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Brönimann S, Ged Y, Singla N. Beyond the knife: strategic patient selection for cytoreductive nephrectomy. Curr Opin Urol 2024; 34:210-216. [PMID: 38240477 DOI: 10.1097/mou.0000000000001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW To evaluate the current role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) within the context of evolving treatment paradigms, focusing on implications for patient selection. RECENT FINDINGS Two randomized trials failed to show significant benefits from CN for intermediate and poor-risk patients undergoing targeted therapy. Despite this, subgroup analysis and retrospective data suggest potential benefits for a subset of good and intermediate-risk patients. Although currently used risk stratification tools guide CN eligibility, they have limitations, including, subjectivity, perioperative variability, and missing validation. Deferred CN may benefit patients responding to systemic treatment, whereas other patients may benefit from upfront CN. Emerging data supports the value of CN with immune checkpoint inhibitors (ICI) in selected patients, emphasizing the need for ongoing trials in the ICI era. SUMMARY The role and timing of CN in mRCC have evolved across therapeutic eras. Although awaiting prospective evidence in the current era of ICI, CN still has a role in the therapeutic approach for a subset of patients. The decision to recommend CN must be personalized and involve multidisciplinary discussions considering both patient- and tumor-related factors.
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Affiliation(s)
- Stephan Brönimann
- Department of Urology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Nirmish Singla
- Department of Oncology
- Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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2
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Mihai R, De Crea C, Guerin C, Torresan F, Agcaoglu O, Simescu R, Walz MK. Surgery for advanced adrenal malignant disease: recommendations based on European Society of Endocrine Surgeons consensus meeting. Br J Surg 2024; 111:znad266. [PMID: 38265812 PMCID: PMC10805373 DOI: 10.1093/bjs/znad266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/02/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Radu Mihai
- Churchill Cancer Centre, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Carmela De Crea
- Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell’Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
- Endocrine Surgery Unit, Hospital Fatebenefratelli Isola Tiberina—Gemelli Isola, Rome, Italy
| | - Carole Guerin
- Department of Endocrine and Metabolic Surgery, Aix-Marseille University, Hôpital de La Conception, Marseille, France
| | - Francesca Torresan
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Orhan Agcaoglu
- Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey
| | - Razvan Simescu
- Department of General and Endocrine Surgery, Medlife-Humanitas Hospital, Cluj-Napoca, Romania
| | - Martin K Walz
- Department of Surgery and Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany
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3
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Mikhail M, Chua KJ, Khizir L, Tabakin A, Singer EA. Role of metastasectomy in the management of renal cell carcinoma. Front Surg 2022; 9:943604. [PMID: 35965871 PMCID: PMC9372304 DOI: 10.3389/fsurg.2022.943604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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4
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Nakamura Y, Taguchi S, Kinjo M, Tambo M, Okegawa T, Fukuhara H. Adrenal metastasis in nivolumab‐treated renal cell carcinoma: A unique entity as a sanctuary site. Int J Urol 2022; 29:597-599. [DOI: 10.1111/iju.14833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Yu Nakamura
- Department of Urology Kyorin University School of Medicine Mitaka Tokyo Japan
| | - Satoru Taguchi
- Department of Urology Kyorin University School of Medicine Mitaka Tokyo Japan
| | - Manami Kinjo
- Department of Urology Kyorin University School of Medicine Mitaka Tokyo Japan
| | - Mitsuhiro Tambo
- Department of Urology Kyorin University School of Medicine Mitaka Tokyo Japan
| | - Takatsugu Okegawa
- Department of Urology Kyorin University School of Medicine Mitaka Tokyo Japan
| | - Hiroshi Fukuhara
- Department of Urology Kyorin University School of Medicine Mitaka Tokyo Japan
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5
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Li Y, Ji Z, Wang D, Xie Y. Bilateral adrenal metastasis of renal cell carcinoma 4 years after radical nephrectomy: A case report and review of literature. Medicine (Baltimore) 2021; 100:e26838. [PMID: 34397852 PMCID: PMC8341217 DOI: 10.1097/md.0000000000026838] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/19/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Renal cell carcinoma (RCC) almost metastasizes to every organ, the possibility of adrenal metastasis is relatively low in patients that have undergone radical nephrectomy, only a few cases of bilateral adrenal metastasis are reported on literature. Although surgical treatment of metastases from RCC is preferred and contributes to the rate of survival, it is considered challenging to manage such cases due to the rarity of bilateral metastasis to the adrenal glands. PATIENT CONCERNS A 64-year-old Manchus female presented with an incidental ultrasonic finding of a left adrenal mass 4 years after radical nephrectomy for left renal cell carcinoma. DIAGNOSIS Abdominal contrast enhanced CT scan revealed bilateral adrenal masses, suggesting metastatic lesion. Examinations indicated neither local recurrence nor distant metastasis anywhere have been detected by whole body Positron Emission Tomography/Computed Tomography (PET/CT) scan except high radioactive uptake in bilateral adrenal glands. INTERVENTIONS Metachronous bilateral adrenalectomy was taken and laparoscopic right adrenalectomy was first performed. She was discharged home on third postoperative day. Pathological examination revealed metastatic renal cell carcinoma. Two months later she was performed laparoscopic left adrenalectomy. OUTCOMES The patient healed without obvious complications and no tumor recurrence. LESSONS Bilateral metastatic adrenal recurrence from RCC is very rare. Early diagnosis of adrenal metastasis is challenging because they are usually silent both anatomically and functionally. Surgical intervention is a wise option for these patients that may improve survival, and metachronous bilateral adrenalectomy is proved to be safe and effective.
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6
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Byrnes KG, Khan JSA, Haroon UM, McCawley N, Cheema IA. Management of colon-invading renal cell carcinoma: Operative technique and systematic review. Urol Ann 2021; 13:1-8. [PMID: 33897156 PMCID: PMC8052896 DOI: 10.4103/ua.ua_86_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/12/2020] [Indexed: 01/04/2023] Open
Abstract
Invasion into adjacent organs by non-metastatic renal cell carcinoma (RCC) occurs in 1% of patients suitable for resection. Colonic invasion is rare and presents technical challenges. No prospective data exists to guide management of these patients. We present the first reported case of a colon-invading RCC managed with simultaneous open right radical nephrectomy and extended right hemicolectomy. PubMed, Scopus and EMBASE databases were searched for relevant case reports reporting management of colon-invading renal cell carcinoma. Case reports, case series and cohort studies were eligible. A chart review was performed on a patient who presented with right-sided colon-invading RCC. Four previously reported cases were identified. The current case was managed with simultaneous open radical nephrectomy and extended right hemicolectomy. The patient remains well six months postoperatively with no evidence of disease recurrence. Histopathological evaluation of the resected specimen confirmed a T4 clear cell RCC with sarcomatoid differentiation. Colon-invading RCC is rare. This is the first reported case of right-sided, colon-invading RCC treated with radical resection. The current case confirms radical resection is a feasible management strategy for similar presentations. En bloc resection of involved organs remains the only potentially curative option for locally advanced disease.
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Affiliation(s)
| | | | | | - Niamh McCawley
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
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7
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Elective partial and radical nephrectomy in patients with renal cell carcinoma in CT1B stadium. VOJNOSANIT PREGL 2021. [DOI: 10.2298/vsp200520008m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
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8
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Kalapara AA, Frydenberg M. The role of open radical nephrectomy in contemporary management of renal cell carcinoma. Transl Androl Urol 2020; 9:3123-3139. [PMID: 33457285 PMCID: PMC7807349 DOI: 10.21037/tau-19-327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Radical nephrectomy (RN) remains a cornerstone of the management of localised renal cell carcinoma (RCC). RN involves the en bloc removal of the kidney along with perinephric fat enclosed within Gerota's fascia. Key principles of open RN include appropriate incision for adequate exposure, dissection and visualisation of the renal hilum, and early ligation of the renal artery and subsequently renal vein. Regional lymph node dissection (LND) facilitates local staging but its therapeutic role remains controversial. LND is recommended in patients with high risk clinically localised disease, but its benefit in low risk node-negative and clinically node-positive patients is unclear. Concomitant adrenalectomy should be reserved for patients with large tumours with radiographic evidence of adrenal involvement. Despite a recent downtrend in utilisation of open RN due to nephron-sparing and minimally invasive alternatives, there remains a vital role for open RN in the management of RCC in three domains. Firstly, open RN is important to the management of large, complex tumours which would be at high risk of complications if treated with partial nephrectomy (PN). Secondly, open RN plays a crucial role in cytoreductive nephrectomy (CN) for metastatic RCC, in which the laparoscopic approach achieves similar results but is associated with a high reoperation rate. Finally, open RN is the current standard of care in the management of inferior vena caval (IVC) tumour thrombus. Management of tumour thrombus requires a multidisciplinary approach and varies with cranial extent of thrombus. Higher level thrombus may require hepatic mobilisation and circulatory support, whilst the presence of bland thrombus may warrant post-operative filter insertion or ligation of the IVC.
