Adrenal metastasis from renal cell carcinoma: significance of adrenalectomy

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.

Metachronous metastasis to contralateral retroperitoneal adipose tissue after radical nephrectomy: a case report and review of the literature

Renal cell carcinoma (RCC) metastasis to the adrenal gland, perirenal adipose tissue, and ureter on the contralateral side is rare. We report a case of solitary metachronous clear cell renal cell carcinoma (ccRCC) metastasis to the contralateral retroperitoneal adipose tissue, which was identified after radical nephrectomy. A patient had undergone retroperitoneal laparoscopic radical nephrectomy for RCC in the right kidney in December 2012. Postoperative pathological analysis showed Fuhrman grade I ccRCC, T_1bN₀M₀. Three years after surgery, a solitary tumor of 1.0 × 1.0 cm was identified by an abdominal computed tomographic scan inside the retroperitoneal fat pad in front of the left posterior abdominal wall, without adhesion to the abdominal wall. The tumor was then completely resected by retroperitoneal laparoscopic resection. Pathological analysis showed that it was a metastasized lesion from a previous tumor. Nine months after surgery, there was no sign of recurrence confirmed by radiographic follow-up. Findings from this case indicate the unpredictability of dissemination of RCC. Our findings support a follow-up regimen that includes regular postoperative computed tomographic scans to identify early metastasis. To the best of our knowledge, this is the first reported case of contralateral retroperitoneal adipose metastasis after laparoscopic tumorectomy.

[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.

Routine adrenalectomy is unnecessary during surgery for large and/or upper pole renal tumors when the adrenal gland is radiographically normal

PURPOSE

Concurrent adrenalectomy during renal surgery for renal cell carcinoma was once routine. More recent data suggest that adrenalectomy should be reserved for tumors 7 cm or greater, particularly those involving the upper pole. We evaluated the radiographic and pathological incidence of adrenal involvement in patients undergoing renal surgery for renal cell carcinoma 7 cm or greater.

MATERIALS AND METHODS

Patients who underwent renal surgery for tumors 7 cm or greater between 1999 and 2008 were identified from our kidney cancer registry. We used Fisher's exact test to determine whether radiographic tumor site predicted adrenal involvement. The Kaplan-Meier method and Cox proportional hazard regression models were used to analyze the impact of adrenal resection on outcome.

RESULTS

Of 1,650 patients we identified 179 patients who underwent surgery for renal cell carcinoma 7 cm or greater. Of these patients 91 underwent concurrent total ipsilateral adrenalectomy at renal surgery with pathological adrenal involvement confirmed in 4 (4.4%). Upper pole site did not predict involvement (p = 0.83). Preoperative adrenal imaging was 100% sensitive and 92% specific to detect adrenal involvement by renal cell carcinoma with 100% negative predictive value. No survival advantage was noted on multivariate analysis when comparing patients who underwent adrenal resection to 88 in whom the adrenal gland was spared (p = 0.38).

CONCLUSIONS

Synchronous ipsilateral adrenal involvement with renal cell carcinoma is rare even in cases of large and/or upper pole tumors, making routine adrenalectomy unnecessary. Preoperative adrenal imaging is highly sensitive and should inform the decision to perform adrenalectomy more than tumor size or site.

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.

Catecholamines can mediate stress-related effects on tumor progression

Studies have implicated behavior as a factor that can influence several aspects of health and have described the complex bidirectional interactions among the CNS, the endocrine system and the immune system that are involved. There is evidence that psychological factors can affect the incidence and progression of some cancers in humans. The hypothesis that stress could be a cofactor is supported by data obtained from animal models. Catecholamines, norepinephrine in particular, have been shown to directly affect various aspects of tumor development that is separate from the well-characterized effects on the cellular immune response to immunogenic tumors. Studies have shown that norepinephrine can directly affect tumor cell behavior and gene expression, further suggesting another mechanism for stress-related modulation of tumor progression. This line of research further suggests that interventions targeting components of the activated sympathetic-adrenal-medullary axis, or the utilization of β-adrenergic receptor-blocking agents, may represent new strategies for slowing down the progression of malignant disease and improving cancer patients' quality of life.

Usefulness of F-18 FDG-PET in a long-term hemodialysis patient with renal cell carcinoma and pheochromocytoma

A patient who had been on long-term hemodialysis (HD) was diagnosed as having renal cell carcinoma (RCC) and pheochromocytoma. Abdominal computed tomography scanning demonstrated a right renal mass and a right adrenal mass, whereas positron emission tomography (PET) using F-18 fluorodeoxyglucose (FDG) revealed increased accumulation in both the renal and adrenal masses. FDG-PET is useful for detecting RCC in HD patients because FDG is not excreted in the urine, but it is difficult to distinguish pheochromocytoma from an adrenal metastasis by this imaging method.

Adrenal metastases: CT-guided and MR-thermometry-controlled laser-induced interstitial thermotherapy

The aim of the study was to evaluate the feasibility, safety and effectiveness of CT-guided and MR-thermometry-controlled laser-induced interstitial thermotherapy (LITT) in adrenal metastases. Nine patients (seven male, two female; average age 65.0 years; range 58.7-75.0 years) with nine unilateral adrenal metastases (mean diameter 4.3 cm) from primaries comprising colorectal carcinoma (n = 5), renal cell carcinoma (n = 1), oesophageal carcinoma (n = 1), carcinoid (n = 1), and hepatocellular carcinoma (n = 1) underwent CT-guided, MR-thermometry-controlled LITT using a 0.5 T MR unit. LITT was performed with an internally irrigated power laser application system with an Nd:YAG laser. A thermosensitive, fast low-angle shot 2D sequence was used for real-time monitoring. Follow-up studies were performed at 24 h and 3 months and, thereafter, at 6-month intervals (median 14 months). All patients tolerated the procedure well under local anaesthesia. No complications occurred. Average number of laser applicators per tumour: 1.9 (range 1-4); mean applied laser energy 33 kJ (range 15.3-94.6 kJ), mean diameter of the laser-induced coagulation necrosis 4.5 cm (range 2.5-7.5 cm). Complete ablation was achieved in seven lesions, verified by MR imaging; progression was detected in two lesions in the follow-up. The preliminary results suggest that CT-guided, MR-thermometry-controlled LITT is a safe, minimally invasive and promising procedure for treating adrenal metastases.

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.