A case of adrenal metastasis of hepatocellular carcinoma diagnosed by endoscopic ultrasound-guided fine-needle aspiration

An 82-year-old man had been treated for lung adenocarcinoma and hepatocellular carcinoma (HCC). Contrast-enhanced computed tomography examination showed swelling of the left adrenal gland, suggesting metastasis of lung adenocarcinoma, HCC, or primary adrenal tumor. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed for the pathological diagnosis, and adrenal metastasis of HCC was diagnosed. No notable complications due to EUS-FNA were found. There have been reports of adrenal metastasis due to various cancers, but there are few reports that can confirm the diagnosis of adrenal metastasis of HCC using EUS-FNA. Adrenal metastasis of HCC is not a rare condition, but it may be difficult to diagnose in the case of multiple cancer complications. We experienced a case in which EUS-FNA was useful for the diagnosis of adrenal metastasis of HCC.

Adrenalectomy for Metastasis: The Impact of Primary Histology on Survival Outcome

Adrenalectomy is commonly considered a curative treatment in case of adrenal gland as site of metastasis. In the present study, we evaluated the impact of primary tumor histology on survival outcomes after a minimally invasive adrenal mastectomy for a solitary metachronous metastasis. From May 2004 to August 2020, we prospectively collected data on minimally invasive adrenalectomies whose pathological examination showed a metastasis. All patients only received metastasectomies that were performed with curative intent, or to achieve non-evidence of disease status. Adjuvant systemic therapy was not administered in any case. Cancer-specific survival (CSS) was assessed using the Kaplan-Meier method. Univariable and multivariable Cox regression analyses were applied to identify independent predictors of CSS. Out of 235 laparoscopic and robotic adrenalectomies, the pathologic report showed metastases in 60 cases. The primary histologies included 36 (60%) renal cell carcinoma (RCC), 9 (15%) lung cancer, 6 (10%) colon cancer, 4 (6.7%) sarcoma, 3 (5%) melanoma and 2 (3.3%) bladder cancer. RCC displayed significantly longer survival rates with a 5-year CSS of 55.9%, versus 22.8% for other histologies (log-rank p = 0.01). At univariable analysis, disease-free interval (defined as the time from adrenalectomy to evidence of disease progression) < 12 months and histology were predictors of CSS (p = 0.003 and p < 0.001, respectively). At multivariable Cox analysis, the only independent predictor of CSS was primary tumor histology (p = 0.005); patients with adrenal metastasis from colon cancer and bladder cancer showed a 5.3- and 75.5-fold increased risk of cancer death, respectively, compared to patients who had RCC as primary tumor histology. Oncological outcomes of adrenal metastasectomies are strongly influenced by primary tumor histology. A proper discussion of the role of surgery in a multidisciplinary context could provide optimal treatment strategies.

Bilateral Adrenal Hemorrhage Heralds Bronchogenic Carcinoma

This case study delves into the unusual presentation of non-small cell lung carcinoma (NSCLC), where bilateral hemorrhagic adrenal metastasis served as the primary indication of an underlying malignancy. Our patient, a 58-year-old male, sought medical attention due to acute abdominal pain and lower back discomfort, leading to an in-depth diagnostic exploration. Radiological examinations revealed bilateral adrenal masses exhibiting hemorrhagic characteristics, a distinctive feature not commonly associated with NSCLC. The subsequent biopsy and histopathological analysis definitively identified metastatic NSCLC as the culprit. The uniqueness of this case lies in the bilateral nature of the metastasis and the presence of hemorrhagic elements, challenging traditional diagnostic expectations. This report emphasizes the necessity for a nuanced approach to diagnostic investigations when confronted with atypical presentations, especially considering the rarity of bilateral involvement and hemorrhagic features in adrenal metastases from NSCLC. It highlights the importance of interdisciplinary collaboration between radiologists, pathologists, and oncologists to ensure accurate and timely diagnosis. The overarching significance of this case extends beyond its rarity; it underscores the imperative for healthcare practitioners to broaden their diagnostic considerations in the absence of conventional symptoms. By presenting this distinctive case, we contribute to the evolving understanding of the diverse clinical manifestations of NSCLC, advocating for heightened vigilance and comprehensive diagnostic approaches in the pursuit of early intervention and optimal patient care.