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Affiliation(s)
| | - Mark Frydenberg
- Department of Surgery, Monash University, Melbourne, Australia.,Cabrini Institute, Cabrini Health, Melbourne, Australia
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9
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Khorsand-Rahimzadeh A, Khatami F, Sefidbakht S, Saffar H, Tavangar SM. Dyspnea as the First Manifestation of Silent Renal Cell Carcinoma. IRANIAN JOURNAL OF PATHOLOGY 2019; 14:87-93. [PMID: 31531106 PMCID: PMC6708564 DOI: 10.30699/ijp.14.1.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 12/24/2018] [Indexed: 11/29/2022]
Abstract
Renal cell carcinoma (RCC) accounts for only 3% of adult malignancies, and the lung is the most common site of metastasis of this tumor, which may be accompanied by pleural metastasis. However, solitary pleural involvement is very rare and its presentation with dyspnea as the first manifestation of RCC is extremely rare. We describe a 39-year-old male with episodes of dyspnea dating back 6 months prior to hospital admission. During paraclinical investigations, chest computed tomography (CT) demonstrated pleural effusion and multiple pulmonary nodules, raising the question of primary mesothelioma or metastasis from distant focus. Histopathology and immuno- histochemical examinations of pleural biopsy provided evidence of metastatic RCC of the clear cell type. Therefore, an abdominal contrast computed tomography (CT) was performed, revealing a 3 cm right renal mass, which was then removed by partial nephrectomy. Physicians and pathologists should be aware of unusual presentations of RCC with no symptoms attributable to the kidneys, including dyspnea as in our case.
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Affiliation(s)
| | - Fatemeh Khatami
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Salma Sefidbakht
- Dept. of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hiva Saffar
- Dept. of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Tavangar
- Dept. of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.,Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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10
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Patient selection for cytoreductive nephrectomy in combination with targeted therapies or immune checkpoint inhibitors. Curr Opin Urol 2019; 29:513-520. [DOI: 10.1097/mou.0000000000000658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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11
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Krabbe LM, Woldu SL, Sanli O, Margulis V. Metastatic Surgery in Advanced Renal Cell Carcinoma. Urol Oncol 2019. [DOI: 10.1007/978-3-319-42623-5_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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12
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Pandey T, Pandey S, Singh V, Sharma A. Bilateral renal cell carcinoma with bilateral adrenal metastasis: a therapeutic challenge. BMJ Case Rep 2018; 11:11/1/e227176. [PMID: 30567248 DOI: 10.1136/bcr-2018-227176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Tanica Pandey
- Radiology, Raghav Pathlabs and Imaging, Haldwani, India
| | | | | | - Ashish Sharma
- Urology, King George's Medical University, Lucknow, India
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13
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Jackson G, Fino N, Bitting RL. Clinical Characteristics of Patients With Renal Cell Carcinoma and Metastasis to the Thyroid Gland. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2017; 11:1179554917743981. [PMID: 29242703 PMCID: PMC5724630 DOI: 10.1177/1179554917743981] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/24/2017] [Indexed: 12/12/2022]
Abstract
Introduction: Renal cell carcinoma (RCC) is the most common malignancy to metastasize to the thyroid gland. The aims of this study are as follows: (1) to analyze the clinical characteristics of patients with thyroid involvement of RCC and (2) in patients with RCC thyroid metastasis, to determine whether RCC metastasis to glandular organs only portends a better prognosis compared with other patterns of RCC metastasis. Methods: Patients from Wake Forest Baptist Medical Center (WFBMC) diagnosed with thyroid metastasis from RCC were identified and medical records retrospectively examined. A systematic review of the literature for cases of RCC involving the thyroid gland was also performed. The clinical characteristics of the institutional cohort and the cases from the literature review were compared. Descriptive statistical analysis was performed, and overall survival (OS) was summarized using Kaplan-Meier methods. Results: The median OS for the WFBMC cohort was 56.4 months. In the literature review cohort, OS of patients with RCC thyroid metastasis was 213.6 months, and there was no statistically significant survival difference based on the site of metastasis. Median survival after thyroid metastasis from RCC for the WFBMC and literature cohort was 21.6 and 45.6 months, respectively. Conclusions: Metastatic RCC should be included in the differential of a new thyroid mass. Treatment directed at the thyroid metastasis results in prolonged survival in some cases. Further analysis into the genomic differences and mechanisms of thyroid metastasis is warranted.
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Affiliation(s)
| | - Nora Fino
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Rhonda L Bitting
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA.,Comprehensive Cancer Center, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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14
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Yoshiji S, Shibue K, Fujii T, Usui T, Hirota K, Taura D, Inoue M, Sone M, Yasoda A, Inagaki N. Chronic primary adrenal insufficiency after unilateral adrenonephrectomy: A case report. Medicine (Baltimore) 2017; 96:e9091. [PMID: 29390437 PMCID: PMC5758139 DOI: 10.1097/md.0000000000009091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Unilateral adrenalectomy as part of surgical resection of renal cell carcinoma (RCC) is not thought to increase the risk of chronic adrenal insufficiency, as the contralateral adrenal gland is assumed to be capable of compensating for the lost function of the resected gland. However, recent studies have indicated that adrenalectomy might cause irreversible impairment of the adrenocortical reserve. We describe a case of chronic primary adrenal insufficiency in a 68-year-old man who previously underwent unilateral adrenonephrectomy, which was complicated by severe postoperative adrenal stress that involved cardiopulmonary disturbance and systemic infection. PATIENT CONCERNS A 68-year-old Japanese man presented with weight loss of 6 kg over a 4-month period, and renal biopsy confirmed a diagnosis of RCC. He underwent adrenonephrectomy for the RCC, but developed postoperative septic shock because of a retroperitoneal cystic infection and ventricular fibrillation that was induced by vasospastic angina. The patient was successfully treated using antibiotics and percutaneous coronary intervention, and was subsequently discharged with no apparent complications except decreased appetite and general fatigue. However, his appetite and fatigue did not improve over time and he was readmitted for an examination. DIAGNOSES The workup revealed a markedly elevated adrenocorticotropic hormone (ACTH) level (151.4 pg/mL, normal: 7-50 pg/mL) and a mildly decreased morning serum cortisol level (6.4 mg/mL, normal: 7-28 mg/mL). In addition to the patient's clinical symptoms and laboratory results, the results from ACTH and corticotropin-releasing hormone stimulation tests were used to make a diagnosis of primary adrenal insufficiency. INTERVENTIONS Treatment was initiated using oral prednisolone (20 mg), which rapidly resolved his symptoms. At the 1-year follow-up, the patient had a markedly decreased serum cortisol level (2.0 mg/mL) with an ACTH level that was within the normal range (44.1 pg/mL) before his morning dose of prednisolone, which confirmed the diagnosis of chronic primary adrenal insufficiency. LESSONS Clinicians must be aware of chronic adrenal insufficiency as a possible complication of unilateral adrenalectomy, especially when patients who underwent unilateral adrenalectomy experience severe adrenal stress.
