected as part of multiorgan metastases. Symptomatic cases, albeit rare, may occur. Long-term survival may be achieved in selected patients in whom an aggressive surgical approach may be adopted.

Prolonged survival after extracranial metastasectomy from synchronous resectable lung cancer

BACKGROUND

Combined resection of solitary synchronous brain metastases and non-small-cell lung cancer has been shown to be successful. Thus, we proposed combining the surgery of solitary, extracranial metastases, and resectable lung cancer.

METHODS

Between March 1987 and December 1994, surgery was performed on nine patients with non-small-cell lung cancer with synchronous, solitary, extracranial, or distant metastasis: adrenal (n = 5), cutaneous (n = 2), axillary lymph node (n = 1) and kidney (n = 1). Criteria for operating on these patients included: primary tumor that was locally resectable in a radical manner, non-small-cell histology, no preoperative evidence of N2 disease, complete resection of histologically proven metastasis, and absence of other metastases found with computed tomography or bone scan.

RESULTS

Resection of the primary tumor and solitary metastases was achieved in all patients. Primary tumor was always resected by lobectomy. No mortality or major morbidity was reported. Five-year survival rate was 55.6%. Five patients who had adrenal (n = 3), or skin (n = 1), or axillary (n = 1) metastases, survived more than 5 years. All N2 patients (n = 2) died.

CONCLUSIONS

The presence of solitary, distant metastasis should not be considered, per se, a factor for denying surgery for locally resectable, non-small-cell lung cancer. Unexpected, prolonged survival was demonstrated in our limited series.

Resection of adrenal metastases from non-small cell lung cancer: a multicenter study

BACKGROUND

In recent case reports and limited series, adrenalectomy was recommended for an isolated adrenal metastasis from non-small cell lung cancer (NSCLC).

METHODS

We retrospectively studied patients with a solitary adrenal metastasis from NSCLC who had undergone potentially curative resection in eight centers.

RESULTS

Forty-three patients were included. Their adrenal gland metastasis was discovered synchronously with NSCLC in 32 patients, and metachronously in 11. It was homolateral to the NSCLC in 31 patients and contralateral in 12 (p < 0.01). Median survival was 11 months, and 3 patients survived more than 5 years. There was no difference between the synchronous and metachronous groups regarding recurrence rate or survival. Survival was not affected by the homolateral location of the metastasis, the histology of the NSCLC, TNM stage, any adjuvant and neoadjuvant treatment, or, in the metachronous group, a disease-free interval exceeding 6 months.

CONCLUSIONS

We confirm the possibility of long-term survival after resection of isolated adrenal metastasis from NSCLC, but no clinical or pathologic criteria were detected to identify patients amenable to potential cure.

Long-term survival after surgical resections of bronchogenic carcinoma and adrenal metastasis

There is some evidence that complete resection of both primary and metastatic sites of non-small cell lung carcinoma has more influence on survival than the locoregional stage of the lung cancer. We describe prolonged survival (>5 years) after complete surgical resection of a bronchogenic carcinoma (T3N0M1) and solitary adrenal metastasis.

Laparoscopic adrenalectomy for cancer

We will review the literature on the operative techniques and patient outcomes of laparoscopic adrenalectomy for cancer. Further, in our own study, an analysis of the preoperative assessment, operative, and hospital course, and postoperative follow-up was performed on all patients undergoing a laparoscopic adrenalectomy for cancer or metastasis from October 1996 through February 1998. Twelve laparoscopic resections were performed in 11 patients. There were six males and five females with an average age of 62 years (range, 40 to 79). The mean American Society of Anesthesiologists (ASA) score was 3.1 (range, 2 to 4). All of the tumors except one were due to metastatic cancer. The metastatic sources included renal cell cancer (four), lung cancer (two), colon cancer (two), adrenal cancer (one), and melanoma (one). Seven patients required a left adrenalectomy, three underwent a right adrenalectomy, and one was bilateral. The approach was transperitoneal in eight cases and retroperitoneal in four. The mean size of the tumors was 5.9 cm (range, 1.8 to 12 cm). Operative time averaged 181 minutes (range, 100 to 315 minutes), and blood loss was 138 cc (range, 20 to 1,300 cc). Average hospital stay was 2.3 days (range, < 1 to 6 days). One patient required conversion to an open approach due to local invasion of the tumor into the lateral wall of the vena cava, which was resected with the specimen. This procedure resulted in the largest blood loss of the series (1,300 cc). All specimens had negative surgical margins. There was one complication (9%), a laceration of the epigastric artery, which was controlled laparoscopically. At a mean follow-up of 8.3 months (range, 0.5 to 19 months), there have been no port site or local recurrences. One patient has developed a new hepatic nodule, which is being worked up for metastatic disease. Ten of the 11 patients (91%) are currently alive; one has died of expansive cerebral metastases from melanoma.