Isolated Castrate-resistant Prostate Cancer Metastasis to Both Adrenal Glands Detected on 68Ga PSMA PET/CT

A 61-year-old male patient, who had undergone radical prostatectomy, underwent 68Ga labeled prostate-specific membrane antigen (PSMA) positron emission tomography/computerized tomography (PET/CT) for evaluation of suspected biochemical recurrence of prostate cancer (PCa). PET/CT scan showed increased 68Ga PSMA expressions in hypodense mass lesions in both adrenal gland localizations. An adrenal gland tru-cut biopsy was performed for the right side, which showed poor-differentiated carcinoma metastases associated with the patient's high-grade PCa. As far as we could determine based on an extensive literature search, this is the second case in which isolated adrenal metastasis was detected by 68Ga PSMA PET/CT study in a patient with PCa.

Primary Testicular Non-Hodgkin's Lymphoma With Bilateral Adrenal Metastasis: A Rare Presentation

Primary testicular lymphoma is the common testicular neoplasm in patients aged more than 65 years. It accounts for a small number of cases of adult testicular malignancies. Though the metastasis to bone marrow, liver, and central nervous system are well known, metastasis to adrenal glands is a very rare entity. It can be mistaken as a germ cell tumor or a dual malignancy. To rule out other causes, a multidisciplinary approach is required. Here, we present a rare case of primary testicular Non-Hodgkin's lymphoma with bilateral adrenal metastasis.

Melanoma metastatic to the adrenal gland: An update on the role of adrenalectomy in multidisciplinary management

BACKGROUND AND OBJECTIVES

Modern systemic therapy (immune checkpoint blockade [ICB], targeted therapy) has improved survival for patients with metastatic melanoma. The role of adrenal metastasectomy is not well characterized in this setting.

METHODS

Consecutive patients treated with adrenalectomy 1/1/2007-1/1/2019 were retrospectively compared to patients treated with systemic therapy alone in the same time period. Overall survival and survival after adrenal metastasis were compared, prognostic factors associated with survival after adrenal metastasis development were evaluated.

RESULTS

A total of 74 patients underwent adrenalectomy and were compared to 69 treated with systemic therapy alone. The most common indications for adrenalectomy were to render the patient disease-free in the setting of isolated adrenal metastasis (n = 32, 43.2%) or treatment of isolated progression in the setting of other stable/responding metastases (n = 32, 43.2%). Patients treated surgically had longer survival (116.9 vs. 11.0 months after adrenal metastasis diagnosis, p < 0.001). On multivariate analysis, receipt of ICB (hazard ratio [HR]: 0.62, 95% confidence interval [CI]: [0.40-0.95]) and selection for adrenalectomy (HR: 0.27, 95% CI: [0.17-0.42]) were the strongest factors associated with improved survival after adrenal metastasis diagnosis.

CONCLUSIONS

Selective application of adrenal metastasectomy is associated with prolonged survival benefit and remains an important consideration in the multidisciplinary management of patients with metastatic melanoma.

Prevalence of Malignancy in Adrenal Nodules With Heterogeneous Microscopic Fat on Chemical-Shift MRI: A Multiinstitutional Study