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Affiliation(s)
- Satoshi Yoshiji
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto
| | - Kimitaka Shibue
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto
| | - Toshihito Fujii
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto
| | - Takeshi Usui
- Department of Medical Genetics, Shizuoka General Hospital, Shizuoka, Japan
| | - Keisho Hirota
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto
| | - Daisuke Taura
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto
| | - Mayumi Inoue
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto
| | - Masakatsu Sone
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto
| | - Akihiro Yasoda
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto
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15
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Metastatic Surgery in Advanced Renal Cell Carcinoma. Urol Oncol 2017. [DOI: 10.1007/978-3-319-42603-7_65-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Bex A, Larkin J, Voss M. Challenging the treatment paradigm for advanced renal cell carcinoma: a review of systemic and localized therapies. Am Soc Clin Oncol Educ Book 2016:e239-47. [PMID: 25993179 DOI: 10.14694/edbook_am.2015.35.e239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The current standard of care for the management of advanced renal cell carcinoma (RCC) revolves around systemic therapy with molecularly targeted agents. Over the last decade, a total of seven targeted drugs have been approved but, altogether, only exploit two molecular targets in this disease: the vascular endothelial growth factor (VEGF) axis and the mammalian target of rapamycin (mTOR). Introduction of these agents has markedly improved outcomes compared with those in the cytokine era, yet comparatively little progress has been made since registration of the first targeted therapeutics occurred 10 years ago. In this article, we review efforts to improve on this current treatment paradigm. We discuss novel targets in this disease and corresponding new agents under investigation. The article dedicates particular attention to targeted immunotherapeutics, which are rapidly emerging as a new category of interest in this disease. Last, we review current data supporting the use of surgical interventions to improve outcomes in patients with metastatic disease.
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Affiliation(s)
- Axel Bex
- From the Netherlands Cancer Institute, Amsterdam, Netherlands; The Royal Marsden NHS Foundation Trust, London, United Kingdom; Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
| | - James Larkin
- From the Netherlands Cancer Institute, Amsterdam, Netherlands; The Royal Marsden NHS Foundation Trust, London, United Kingdom; Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
| | - Martin Voss
- From the Netherlands Cancer Institute, Amsterdam, Netherlands; The Royal Marsden NHS Foundation Trust, London, United Kingdom; Memorial Sloan Kettering Cancer Center, New York, NY; Weill Cornell Medical College, New York, NY
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17
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Barone M, Di Nuzzo D, Cipollone G, Camplese P, Mucilli F. Oligometastatic non-small cell lung cancer (NSCLC): adrenal metastases. Experience in a single institution. Updates Surg 2015; 67:383-7. [PMID: 26589602 DOI: 10.1007/s13304-015-0336-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 11/04/2015] [Indexed: 01/29/2023]
Abstract
Though the actual incidence of an adrenal oligometastasis is between 1.5 and 3.5 %, secondary adrenal neoplasms occur in less than 10 % patients with non-small cell lung cancer (NSCLC). According to 7° ed. TNM staging system, the presence of an adrenal metastasis (M1b disease) configures stage IV, which is usually associated with poor prognosis. We evaluated if metastasectomy in selected patients with oligometastatic disease improves overall survival. A 15-year retrospective study concerning patients with NSCLC was performed and an oligometastatic disease was found in 1.61 % of the patients. 18 adrenalectomies were performed. Clustering the population according to different therapeutic strategies, a benefit in terms of survival was found in patients who underwent adrenalectomy. A statistical relevance was found, indeed, between adrenalectomy (p < 0.01), metachronous disease (p < 0.01), the presence of a homolateral disease (p < 0.05) and overall survival. Adrenalectomy should be offered in selected patients with oligometastatic disease.
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Affiliation(s)
- Mirko Barone
- Department of General and Thoracic Surgery, University Hospital "SS. Annunziata", Chieti, Italy.
| | - Decio Di Nuzzo
- Department of General and Thoracic Surgery, University Hospital "SS. Annunziata", Chieti, Italy
| | - Giuseppe Cipollone
- Department of General and Thoracic Surgery, University Hospital "SS. Annunziata", Chieti, Italy
| | - Pierpaolo Camplese
- Department of General and Thoracic Surgery, University Hospital "SS. Annunziata", Chieti, Italy
| | - Felice Mucilli
- Department of General and Thoracic Surgery, University Hospital "SS. Annunziata", Chieti, Italy
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18
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Weight CJ, Mulders PF, Pantuck AJ, Thompson RH. The Role of Adrenalectomy in Renal Cancer. Eur Urol Focus 2015; 1:251-257. [PMID: 28723393 DOI: 10.1016/j.euf.2015.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 08/25/2015] [Accepted: 09/08/2015] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
| | - Peter F Mulders
- Radbount University, Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Allan J Pantuck
- University of California at Los Angles, Los Angeles, CA, USA
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Desai A, Rai H, Haas J, Witten M, Blacksburg S, Schneider JG. A Retrospective Review of CyberKnife Stereotactic Body Radiotherapy for Adrenal Tumors (Primary and Metastatic): Winthrop University Hospital Experience. Front Oncol 2015; 5:185. [PMID: 26347852 PMCID: PMC4538288 DOI: 10.3389/fonc.2015.00185] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 08/03/2015] [Indexed: 11/19/2022] Open
Abstract
The adrenal gland is a common site of cancer metastasis. Surgery remains a mainstay of treatment for solitary adrenal metastasis. For patients who cannot undergo surgery, radiation is an alternative option. Stereotactic body radiotherapy (SBRT) is an ablative treatment option allowing larger doses to be delivered over a shorter period of time. In this study, we report on our experience with the use of SBRT to treat adrenal metastases using CyberKnife technology. We retrospectively reviewed the Winthrop University radiation oncology data base to identify 14 patients for whom SBRT was administered to treat malignant adrenal disease. Of the factors examined, the biological equivalent dose (BED) of radiation delivered was found to be the most important predictor of local adrenal tumor control. We conclude that CyberKnife-based SBRT is a safe, non-invasive modality that has broadened the therapeutic options for the treatment of isolated adrenal metastases.
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Affiliation(s)
- Amishi Desai
- Department of Hematology and Oncology, Winthrop University Hospital , Mineola, NY , USA
| | - Hema Rai
- Department of Hematology and Oncology, Winthrop University Hospital , Mineola, NY , USA
| | - Jonathan Haas
- Department of Hematology and Oncology, Winthrop University Hospital , Mineola, NY , USA
| | - Matthew Witten
- Department of Hematology and Oncology, Winthrop University Hospital , Mineola, NY , USA
| | - Seth Blacksburg
- Department of Hematology and Oncology, Winthrop University Hospital , Mineola, NY , USA
| | - Jeffrey G Schneider
- Department of Hematology and Oncology, Winthrop University Hospital , Mineola, NY , USA
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Bex A. Integrating metastasectomy and stereotactic radiosurgery in the treatment of metastatic renal cell carcinoma. EJC Suppl 2015. [PMID: 26217128 PMCID: PMC4041303 DOI: 10.1016/j.ejcsup.2013.07.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Axel Bex
- The Netherlands Cancer Institute, Department of Urology, Amsterdam, The Netherlands
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Gabr AH, Steinberg Z, Eggener SE, Stuart Wolf J. Indications for adrenalectomy during radical nephrectomy for renal cancer. Arab J Urol 2015; 12:304-8. [PMID: 26019967 PMCID: PMC4434884 DOI: 10.1016/j.aju.2014.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 08/03/2014] [Accepted: 09/24/2014] [Indexed: 11/26/2022] Open
Abstract
Objectives To determine if the selection criteria for ipsilateral adrenalectomy during laparoscopic radical nephrectomy (RN) can be further restricted, with the goal of sparing more patients unnecessary adrenalectomy while preserving the removal of adrenal glands containing malignancy, as recent evidence suggests that adrenalectomy in association with RN for renal cancer can be limited to patients with abnormalities on adrenal imaging or large upper-pole renal tumours. Patients and methods The cohort consisted of two data sets, each from one institution, i.e., a training set and a validation set. All patients underwent RN for radiographically localised disease. Removal of the adrenal gland was based on the surgeon’s preference, related to the presence of a suspect adrenal lesion on preoperative imaging, suspicion for involvement of the adrenal gland intraoperatively, location of the tumour, size of the tumour and local tumour stage. Results Of 159 patients in the training cohort, three (2%) had metastatic renal cancer in the ipsilateral adrenal gland. All three patients had tumours of >7 cm and either an abnormal radiographic appearance of the adrenal gland or suspect intraoperative findings. In the validation cohort of 74 patients, seven (10%) had adrenal metastasis, of which one had a tumour of <7 cm and the indication for adrenalectomy was the high intraoperative suspicion. Conclusion We recommend performing ipsilateral adrenalectomy in association with RN for renal cancer when there is either abnormal radiographic appearance of the adrenal gland or suspect intraoperative findings, with no regard for primary tumour size.