Surgical management of adrenal metastases from lung cancer

BACKGROUND AND OBJECTIVES

Adrenal metastases from lung cancer usually indicate systemic disease and incurability. However, a small subset of patients with isolated adrenal metastases may achieve long-term survival with aggressive surgical resection of the adrenal gland. To clarify the role of adrenalectomy for metastatic lung cancer, we undertook a review of the published literature on this topic.

METHODS

The English-language medical literature was searched for papers reporting surgical resection of adrenal metastases from lung cancer. Eleven articles were retrieved and their data pooled for analysis.

RESULTS

Sixty patients (including seven previously reported from our institution) formed the basis of this collective review. Thirty-two patients pooled from small series and case reports had a median survival of 24 months, and approximately one-third were 5-year survivors. Twenty-eight patients reported in two large series had a less favorable survival (approximately 14 months median survival).

CONCLUSIONS

Surgical resection of isolated adrenal metastases from lung cancer appears to have a modest survival advantage over nonoperative therapy, and it occasionally results in long-term survival. However, the relatively encouraging survival results reported in the literature could be related to careful patient selection for this aggressive therapy, publication bias in favor of positive treatment outcomes, or a combination of the two. Nevertheless, the results are encouraging enough to justify further investigation of this aggressive treatment strategy. Practical guidelines for management are proposed.

A comparison of adrenalectomy with other resections for metastatic cancers

BACKGROUND

Although adrenal metastases were once considered incurable, recent anecdotal reports recommend adrenalectomy for isolated metastases.

METHODS

Computerized files of all US Department of Veterans Affairs (DVA) hospital admissions and deaths from 1988 to 1994 identified patients undergoing isolated adrenal resections, and hospitalization records were obtained. Patients without a death record were assumed to be alive.

RESULTS

In 47 patients with adrenalectomy for metastases, only 5 patients did not die within 3 years: 2 each had metachronous renal or colorectal metastases, and 1 had a pulmonary primary. Thirteen patients with other primary sites all expired within 3 years. Operative mortality was 4% in these 47 patients and also in 706 other adrenalectomies without metastases.

CONCLUSIONS

Adrenalectomy for metastatic carcinoma in the DVA was safe, with a projected 5-year survival rate (13%) that is significantly inferior (P < or = 0.05) to resections for colorectal metastases to lung (36%) or liver (26%), but superior to brain (none).

Adrenalectomy for a solitary adrenal metastasis from lung cancer

BACKGROUND

Several case reports have shown that patients with truly solitary adrenal gland metastases can undergo resection with long-term survival.

METHODS

We assessed consecutive patients with operable or operated non-small cell lung cancer in whom the presence of a unilateral solitary adrenal metastasis was confirmed histologically. Synchronous homolateral adrenal metastases were resected at the same time as the non-small cell lung carcinoma through a transphrenic approach. Synchronous contralateral or metachronous adrenal metastases were resected through an elective approach.

RESULTS

Of 598 patients with operable or operated non-small cell lung carcinoma, 11 had a unilateral solitary adrenal gland metastasis and underwent adrenalectomy with no additional mortality or morbidity. One patient died of late postoperative complications and 7 patients died of other distant metastases between 4 and 24 months after adrenalectomy. Two patients are still alive and free of recurrent disease and 1 patient is still alive with brain metastasis 66, 6, and 10 months, respectively, after adrenalectomy.

CONCLUSIONS

In the absence of selection criteria to identify the subgroup of patients who will benefit from surgical resection, we suggest the resection of synchronous lesions in patients without N2 involvement and the careful selection of patients with metachronous adrenal metastases according to the evolution of their disease.