BACKGROUND. Homogeneous microscopic fat within adrenal nodules on chemical-shift MRI (CS-MRI) is diagnostic of benign adrenal adenoma, but the clinical relevance of heterogeneous microscopic fat is not well established. OBJECTIVE. This study sought to determine the prevalence of malignancy in adrenal nodules with heterogeneous microscopic fat on dual-echo T1-weighted CS-MRI. METHODS. We performed a retrospective study of adult patients with adrenal nodules detected on MRI performed between August 2007 and November 2020 at seven institutions. Eligible nodules had a short-axis diameter of 10 mm or larger with heterogeneous microscopic fat (defined by an area of signal loss of < 80% on opposed-phase CS-MRI). Two radiologists from each center, blinded to reference standard results, determined the signal loss pattern (diffuse, two distinct parts, speckling pattern, central loss, or peripheral loss) within the nodules. The reference standard used was available for 283 nodules (pathology for 21 nodules, ≥ 1 year of imaging follow-up for 245, and ≥ 5 years of clinical follow-up for 17) in 282 patients (171 women and 111 men; mean age, 60 ± 12 [SD] years); 30% (86/282) patients had prior malignancy. RESULTS. The mean long-axis diameter was 18.7 ± 7.9 mm (range, 10-80 mm). No malignant nodules were found in patients without prior cancer (0/197; 95% CI, 0-1.5%). Four of the 86 patients with prior malignancy (hepatocellular carcinoma [HCC], renal cell carcinoma [RCC], lung cancer, or both colon cancer and RCC) (4.7%; 95% CI, 1.3-11.5%) had metastatic nodules. Detected patterns were diffuse heterogeneous signal loss (40% [114/283]), speckling (28% [80/283]), two distinct parts (18% [51/283]), central loss (9% [26/283]), and peripheral loss (4% [12/283]). Two metastases from HCC and RCC showed diffuse heterogeneous signal loss. Lung cancer metastasis manifested as two distinct parts, and the metastasis in the patient with both colon cancer and RCC showed peripheral signal loss. CONCLUSION. Presence of heterogeneous microscopic fat in adrenal nodules on CS-MRI indicates a high likelihood of benignancy, particularly in patients without prior cancer. This finding is also commonly benign in patients with cancer; however, caution is warranted when primary malignancies may contain fat or if the morphologic pattern of signal loss may indicate a collision tumor. CLINICAL IMPACT. In the absence of prior cancer, adrenal nodules with heterogeneous microscopic fat do not require additional imaging evaluation.

Incidental, Solitary, and Unilateral Adrenal Metastasis as the Initial Manifestation of Lung Adenocarcinoma

An adrenal incidentaloma is an adrenal mass ≥ 1 cm in size discovered on imaging performed for indications other than suspected adrenal disease. It has variable etiologies, which can be benign or malignant, including primary or metastatic disease. We present a rare case of metastatic lung adenocarcinoma with isolated unilateral adrenal metastases, presenting as an adrenal incidentaloma in an asymptomatic patient with no known history of malignancy. A 76-year-old man with a past medical history of chronic obstructive pulmonary disease (COPD) and heavy tobacco use was admitted for the evaluation and treatment of pneumonia. He was found to have an incidental 4.6 cm unilateral adrenal mass on his CT chest. He underwent a workup for the mass, including further imaging studies that were indeterminate and a hormonal workup that concluded that the mass was nonfunctional. Due to the patient's comorbidities, it was determined that he was not a surgical candidate. A multidisciplinary team recommended a biopsy, which revealed metastatic lung adenocarcinoma. The primary lung cancer was located using positron emission tomography with 2-deoxy-2-(fluorine-18) fluoro-D-glucose combined with computed tomography (F-FDG-PET/CT). The patient was evaluated by an oncology service and started on chemotherapy. In this case report, we discuss the approach for evaluating adrenal incidentalomas as well as the role the biopsy has in this process based on a literature review. In addition, we draw a comparison between our case and similar cases in the literature while highlighting the differences that make this case unique.

Outcomes of surgical treatment for isolated adrenal metastasis from non-small cell lung cancer

Objective

Long-term survival of patients who undergo surgical resection of isolated adrenal metastasis instead of nonsurgical treatment has shown higher values than those described for stage IVA. The primary endpoint was to evaluate overall survival (OS) of patients with single adrenal metastasis from non-small cell lung cancer (NSCLC), who underwent surgical treatment. The secondary endpoint was to evaluate and compare the OS and disease-free survival (DFS) according to: pathological lung tumour size, histology, lymph node involvement, type of metastasis at the time of diagnosis and laterality of the metastasis according to the primary lung tumour.

Methods

From August 2007 to March 2020, 13 patients with isolated adrenal gland metastasis were identified. We performed a descriptive observational study including patients with diagnosed single adrenal gland metastasis of resectable primary lung cancer and no history of other malignant disease. Clinical data obtained included patient demographics, metastases characteristics, laterality of the metastasis, time between surgeries, length of follow-up, survival status, pathological lung tumour size, histology and lymph node involvement. The variables analysed were OS and DFS.