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Affiliation(s)
- Ahmed H Gabr
- Department of Urology, Minia University, Egypt ; Department of Urology, Salman Bin Abdulaziz University, Saudi Arabia
| | - Zoe Steinberg
- Section of Urology, University of Chicago, Chicago, USA
| | | | - J Stuart Wolf
- Department of Urology, University of Michigan, Michigan, USA
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Hasegawa T, Yamakado K, Nakatsuka A, Uraki J, Yamanaka T, Fujimori M, Miki M, Sasaki T, Sakuma H, Sugimura Y. Unresectable Adrenal Metastases: Clinical Outcomes of Radiofrequency Ablation. Radiology 2015; 277:584-93. [PMID: 25997031 DOI: 10.1148/radiol.2015142029] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE To retrospectively evaluate the clinical outcomes of radiofrequency (RF) ablation for the treatment of unresectable adrenal metastasis. MATERIALS AND METHODS The institutional review board approved this retrospective study, and informed consent to perform adrenal RF ablation was obtained from all patients. From February 2005 through May 2014, 35 patients (25 men and 10 women; mean age, 64.7 years ± 9.6; age range, 39-82 years) underwent RF ablation to treat 41 metastatic adrenal tumors from lung cancer (n = 15), renal cell carcinoma (n = 9), colorectal cancer (n = 5), hepatocellular carcinoma (n = 4), and other tumors (n = 2). Tumors ranged in size from 1.2 to 8.2 cm (mean, 3.3 cm ± 1.6). The diagnosis was established mainly on the basis of radiologic findings. Adrenal arterial embolization was combined with RF ablation in 12 of the 35 patients (34%). Technical success, safety, local tumor progression, and survival were evaluated. The Kaplan-Meier method and Cox proportional hazard model were used to evaluate prognostic factors. RESULTS There were 48 completed sessions with planned procedures and treatment protocols with no mortality and a major complication rate of 8.3% (four of 48 sessions). Tumor enhancement disappeared after initial adrenal RF ablation in 33 of the 35 patients (94%). Local tumor progression developed in eight of the 35 patients (23%); two patients received repeated RF ablation, resulting in adrenal tumor control in 27 of the 35 patients (77%) at the last follow-up (mean, 30.1 months ± 27.5; range 1.2-96.8 months). The 1-, 3-, and 5-year overall survival rates were 75% (95% confidence interval [CI], 61%, 90%), 34% (95% CI: 17%, 52%), and 30% (95% CI: 13%, 48%), respectively, with a median survival time of 26.0 months. Existence of extra-adrenal tumors (P = .005) and age of 65 years or older (P = .04) were significant indicators of a poor prognosis. CONCLUSION Adrenal RF ablation is a feasible and useful method for controlling adrenal metastases and offers patients opportunities for improved survival.
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Affiliation(s)
- Takaaki Hasegawa
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Koichiro Yamakado
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Atsuhiro Nakatsuka
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Junji Uraki
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Takashi Yamanaka
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Masashi Fujimori
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Manabu Miki
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Takeshi Sasaki
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Hajime Sakuma
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Yoshiki Sugimura
- From the Departments of Radiology (T.H., K.Y., A.N., J.U., T.Y., M.F., H.S.) and Urology (M.M., T.S., Y.S.), Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
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Ganeshan D, Morani A, Ladha H, Bathala T, Kang H, Gupta S, Lalwani N, Kundra V. Staging, surveillance, and evaluation of response to therapy in renal cell carcinoma: role of MDCT. ACTA ACUST UNITED AC 2015; 39:66-85. [PMID: 24077815 DOI: 10.1007/s00261-013-0037-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Renal cell carcinoma is the most common malignant renal tumor in the adults. Significant advances have been made in the management of localized and advanced renal cell carcinoma. Surgery is the standard of care and accurate pre-operative staging based on imaging is critical in guiding appropriate patient management. Besides staging, imaging plays a key role in the post-operative surveillance and evaluation of response to systemic therapies. Both CT and MR are useful in the staging and follow up of renal cell carcinoma, but CT is more commonly used due to its lower costs and wider availability. In this article, we discuss and illustrate the role of multi-detector CT in pre-operative staging, post-operative surveillance, and evaluation of response to systemic therapy in renal cell carcinoma.
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Ploumidis A, Spinoit AF, De Naeyer G, Ficarra V, Mottrie A. Robot-assisted radical adrenalectomy with clamping of the vena cava for excision of a metastatic adrenal vein thrombus: a case report. Int J Med Robot 2015; 11:413-7. [PMID: 25727563 DOI: 10.1002/rcs.1641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/06/2014] [Accepted: 12/12/2014] [Indexed: 11/05/2022]
Abstract
BACKGROUND Renal or adrenal neoplastic vein thrombi are relative contra-indications for laparoscopic treatment. To the best of our knowledge, we present the first robot-assisted radical adrenalectomy (RARA) with the presence of a thrombus in the adrenal vein. METHODS A 54 year-old male with a history of laparoscopic left radical nephrectomy for clear cell carcinoma was referred to our department with a diagnosed right adrenal tumour extending into the adrenal vein. A RARA was planned through a trans-peritoneal approach, and an en bloc resection of the adrenal and its vein with clamping of the vena cava was performed. RESULTS Console time was 94 min and the estimated blood loss was 44 ml. The pathology report confirmed clear cell carcinoma with negative surgical margins. Convalescence was uneventful. CONCLUSION RARA with thrombectomy and vascular reconstruction can be safe, effective and feasible in experienced hands, using robotic bulldogs.
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Affiliation(s)
- Achilles Ploumidis
- Department of Urology, OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium
| | - Anne-Françoise Spinoit
- Department of Urology, OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium.,Department of Urology, Ghent University Hopsital, Ghent, Belgium
| | - Geert De Naeyer
- Department of Urology, OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium
| | - Vincenzo Ficarra
- Department of Urology, OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium.,Department of Experimental and Clinical Medical Sciences, Urologic Clinic, University of Padoua, Italy
| | - Alexandre Mottrie
- Department of Urology, OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium
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Öztürk H. Bilateral synchronous adrenal metastases of renal cell carcinoma: A case report and review of the literature. Oncol Lett 2015; 9:1897-1901. [PMID: 25789064 PMCID: PMC4356352 DOI: 10.3892/ol.2015.2915] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 10/31/2014] [Indexed: 11/23/2022] Open
Abstract
Renal cell carcinomas (RCCs) metastasize to the adrenal glands via various mechanisms, including lymphatic vessel arterial embolism and retrograde venous embolism. The rate of ipsilateral metastasis is 3–5% and the rate of contralateral metastasis is ~0.7%, however, synchronous bilateral adrenal metastases are extremely rare. Therefore, the optimal diagnosis and treatment strategy for this condition is yet to be thoroughly defined. In the present study, a 50-year-old male patient presented with right flank pain. Ultrasonography (US) revealed a right renal mass and bilateral adrenal metastases, and a computerized tomography (CT) scan determined the size of the lesions: An 86×83×66-mm mass in the lower pole of the right kidney, an 18×12×10-mm mass in the right adrenal gland, and a 69×51×53-mm mass in the left adrenal gland with central necrosis and peripheral contrast uptake. A US-guided biopsy was performed which determined a diagnosis of right RCC and bilateral synchronous adrenal metastasis. Immunohistochemical examination of the biopsy revealed clear cell carcinoma (Fuhrman grade, III). Consequently, right radical nephrectomy, right partial adrenalectomy (with frozen section examination) and left adrenalectomy were planned. The bilateral synchronous adrenal metastases posed a challenge in the diagnosis and treatment of the disease, as there is no standard approach in the literature for the treatment of such patients. However, metastasectomy was selected, as it appears to be the most effective treatment strategy for increasing the rate of cancer-specific survival. As an adrenal mass was present in the current patient, a hormonal examination was recommended and an adrenal-preserving minimally invasive surgical procedure using frozen section examination during surgery was particularly important to prevent the patient from developing adrenal insufficiency.
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Affiliation(s)
- Hakan Öztürk
- Department of Urology, School of Medicine, Sifa University, Izmir 35240, Turkey
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26
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Dabestani S, Bex A. Metastasectomy. KIDNEY CANCER 2015. [DOI: 10.1007/978-3-319-17903-2_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Avances en imágenes para la estadificación y seguimiento de pacientes con carcinoma de células renales. Rev Urol 2014. [DOI: 10.1016/s0120-789x(14)50057-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Bilateral Metachronous Adrenal Metastases of Operated Renal Cell Carcinoma. Urologia 2014; 82:114-7. [DOI: 10.5301/uro.5000094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2014] [Indexed: 11/20/2022]
Abstract
Background The adrenal glands are among the target metastatic organs due to the potential of systemic metastasis from renal cell carcinoma (RCC). The number of cases with bilateral metachronous metastases from RCC is about twenty. Patients and Methods A sixty-one-year-old man presented for routine checks due to an operated left renal tumor (clear cell carcinoma, PT2N0M0, Fuhrman grade III). The patient underwent 18FDG-PET/CT in order to restage the disease upon observation of bilateral adrenal masses on ultrasound and CT. A bilateral metachronous metastasis was found, whose SUVmax was 6.7 × 50 × 38 × 20 cm on the left adrenal gland, and another metastasis whose SUVmax was 5.5 40 × 29 × 20 on the right adrenal gland. Results The patient underwent a CT-guided biopsy and diagnosis of adrenal metastasis was made by pathological and immunohistochemical examination. The laparoscopic treatment was performed. Conclusions There is no standard approach for the treatment of these patients in the literature. But metastasectomy is the most realistic part of the treatment. Making definitive diagnosis with biopsy, following hormonal examination and treatment with minimally invasive adrenal sparing surgical procedure containing frozen-section are strongly recommended. Cancer specific survival significantly increases with metastasectomy.
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Krabbe LM, Bagrodia A, Margulis V, Wood CG. Surgical management of renal cell carcinoma. Semin Intervent Radiol 2014; 31:27-32. [PMID: 24596437 DOI: 10.1055/s-0033-1363840] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Surgical resection of renal cell carcinoma (RCC) is the benchmark for long-term cure of the disease. Although open or laparoscopic radical nephrectomy is considered the gold standard for stage T1b-T4 tumors, nephron-sparing surgery is the preferred operative modality for small renal masses demonstrating equivalent oncologic efficacy and improved renal function outcomes compared with complete nephrectomy. With the advance of minimally invasive surgery, nephron-sparing procedures can safely be conducted laparoscopically with or without robotic assistance. RCC with intravenous tumor thrombus presents a surgical challenge, but multidisciplinary surgical approaches can provide long-term benefit in these patients. The role of cytoreductive nephrectomy and metastasectomy in patients with metastatic RCC (mRCC) is controversial, but seems to be beneficial for patients in the era of targeted therapy.
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Affiliation(s)
- Laura-Maria Krabbe
- Department of Urology, the University of Muenster Medical Center, Muenster, Germany ; Department of Urology, UT Southwestern Medical Center, Dallas, Texas
| | - Aditya Bagrodia
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas
| | - Vitaly Margulis
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas
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Paunovic· I, Zivaljevic V, Diklic A, Tausanovic K, Stojanic R, Sipetic S. Prognostic parameters after surgery for adrenal metastases: a single institution experience. Acta Chir Belg 2014; 114:198-202. [PMID: 25102710 DOI: 10.1080/00015458.2014.11681008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Clinically isolated adrenal metastases are rare and therefore present a therapeutic challenge. We report our experience with surgery of adrenal metastases and analyze factors that may influence postoperative survival. METHODS A consecutive series of 31 patients (16 male, 15 female) underwent adrenal surgery for metastases at a single institution over 10-year period (1999-2008). The Kaplan-Meier method and log-rank test were used to determine overall survival. Potential prognostic factors were identified by univariate and multivariate Cox regression analysis. RESULTS The primary tumor diagnoses were non-small-cell lung carcinoma (NSCLC) 20, colorectal carcinoma 5, renal cell carcinoma (RCC) 2, malignant melanoma and breast carcinoma, one each. The median survival was 12 months, with one year and five year survival of 21% and 3.4% respectively. According to multivariate analysis independent prognostic factors of favorable survival were disease free interval (DFI) longer than 12 months (Hazard ratio (HR) = 0.28, 95% CI = 0.09-0.90), potentially curative resection (Hazard ratio (HR) = 0.35, 95% CI = 0.12-1.00) and postoperative radiotherapy of adrenal bed (Hazard ratio (HR) = 0.33, 95% CI = 0.12-0.91). CONCLUSIONS Overall survival after surgery for adrenal metastases is poor. In multivariate analyses, survival is influenced by DFI, curative resection, and postoperative radiotherapy.
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Affiliation(s)
- I. Paunovic·
- Center for endocrine surgery, Clinical center of Serbia, Belgrade, Serbia
- Medical school University of Belgrade, Belgrade, Serbia
| | - V. Zivaljevic
- Center for endocrine surgery, Clinical center of Serbia, Belgrade, Serbia
- Medical school University of Belgrade, Belgrade, Serbia
| | - A. Diklic
- Center for endocrine surgery, Clinical center of Serbia, Belgrade, Serbia
- Medical school University of Belgrade, Belgrade, Serbia
| | - K. Tausanovic
- Center for endocrine surgery, Clinical center of Serbia, Belgrade, Serbia
| | - R. Stojanic
- Center for endocrine surgery, Clinical center of Serbia, Belgrade, Serbia
| | - S. Sipetic
- Medical school University of Belgrade, Belgrade, Serbia
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Margulis V, Wood CG. Update on staging controversies for locally advanced renal cell carcinoma. Expert Rev Anticancer Ther 2014; 7:909-14. [PMID: 17627450 DOI: 10.1586/14737140.7.7.909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hirayama T, Fujita T, Koguchi D, Nishi M, Kurosaka S, Tsumura H, Tabata KI, Iwamura M. Laparoscopic adrenalectomy for metastatic adrenal tumor. Asian J Endosc Surg 2014; 7:43-7. [PMID: 24251723 DOI: 10.1111/ases.12076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/22/2013] [Accepted: 10/02/2013] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Treating adrenal metastases from primary malignancies with laparoscopic adrenalectomy (LA) remains controversial. The aim of this study was to evaluate the feasibility, effectiveness and efficiency of LA for solitary adrenal metastasis. METHODS From November 2003 to September 2012, eight consecutive patients with adrenal metastasis were treated with LA. A retrospective study was conducted, and clinical and histological data were analyzed. RESULTS All LA were successfully performed. There were no major complications, blood transfusions or conversions to open adrenalectomy. The patients included seven men and one woman with a median age of 59 years at the time of operation. Adrenal metastases were most commonly noted to be from non-small-cell lung cancer (four patients) and renal cell carcinoma (four patients). The majority of adrenal metastases were unilateral (right: one patient; left: seven patients). One patient had bilateral metastases. The median overall survival was 14 months. Four patients (two with non-small-cell lung cancer; two with renal cell carcinoma) were alive with no evidence of metastatic disease as of October 2013. CONCLUSION LA is a safe and effective procedure for patients with isolated metastases. Surgical resection with LA for a solitary adrenal metastasis from primary malignancy can achieve a good prognosis.