Results

Median global OS was 31.9 months (interquartile range (IQR), 19.1-51.4). The 2- and 5-year OS estimated was 54% (95% CI: 29.5%-77.4%) and 36% (95% CI: 13.4%-68.1%), respectively. In patients with NSCLC without mediastinal lymph node involvement, we obtain a median OS of 40 months (IQR, 27.4-51.4) and a 2- and 5-year OS estimated of 75% (95% CI: 43.2%-92.2%) and 50% (95% CI: 18.7%-81.2%), respectively. Recurrence was detected in five patients with a median DFS of 11.9 months (IQR, 6-34.2).

Conclusion

The resection of the adrenal metastasis should be considered if the primary lung cancer is resectable. Presence of mediastinal lymph node involvement should be ruled out through invasive staging of the mediastinum before performing adrenal and lung surgery. Proper selection of patients who would benefit from surgery is essential to obtain better survival results.

Outcomes after Surgical Treatment of Metastatic Disease in the Adrenal Gland; Valuable for the Patient?

Simple Summary

Adrenal glands are common dissemination sites for metastases of various solid tumors. The rapid development of new treatment strategies, such as targeted therapy and immunotherapy for different cancer types, has led to increased metastatic adrenalectomies. Therefore, clear communication between oncologists and adrenal gland specialists has become increasingly important to outweigh surgical risks versus oncological advantages of adrenalectomies in these patients. This study assesses trends in diagnosis, type of surgery, and short-term and long-term surgical outcomes of patients who underwent metastatic adrenalectomy. We included a total of 95 patients with an adrenal metastasis of non-adrenal primary tumors, most often colorectal or lung cancer, who underwent (minimal invasive) adrenalectomy. 37.9% of the patients experienced one or more complications after adrenalectomy. Within our patient cohort, an increased demand for metastatic adrenalectomy was observed over the past years, which might be associated with the rise of targeted- and immunotherapy. Our data aims to assist multidisciplinary teams with weighing the pros and cons of resection of the metastasized adrenal gland of cancer patients.

Abstract

The adrenal glands are common dissemination sites for metastasis of various solid tumors. Surgical treatment is often recommended because targeted therapies and immunotherapy are frequently ineffective for adrenal metastasis. We report the experience with short-term and long-term surgical outcomes of patients undergoing surgery for adrenal metastasis in two hospitals. A retrospective, multicenter study was performed to analyze patient characteristics, tumor-related data, perioperative outcomes, and oncological outcomes. Postoperative complications that occurred within 30 days were scored according to the Clavien Dindo classification. Metastatic adrenalectomy was performed in 95 patients. We observed an increase from an average of 3 metastatic adrenalectomies per year between 2001–2005 to 10 between 2015–2019. The most frequent underlying malignancies were colorectal and lung cancer. In 55.8%, minimal invasive adrenalectomy was performed, including six conversions to open surgery. A total of 37.9% of patients had postoperative complications, of which ileus or gastroparesis, wound problems, pneumonia, and heart arrhythmias were the most occurring complications. Improved cancer care has led to an increased demand for metastatic adrenalectomy over the past years. Complication rates of 37.9% are significant and cannot be neglected. Therefore, multidisciplinary teams should weigh the decision to perform metastatic adrenalectomy for each patient individually, taking into account the drawbacks of the described morbidity versus the potential benefits.

Prognostic significance of the postoperative/preoperative serum CEA level ratio in patients with solitary adrenal metastasis from lung cancer