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Affiliation(s)
- Takahiro Hirayama
- Department of Urology, Kitasato University School of Medicine, Sagamihara, Japan
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Simutis G, Lengvenis G, Beiša V, Strupas K. Endoscopic retroperitoneal adrenalectomy for adrenal metastases. Int J Endocrinol 2014; 2014:806194. [PMID: 25276132 PMCID: PMC4170751 DOI: 10.1155/2014/806194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 07/20/2014] [Accepted: 08/05/2014] [Indexed: 12/13/2022] Open
Abstract
Objectives. To evaluate whether retroperitoneal approach for adrenalectomy is a safe and effective treatment for adrenal metastases (AM). Methods. From June 2004 to January 2014, nine consecutive patients with AM were treated with endoscopic retroperitoneal adrenalectomy (ERA). A retrospective study was conducted, and clinical data, tumor characteristics, and oncologic outcomes were acquired and analyzed. Results. Renal cancer was the primary site of malignancy in 44.4% of cases. The mean operative time was 132 ± 10.4 min. There were 5 synchronous and 4 metachronous AM. One patient required conversion to transperitoneal laparoscopic procedure. No mortality or perioperative complications were observed. The median overall survival was 11 months (range: 2-42 months). Survival rates of 50% and 25% were identified at 1 and 3 years, respectively. At the end of the study, 4 patients were alive with a mean observed follow-up of 20 months. No patients presented with local tumor relapse or port-site metastases. Conclusions. This study shows that ERA is a safe and effective procedure for resection of AM and advances the surgical treatment of adrenal disease. The use of the retroperitoneal approach for adrenal tumors less than 6 cm can provide very favorable surgical outcomes.
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Affiliation(s)
- Gintaras Simutis
- Clinic of Gastroenterology, Nephrourology and Surgery, Center of Abdominal Surgery, Faculty of Medicine, Vilnius University, Santariškiu 2, 08661 Vilnius, Lithuania
- *Gintaras Simutis:
| | - Givi Lengvenis
- Faculty of Medicine, Vilnius University, M.K.Čiulionio 21, 03101 Vilnius, Lithuania
| | - Virgilijus Beiša
- Clinic of Gastroenterology, Nephrourology and Surgery, Center of Abdominal Surgery, Faculty of Medicine, Vilnius University, Santariškiu 2, 08661 Vilnius, Lithuania
| | - Kęstutis Strupas
- Clinic of Gastroenterology, Nephrourology and Surgery, Center of Abdominal Surgery, Faculty of Medicine, Vilnius University, Santariškiu 2, 08661 Vilnius, Lithuania
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Chen JYR, Ardestani A, Tavakkoli A. Laparoscopic adrenal metastasectomy: appropriate, safe, and feasible. Surg Endosc 2013; 28:816-20. [PMID: 24337189 DOI: 10.1007/s00464-013-3274-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 10/07/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The role of adrenalectomy in management of isolated metastatic adrenal tumors is increasingly established. Laparoscopy is becoming the preferred approach for these resections. We evaluated surgical and oncological outcomes of patients who underwent laparoscopic versus open adrenal metastasectomy and assessed the effect of such surgery on postoperative adjuvant therapy and survival. METHODS We reviewed our institutional experience with adult patients who underwent an adrenal metastasectomy from 1997 to 2013. We assessed preoperative tumor size, operating room (OR) time, status of resection margin, and length of stay (LOS), as well as oncological outcomes including the use of adjuvant chemotherapy and radiotherapy within 1 year of surgery and 5-year survival. The χ (2) test, Mann-Whitney U test, and Kaplan-Meier curve were used for statistical analysis. RESULTS Thirty-eight patients were identified. Lung was the primary site of malignancy (52.6 % of cases). Of the metastasectomies, 55.2 % (n = 21) were performed laparoscopically and 44.7 % (n = 17) were open. In the laparoscopic group, median tumor size was 2.6 cm versus 4.8 cm in the open group (p = 0.09). Median OR time and complication rates were similar between the 2 groups. The laparoscopic group, however, trended toward a shorter LOS (3 days laparoscopic vs. 4 days for open; p = 0.07). At 1 year, 37 % of all patients had not required any adjuvant chemotherapy or adjuvant radiotherapy. CONCLUSIONS This series confirms that adrenal metastasectomy leads to favorable oncological outcomes in select patient groups, with over one-third of patients not requiring adjuvant therapy for at least 1 year after their resection. Laparoscopic approach leads to excellent oncological resection margins without increasing OR time and with a possible reduction in LOS.
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Affiliation(s)
- Judy Y R Chen
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA,
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Bradley CT, Strong VE. Surgical management of adrenal metastases. J Surg Oncol 2013; 109:31-5. [PMID: 24338382 DOI: 10.1002/jso.23461] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 09/10/2013] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Ciarán T Bradley
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
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Bigot P, Lebdai S, Ravaud A, Azzouzi AR, Ferrière JM, Patard JJ, Bernhard JC. The role of surgery for metastatic renal cell carcinoma in the era of targeted therapies. World J Urol 2013; 31:1383-8. [PMID: 23542915 DOI: 10.1007/s00345-013-1060-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 03/15/2013] [Indexed: 12/23/2022] Open
Abstract
PURPOSE With the emergence of targeted therapies, the indications of cytoreductive nephrectomy have to be redefined. This review article presents the evidence data guiding our current indications of surgery in the management of metastatic renal cell carcinoma (mRCC) in the era of targeted therapies. METHODS A nonsystematic review of the electronic databases PubMed and MEDLINE from 1980 to 2012 was performed and limited to English language. RESULTS Two studies based on immunotherapy (EORTC 30947 and SWOG 8949) were at the origins of the recommendations on initial nephrectomy for patients with mRCC. Since the introduction of angiogenesis inhibitors, there is still no high-level evidence from prospective studies assessing the indication of surgery for mRCC. However, surgery still has its importance in the management of primary tumors and metastasis with the objective of an optimal balance between morbidity, quality of life, and survival. The treatment sequence between surgery and targeted therapies is still to be established and two randomized prospective studies were then specifically designed and are currently recruiting. CONCLUSIONS Preliminary evidence data from retrospective series seem to be in favor of a benefit of surgery for patients with good and intermediate prognosis. However, patients' inclusions in current prospective studies are highly recommended to clearly precise nephrectomy's indications.
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Affiliation(s)
- Pierre Bigot
- Department of Urology, Angers University Hospital, Angers, France,
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Filson CP, Miller DC, Colt JS, Ruterbusch J, Linehan WM, Chow WH, Schwartz K. Surgical approach and the use of lymphadenectomy and adrenalectomy among patients undergoing radical nephrectomy for renal cell carcinoma. Urol Oncol 2012; 30:856-63. [PMID: 21419672 PMCID: PMC3123686 DOI: 10.1016/j.urolonc.2010.08.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 08/23/2010] [Accepted: 08/24/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We assessed the influence of tumor size and surgical approach on the use of lymphadenectomy and adrenalectomy with radical nephrectomy. METHODS We evaluated patients with renal cell carcinoma (RCC) enrolled in the U.S. Kidney Cancer Study, a case-control study in the metropolitan areas of Detroit and Chicago from 2002 to 2007. We identified patients who underwent open (ORN) or laparoscopic radical nephrectomy (LRN). We used medical records and Surveillance, Epidemiology, and End Results (SEER) data to determine the proportion of patients who underwent lymphadenectomy or adrenalectomy. Bivariate analyses were performed to evaluate associations between tumor size, surgical approach, and receipt of lymphadenectomy or adrenalectomy. RESULTS We identified 730 patients who underwent ORN (427, 58%) or LRN (303, 42%) for RCC from 2002 to 2007. Among this group, 11% and 24% underwent lymphadenectomy or adrenalectomy, respectively. Lymphadenectomy was more common among patients treated from an open surgical approach (14.1% ORN vs. 5.9% LRN, P < 0.01); this difference was most pronounced for cases with tumors between 4 and 7 cm (15.9% vs. 2.9%, P = 0.01). Patients treated with ORN were also more likely to undergo adrenalectomy, with the greatest discrepancy among cases with tumors ≤ 4 cm (21.7% vs. 11.4%, P < 0.01). CONCLUSIONS Among patients undergoing radical nephrectomy for RCC, the use of lymphadenectomy and adrenalectomy is relatively uncommon and varies by tumor size and surgical approach. With an increasing number of patients with small tumors, the diffusion of laparoscopy, and the emergence of clinical trials evaluating systemic adjuvant therapies, our findings highlight important considerations for optimizing surgical management of patients with RCC.