The present study aimed to evaluate the prognostic significance of the postoperative to preoperative serum carcinoembryonic antigen (CEA) level ratio (CEA ratio) in patients with lung cancer with solitary metastasis of the adrenal gland after adrenalectomy. Furthermore, the optimal CEA ratio cutoff value for predicting disease-free survival (DFS) in patients with lung cancer after adrenalectomy was determined. The medical records of patients with lung cancer with isolated adrenal metastasis who underwent adrenalectomy at the National Cancer Center Hospital East (Kashiwa, Japan) between January 2013 and December 2020 were retrospectively reviewed. Receiver operating characteristic curve analysis was used to segregate patients into two groups (high and low CEA groups) and the clinical prognosis for the two groups was determined. In addition, the association between the CEA ratio and clinical factors was determined. A total of 14 patients with a median age of 68 years (range, 50-75 years) were analyzed, of which 9 (64%) were males. The optimal cutoff value for the CEA ratio to predict DFS was 0.60. The high CEA ratio group (≥0.60) displayed poorer DFS and cancer-specific survival (P=0.03 and 0.02, respectively). The CEA ratio was significantly associated with the preoperative CEA level (P=0.01) and the high CEA ratio (≥0.60) group had lower preoperative CEA levels. The study suggested that the perioperative CEA ratio may be an important emerging prognostic factor for patients with lung cancer with solitary adrenal gland metastasis. As the sample size was limited, a further study with a larger cohort is required to validate the present findings.

Incidental Adrenal Mass in a Patient With Surgically Treated Lung Adenocarcinoma

Adrenal metastases are not uncommon in patients with widespread metastatic lung cancer. Isolated metachronous adrenal metastases in cases of surgically treated lung cancer without long-term evidence of disease are rare and may pose a diagnostic and treatment dilemma. The current literature suggests that in such cases, adrenalectomy provides better median and overall survival rates. This case presents an incidentally discovered isolated adrenal mass in a patient with a past medical history of lung adenocarcinoma that was surgically removed three years before metastasis discovery. The patient successfully underwent adrenalectomy and was disease-free with no apparent complications at her three-month follow-up visit. The case highlights the importance of long-term radiographic surveillance after surgical resection of lung adenocarcinoma for the prompt diagnosis and timely treatment of metachronous metastases.

Advanced hepatocellular carcinoma with response to lenvatinib after atezolizumab plus bevacizumab

RATIONALE

Various treatments are available for treating hepatocellular carcinoma (HCC). The immune checkpoint inhibitor combination of atezolizumab plus bevacizumab was recently approved for the treatment of unresectable HCC, but there are few reports on the failure of the combination treatment. Here, we present a case of unresectable HCC with adrenal metastasis that was eventually operated on after lenvatinib (LEN) treatment that followed failed treatment with atezolizumab plus bevacizumab.

PATIENT CONCERNS

A 68-year-old man was diagnosed with non-alcoholic steatohepatitis-based HCC with adrenal metastasis.

DIAGNOSIS

Cirrhosis was classified as Child-Pugh score of 5. HCC was diagnosed as Barcelona Clinic Liver Cancer stage C.

INTERVENTIONS

We initiated treatment with atezolizumab plus bevacizumab. Liver dysfunction appeared 2 days after the first administration but was improved by intravenous rehydration and did not appear after the second course. The HCC shrank, but the adrenal metastasis grew bigger after the fourth course, so we changed the therapy to LEN. After HCC and adrenal metastasis were necrotic by LEN, conversion surgery was performed.

OUTCOMES

After successful conversion therapy, the general condition of the patient was good, and has been carefully followed for 4 months to date without any evidence of further recurrences.

LESSONS

This case showed that even if atezolizumab plus bevacizumab is not effective, multidisciplinary treatment such as LEN and conversion surgery is possible. Given the efficacy of LEN after atezolizumab plus bevacizumab, it is important to consider that there is a possibility of cure even when first-line treatment is not effective for a patient with unresectable HCC.

Progressive Disseminated Histoplasmosis Mimicking as Anal Carcinoma - Look at the Mountain, Not at Stone: A Case Report

Disseminated histoplasmosis is a systemic disease caused by the dimorphic fungus Histoplasma capsulatum. Here, we are presenting a case of shock who was diagnosed to have primary adrenal insufficiency. This 68-year-old man had bilateral adrenal mass and later presented with chronic fever and ulcerated anal mass in the oncology clinic. The oncologist made a provisional diagnosis of anal carcinoma with adrenal metastasis. He was suspected of having an adrenal crisis and was admitted to the intensive care unit. He also had granulomatous hepatitis and acute kidney injury. The working diagnosis was changed to systemic inflammatory/infective pathology. The biopsy of the anal tissue done to look for the aetiology showed Histoplasma. He was started on oral itraconazole therapy. He improved symptomatically (resolution of fever, improvement in pain) when assessed after seven days. His anal ulcer healed after 21 days of itraconazole therapy.

Bilateral adrenal metastases of endometrial cancer with adrenal insufficiency

Adrenal metastasis from endometrial cancer is extremely rare and has a poor prognosis, especially for bilateral adrenal metastases. It is usually asymptomatic without any adrenal hormonal abnormalities. A 50-year-old postmenopausal woman presented with acute right-sided back pain and history of occasional abnormal uterine bleeding. She was diagnosed with endometrial cancer with ruptured bilateral adrenal metastases. She underwent total hysterectomy and bilateral salpingo-oophorectomy, and the pathological findings revealed dedifferentiated carcinoma. After three courses of adjuvant chemotherapy, the bilateral adrenal metastases had increased in size, with worsening back pain and adrenal hormone insufficiency. The patient died 6 months after the identification of adrenal tumors. Acute back pain may lead to the identification of a ruptured adrenal metastasis. The possibility of gradual adrenal insufficiency should be considered in bilateral adrenal metastases. Although the prognosis is poor, tumor debulking surgery followed by adjuvant chemotherapy could be suggested to improve the prognosis.

Bilateral adrenal metastasis of renal cell carcinoma 4 years after radical nephrectomy: A case report and review of literature

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.

Pemetrexed-Platinum With or Without Bevacizumab for Chinese Chemo-Naive Advanced Lung Adenocarcinoma Patients: A Real-World Study

Despite recent advances in the treatment of advanced non-small-cell lung cancer (NSCLC), bevacizumab plus platinum-based doublet chemotherapy remains a commonly used first-line regimen. This study was conducted to compare the efficacy and safety of pemetrexed-platinum with or without bevacizumab in Chinese chemo-naive advanced lung adenocarcinoma patients in a real-world setting. We retrospectively collected 100 patients who received pemetrexed-platinum with or without bevacizumab (PP, n = 46; Bev+PP, n = 54) until disease progression or unacceptable toxicity. Clinical characteristics of patients were balanced, except for the proportion of stage IV b+c (Bev+PP and PP: 67.4 vs. 37.0%, p = 0.0066). Bev+PP significantly improved the objective response rate (ORR, 65 vs. 30%, p = 0.0004) and progression-free survival (PFS, 7.4 vs. 6.8 months, p = 0.009), but not overall survival (OS, 17.5 vs. 15.0 months, p = 0.553) compared with PP. Treatment (p = 0.001), gender (p = 0.008), adrenal metastasis (p = 0.001), and liver metastasis (p = 0.013) were independent risk factors for PFS. Patients with adrenal metastasis tended to be at the highest risk of not benefiting from bevacizumab addition (HR [95% CI]: 2.244 [0.6495-7.753]). The safety profile was acceptable, and grade ≥3 toxicity occurred similarly. This study showed that pemetrexed-platinum plus bevacizumab was effective compared to chemotherapy alone in Chinese patients with advanced NSCLC.

An adrenal incidentaloma caused by synchronous and isolated metastasis

We report a patient with adrenal incidentaloma due to synchronous and isolated metastasis from lung cancer, which is a relatively rare condition. Close checkups for incidentaloma in oncologic patients are mandatory, leading to successful operation.

A rare association of two endocrine tumours: non-functional oncocytic adrenocortical carcinoma and Papillary thyroid carcinoma

OBJECTIVES

To describe a rare association of two endocrine tumours in a clinical case.