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Affiliation(s)
| | - David C. Miller
- Department of Urology, University of Michigan, Ann Arbor, MI
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
| | - Joanne S. Colt
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | | | | | - Wong-Ho Chow
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Kendra Schwartz
- Karmanos Cancer Institute, Detroit, MI
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI
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Yap SA, Alibhai SM, Abouassaly R, Timilshina N, Margel D, Finelli A. Ipsilateral adrenalectomy at the time of radical nephrectomy impacts overall survival. BJU Int 2012; 111:E54-8. [DOI: 10.1111/j.1464-410x.2012.11435.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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MacLennan S, Imamura M, Lapitan MC, Omar MI, Lam TBL, Hilvano-Cabungcal AM, Royle P, Stewart F, MacLennan G, MacLennan SJ, Canfield SE, McClinton S, Griffiths TRL, Ljungberg B, N'Dow J. Systematic review of oncological outcomes following surgical management of localised renal cancer. Eur Urol 2012; 61:972-93. [PMID: 22405593 DOI: 10.1016/j.eururo.2012.02.039] [Citation(s) in RCA: 191] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 02/16/2012] [Indexed: 02/08/2023]
Abstract
CONTEXT Renal cell carcinoma (RCC) accounts for 2-3% of adult malignancies. There remain uncertainties over the oncological outcomes for the surgical management of localised RCC. OBJECTIVE Systematically review relevant literature comparing oncological outcomes of surgical management of localised RCC (T1-2N0M0). EVIDENCE ACQUISITION Relevant databases including Medline, Embase, and the Cochrane Library were searched up to October 2010, and an updated scoping search was performed up to January 2012. Randomised controlled trials (RCTs) or quasi-RCTs, prospective observational studies with controls, retrospective matched-pair studies, and comparative studies from well-defined registries/databases were included. The main outcomes were overall survival, cancer-specific survival, recurrence, and metastases. The Cochrane risk of bias tool was used to assess RCTs, and an extended version was used to assess nonrandomised studies (NRSs). The quality of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). EVIDENCE SYNTHESIS A total of 4580 abstracts and 389 full-text articles were assessed. Thirty-four studies met the inclusion criteria (6 RCTs and 28 NRSs). Meta-analyses were planned but were deemed inappropriate due to data heterogeneity. There were high risks of bias and low-quality evidence across the evidence base. Open radical nephrectomy and open partial nephrectomy showed similar cancer-specific and overall survival, but when both open and laparoscopic approaches are considered together, the evidence showed improved survival for partial nephrectomy for tumours ≤4cm. The overall evidence suggests either equivalent or better survival with partial nephrectomy. Laparoscopic radical nephrectomy offered equivalent survival to open radical nephrectomy, and all laparoscopic approaches achieved equivalent survival. Open and laparoscopic partial nephrectomy achieved equivalent survival. The issue of ipsilateral adrenalectomy or complete lymph node dissection with radical nephrectomy or partial nephrectomy remains unresolved. CONCLUSIONS The evidence base suggests localised RCCs are best managed by nephron-sparing surgery where technically feasible. However, the current evidence base has significant limitations due to studies of low methodological quality marked by high risks of bias.
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Zheng QY, Zhang GH, Zhang Y, Guo YL. Adrenalectomy may increase survival of patients with adrenal metastases. Oncol Lett 2012; 3:917-920. [PMID: 22741018 DOI: 10.3892/ol.2012.595] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 01/23/2012] [Indexed: 11/06/2022] Open
Abstract
The much improved diagnostic accuracy of computed tomography (CT) and positron emission tomography (PET) has enabled urologists and medical oncologists to identify and treat more patients with metastases to the adrenal glands. The aim of this retrospective study was to analyze the clinical aspects of adrenal metastases in a series of patients and to evaluate the effect of adrenalectomy, by laparoscopic or open resection of adrenal metastases, on the survival of these patients. A total of 47 patients (32 males, 15 females) with metastatic disease in the adrenal glands were included in this study. Type B ultrasound and CT were utilized to diagnose the adrenal metastases. Open resection was performed in certain patients with primary tumor and adrenal metastasis. The results showed that adrenal metastases in these patients had various origins, including lung carcinoma, kidney carcinoma, breast cancer, melanoma and other uncharacterized carcinomas. The median survival of the 37 followed-up patients was 29.7±3.23 months (range, 2-62) after the diagnosis/surgical removal of adrenal metastases. The survival rate of the 31 patients with surgically removed adrenal metastases (average, 34.2±4.7 months; range 2-62) was higher than the survival rates of the 6 patients without surgical resection (average, 6.3±2.7 months; range, 4-8). The results of this study are in support of adrenalectomy for patients with adrenal metastases.
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Affiliation(s)
- Qing-You Zheng
- The Military General Hospital of Beijing PLA, Beijing 100700, P.R. China
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41
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Bex A. Metastasectomy. KIDNEY CANCER 2012. [DOI: 10.1007/978-3-642-21858-3_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Sancho JJ, Triponez F, Montet X, Sitges-Serra A. Surgical management of adrenal metastases. Langenbecks Arch Surg 2011; 397:179-94. [DOI: 10.1007/s00423-011-0889-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 11/30/2011] [Indexed: 10/14/2022]
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Yap SA, Alibhai SM, Abouassaly R, Timilshina N, Finelli A. Do we continue to unnecessarily perform ipsilateral adrenalectomy at the time of radical nephrectomy? A population based study. J Urol 2011; 187:398-404. [PMID: 22177155 DOI: 10.1016/j.juro.2011.10.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE Since the mid 1990s evidence has supported ipsilateral adrenal gland sparing radical nephrectomy unless the gland appears involved on imaging or the primary tumor is large and located in the upper pole. However, it is unclear whether this shift in surgical practice has been adopted at the population level. MATERIALS AND METHODS Using the Ontario Cancer Registry we identified 5,135 patients in the province of Ontario who underwent radical nephrectomy between 1995 and 2004. Ipsilateral adrenalectomy and tumor involvement of the adrenal gland were ascertained from pathology reports. Further variables analyzed included age, gender, pathology, surgeon year of graduation, academic status of hospital/surgeon, hospital and surgeon volume, and year of surgery. We used multivariable logistic regression to assess outcomes. RESULTS The overall rate of adrenal gland involvement with cancer was 1.4%. The adrenal was involved in 3.2% of tumors larger than 7 cm vs only 0.89% of tumors 4 to 7 cm and 0.63% of tumors smaller than 4 cm. Factors predictive of adrenal involvement on multivariable analysis were tumor size greater than 7 cm and fat invasion. The overall adrenalectomy rate was 40.1%, which decreased slightly over time (40.6% in 1995 vs 34.8% in 2004). Variables predictive of adrenal removal on multivariable analysis included tumor size greater than 7 cm, presence of venous thrombus, upper pole location, higher hospital volume, and academic status of hospital or surgeon. CONCLUSIONS Despite evidence to support preservation of the ipsilateral adrenal gland during radical nephrectomy, the rate of adrenalectomy decreased only slightly in 10 years. Adrenalectomy remains overused in populations that are unlikely to benefit from the procedure.
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Affiliation(s)
- Stanley A Yap
- Department of Health Policy, University of Toronto, Toronto, Ontario, Canada
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Vourganti S, Shuch B, Bratslavsky G. Surgical management of large renal tumors. Expert Rev Anticancer Ther 2011; 11:1889-900. [PMID: 22117156 DOI: 10.1586/era.11.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The surgical management of patients with renal cell carcinoma has undergone many changes. With equivalent oncologic outcomes and appreciation of the importance of renal functional preservation, the utilization of nephron-sparing partial nephrectomy has increased in recent years. Nevertheless, tumors of larger size continue to be preferentially treated with radical nephrectomy. Here, we present evidence that improvements in techniques and durability of oncologic outcomes has justified the use of nephron sparing to accomplish renal functional preservation even in patients with large renal tumors. In addition, surgical technical considerations when managing such tumors are discussed. Finally, we discuss cytoreductive surgery and the evolving role of systemic targeted therapies in the management of advanced metastatic disease.