CASE PRESENTATION

A 54-year-old woman with a classic Papillary thyroid cancer (PTC) assessed by the Endocrinology Department of a tertiary hospital from May-2015 to May-2020. PTC was treated with a total thyroidectomy and lymphadenectomy in May-2015. Initial staging (AJCC/TNM 7th edition): T3N1bMx. Additionally, two ablative doses of 150 mCi of 131-I (RAI) were administered until September-2016. No pathological uptake was found on the post-RAI whole-body scan at any level. Due to a persistent incomplete biochemical response in February-2017, a ¹⁸Fluor-dexosiglucose positron emission computed tomography (FDG-PET) was performed. FDG-PET showed an intense pathological deposit in the right adrenal, suggestive of malignancy. Right adrenalectomy was carried out, and pathology revealed an Adrenocortical carcinoma (ACC). Genetic syndromes associated to ACC are: Li-Fraumeni syndrome (caused by an autosomal mutation in the TP53 gene), the Multiple Endocrine Neoplasia (MEN) type 1 (caused by Menin gene mutations), and MEN type 4 (caused by heterozygous mutations in the CDNK1B gene). However, none of them are associated to PTC.

CONCLUSIONS

To our knowledge this is the sixth published case reporting an ACC in presence of a PTC. The pathological factors behind the relation between these malignancies have not been elucidated. We do not discard the possibility of a genetic relationship between PTC and ACC.

Large adrenal tumor in a 76-year-old man

Among various adrenal tumors, metastatic ones are the most common. PET/CT scanning facilitates early detection. Occurrence of isolated and synchronous metastasis is very rare and poses serious diagnostic and therapeutic challenges.

Nonseminomatous Germ-Cell Tumor Presenting as Bilateral Adrenal Masses

Objective

Many tumors can metastasize to the adrenal glands, making the diagnosis of adrenal masses challenging. Awareness that rare primary tumors can metastasize to the adrenals and consideration of biopsy for their diagnosis, sometimes at extra-adrenal sites, is essential to prevent unnecessary adrenalectomies and facilitate the right treatment. We report a rare case of bilateral adrenal masses due to metastasis from a nonseminomatous germ-cell tumor of a retroperitoneal lymph node origin.

Methods

The diagnosis of the adrenal masses from the nonseminomatous germ-cell tumor of a retroperitoneal lymph node origin was based on a retroperitoneal lymph node core biopsy. An initial core biopsy of the adrenal gland revealed necrotic tissue and inflammatory cells without evidence of malignancy. Due to nondiagnostic findings, the core biopsy was repeated, which showed degenerating cells with a high mitotic index and immunohistochemical staining positive for vimentin, suggesting the possibility of a high-grade sarcoma. A retroperitoneal lymph node biopsy was performed. The patient was started on chemotherapy.

Results

A 34-year-old man presented with acute left upper-abdominal pain of 2 weeks and tenderness on the left upper quadrant of the abdomen, and he was found to have bilateral adrenal masses. Laboratory results showed the following: adrenocorticotropic hormone 41 pg/mL (7-69 pg/mL), metanephrine <0.1 nmol/L (0-0.49 nmol/L), normetanephrine 0.99 nmol/L (0-0.89 nmol/L), and morning cortisol 3.1 μg/dL after a 1-mg dexamethasone-suppression test. His dehydroepiandrosterone sulfate level was 62 μg/dL (120-520 μg/dL), and 17OH progesterone level was 36 ng/dL (<138 ng/dL); androstenedione and serum estradiol levels were normal. Laboratory tests for tumor markers revealed the following: testosterone 21 ng/dL (241-827 ng/dL), prostate-specific antigen 0.57 ng/mL (0-4 ng/mL), alpha-fetoprotein 1.9 IU/mL (0.6-6 IU/ml), and beta-human chorionic gonadotropin 134 mIU/mL (0-1 mIU/mL).

Conclusion

We report a rare case of rapidly progressing adrenal masses in a young man, found to have metastasized from nonseminomatous germ-cell tumors. Histopathologic confirmation of the metastatic tumor was done, which prevented unnecessary adrenalectomy. The patient received appropriate chemotherapy.

Synchronous Robot-Assisted Pulmonary and Urologic Resections for Cancer

Synchronous cancers should be first evaluated at high-volume referral oncological centers. Multidisciplinary evaluation, as the first step of multimodal treatment strategy, is also a way to select candidates fit for surgical resections. Concurrent minimally invasive approaches are a safe and effective option that may result in long-term control of the disease. Robot-assisted surgery allows obtaining the oncological radicality with lower invasiveness for the patient, thus retaining greater surgical aggressiveness even in high-risk patients. The reports of successful synchronous robot-assisted pulmonary and urologic resections for cancer in frail elderly subjects are described here.