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Affiliation(s)
- Srinivas Vourganti
- Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, 10 Center Drive, Bethesda, MD 20892-1107, USA
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Abstract
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.
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Affiliation(s)
- A Heidenreich
- Klinik und Poliklinik für Urologie, Universitätsklinikum Aachen, Pauwelsstrasse 30, Aachen, Germany.
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Renal cell carcinoma: what the surgeon and treating physician need to know. AJR Am J Roentgenol 2011; 196:1255-62. [PMID: 21606286 DOI: 10.2214/ajr.10.6249] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The multimodality approach to treating both localized and metastatic renal cell carcinoma has led to a demand for improved imaging evaluation. We review the information needed from the radiologic studies used to determine treatment strategies. CONCLUSION Adequate preoperative radiologic assessment provides the treating physician with information critical in determining the sequence of treatments, role of nephron-sparing surgery, surgical approach, and timing of systemic therapy for metastatic disease.
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Abstract
The most important and widely utilized system for providing prognostic information following surgical management for renal cell carcinoma (RCC) is currently the tumor, nodes, and metastasis (TNM) staging system. An accurate and clinically useful staging system is an essential tool used to provide patients with counseling regarding prognosis, select treatment modalities, and determining eligibility for clinical trials. Data published over the last few years has led to significant controversies as to whether further revisions are needed and whether improvements can be made with the introduction of new, more accurate predictive prognostic factors. Staging systems have also evolved with an increase in the understanding of RCC tumor biology. Molecular tumor biomarkers are expected to revolutionize the staging of RCC by providing more effective prognostic ability over traditional clinical variables alone. This review will examine the components of the TNM staging system, current staging modalities including comprehensive integrated staging systems, and predictive nomograms, and introduce the concept of molecular staging for RCC.
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Affiliation(s)
- John S Lam
- Roy and Patricia Disney Family Cancer Center, Providence Saint Joseph Medical Center, Burbank, CA 91505, USA
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Immunohistochemical distinction of primary adrenal cortical lesions from metastatic clear cell renal cell carcinoma: a study of 248 cases. Am J Surg Pathol 2011; 35:678-86. [PMID: 21490444 DOI: 10.1097/pas.0b013e3182152629] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The diagnosis of metastatic clear cell renal cell carcinoma (CC-RCC) can be difficult because of its morphologic heterogeneity and the increasing use of small image-guided biopsies that yield scant diagnostic material. This is further complicated by the degree of morphologic and immunophenotypic overlap with nonrenal neoplasms and tissues, such as adrenal cortex. In this study, a detailed immunoprofile of 63 adrenal cortical lesions, which included 54 cortical neoplasms, was compared with 185 metastatic CC-RCCs using traditional [anticalretinin, CD10, antichromogranin, antiepithelial membrane antigen, anti-inhibin, antimelanA, anticytokeratins (AE1/AE3 and AE1/CAM5.2), antirenal cell carcinoma marker, and antisynaptophysin)] and novel [anticarbonic anhydrase-IX, antihepatocyte nuclear factor-1b, antihuman kidney injury molecule-1 (hKIM-1), anti-PAX-2, anti-PAX-8, antisteroidogenic factor-1 (SF-1), and anti-T-cell immunoglobulin mucin-1] antibodies. Tissue microarray methodology was used to simulate small image-guided biopsies. Staining extent and intensity were scored semiquantitatively for each antibody. In comparing different intensity thresholds required for a "positive" result, a value of ≥2+ was identified as optimal for diagnostic sensitivity/specificity. For the distinction of adrenal cortical lesions from metastatic CC-RCCs, immunoreactivity for the adrenal cortical antigens SF-1 (86% adrenal; 0% CC-RCC), calretinin (89% adrenal; 10% CC-RCC), inhibin (86% adrenal; 9% CC-RCC), and melanA (86% adrenal; 10% CC-RCC) and for the renal epithelial antigens hKIM-1 (0% adrenal; 83% CC-RCC), PAX-8 (0% adrenal; 83% CC-RCC), hepatocyte nuclear factor-1b (0% adrenal; 76% CC-RCC), epithelial membrane antigen (0% adrenal; 78% CC-RCC), and carbonic anhydrase-IX (3% adrenal; 87% CC-RCC) had the most potential use. Use of novel renal epithelial markers hKIM-1 (clone AKG7) and/or PAX-8 and the adrenocortical marker SF-1 in an immunohistochemical panel for distinguishing adrenal cortical lesions from metastatic CC-RCC offers improved diagnostic sensitivity and specificity.
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Takayama T, Sugiyama T, Kai F, Ito T, Furuse H, Mugiya S, Ozono S. Should ipsilateral solitary adrenal involvement in renal cell carcinoma be staged as M1? Jpn J Clin Oncol 2011; 41:792-6. [PMID: 21498850 DOI: 10.1093/jjco/hyr031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Tatsuya Takayama
- Department of Urology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka 431-3192, Japan.
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Weight CJ, Kim SP, Lohse CM, Cheville JC, Thompson RH, Boorjian SA, Leibovich BC. Routine adrenalectomy in patients with locally advanced renal cell cancer does not offer oncologic benefit and places a significant portion of patients at risk for an asynchronous metastasis in a solitary adrenal gland. Eur Urol 2011; 60:458-64. [PMID: 21514718 DOI: 10.1016/j.eururo.2011.04.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 04/07/2011] [Indexed: 01/24/2023]
Abstract
BACKGROUND The indications for the removal of the ipsilateral adrenal gland in patients with renal cell carcinoma (RCC) and the long-term outcomes have not been well studied. OBJECTIVE We evaluated the risk of synchronous and asynchronous adrenal involvement in patients with RCC and the effect of adrenalectomy on recurrence and survival in a large, single-institution cohort. DESIGN, SETTING, AND PARTICIPANTS From 1970 to 2006, 4018 consecutive patients with RCC treated by surgical extirpation (radical nephrectomy [RN]: 3107; partial nephrectomy [PN]: 911) from Mayo Clinic were studied for adrenal involvement. Risk of asynchronous adrenal metastasis and cancer-specific survival (CSS) were also compared between those who underwent concomitant ipsilateral adrenalectomy (n = 1541) and those who did not (n = 2477) using multivariate Cox models. INTERVENTION Surgical removal of the adrenal gland at the time of kidney tumor resection. MEASUREMENTS Primary outcome is cancer specific survival; secondary outcomes are incidence of synchronous and asynchronous adrenal metastases. RESULTS AND LIMITATIONS Median postoperative follow-up among those still alive was 8.2 yr (interquartile range [IQR]: 5.3-13.6). Synchronous ipsilateral adrenal involvement was rare (n = 88; 2.2%). Ipsilateral adrenalectomy at the time of nephrectomy did not lower the risk of subsequent adrenal metastasis (hazard ratio [HR]: 0.96; 95% confidence interval [CI], 0.64-1.42) or improve CSS (HR: 1.08; 95% CI, 0.95-1.22). The development of asynchronous adrenal metastasis occurred in 147 patients (3.7%) at a median of 3.7 yr (IQR: 1.2-7.7) after initial surgery. The risk of developing an ipsilateral versus a contralateral asynchronous adrenal metastasis was equivalent at 10 yr in those who did not undergo adrenalectomy at initial surgery. This study is limited by its single-institution, nonrandomized nature. CONCLUSIONS Routine ipsilateral adrenalectomy in patients with high-risk features does not appear to offer any oncologic benefit while placing a significant portion of patients at risk for metastasis in a solitary adrenal gland. Therefore, adrenalectomy should only be performed with radiographic or intraoperative evidence of adrenal involvement.
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