Predicting malignancy in patients with adrenal tumors using 18 F-FDG-PET/CT SUVmax

BACKGROUND AND OBJECTIVES

¹⁸ F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸ F-FDG-PET/CT) parameters may help distinguish malignant from benign adrenal tumors, but few have been externally validated or determined based on definitive pathological confirmation. We determined and validated a threshold for ¹⁸ F-FDG-PET/CT maximum standard uptake value (SUVmax) in patients who underwent adrenalectomy for a nonfunctional tumor.

METHODS

Database review identified patients with ¹⁸ F-FDG-PET/CT images available (training cohort), or only SUVmax values (validation cohort). Discriminative accuracy was assessed by area under the curve (AUC), and the optimal cutoff value estimated by maximally selected Wilcoxon rank statistics.

RESULTS

Of identified patients (n = 171), 86 had adrenal metastases, 20 adrenal cortical carcinoma, and 27 adrenal cortical adenoma. In the training cohort (n = 96), SUVmax was significantly higher in malignant versus benign tumors (median 8.3 vs. 3.0, p < .001), with an AUC of 0.857. Tumor size did not differ. The optimal cutoff SUVmax was 4.6 (p < .01). In the validation cohort (n = 75), this cutoff had a sensitivity of 75% and specificity 55%.

CONCLUSIONS

¹⁸ F-FDG-PET/CT SUVmax was associated with malignancy. Validation indicated that SUVmax ≥ 4.6 was suggestive of malignancy, while lower values did not reliably predict benign tumor.

Angiomyolipoma of the adrenal gland: clinical experience and literature review

Angiomyolipomas, a type of benign mesenchymal tumor originating from perivascular epithelioid cells, are composed of mature adipose tissue, smooth muscle, and thick-walled vessels. With fewer than 20 cases reported in English literature, adrenal angiomyolipoma is extremely rare. In these cases, the patient is usually asymptomatic and the tumor is found incidentally. Adrenal angiomyolipoma has never been reported in association with lung cancer. A 62-year-old man presented with an enlarged mass in the left adrenal gland. The mass had persisted for two years previously and was first discovered during a routine follow-up CT examination after lung cancer resection in 2016. Subsequently, partial left adrenal resection was performed. Postoperative histopathology confirmed a benign angiomyolipoma comprising adipose tissue, blood vessels, and smooth muscle cells. At three months follow-up, the patient was alive and had experienced no recurrence after the operation. Eighteen cases were identified on literature review, among which no patients had a history of lung cancer. These cases occurred more often in females and lesions mostly located on the right side. All of the reported cases were nonfunctional, ranging in size from 0.2 to 16 cm (95% of the masses exceeding 4 cm). In this case report, we consider a rare case of a patient with an adrenal angiomyolipoma with a history of lung cancer. Adrenal angiomyolipoma should be considered as one of the differential diagnoses of adrenal metastasis for patients with a history of primary tumors.

Gastric and adrenal metastasis from breast cancer: Case report and review of literature

RATIONALE

Breast cancer is the most commonly diagnosed malignancies in females. The most common sites of metastasis are bone, lung, liver, and brain. Gastrointestinal and adrenal gland metastasis from breast cancer are rare. Simultaneous metastases are extremely rare. Therefore, it is critically important to choose proper examination and treatment since the rapid diagnosis and primary treatment can significantly affect the survival of patients. To the best of our knowledge, this was the first case of initial dual metastasis.

PATIENT CONCERNS

The patient had a history of left breast cancer, and she underwent left breast-conserving surgery with sentinel lymph node biopsy 2 years ago. She was hospitalized in our center with the complaints of a stomach and lower back pain, which started suddenly and was progressively increased for half a month.

DIAGNOSIS

Computed tomography, gastroscopy, and immunohistochemical staining, especially GATA3 and mammaglobin, confirmed that there was simultaneous gastric and adrenal metastases.

INTERVENTIONS

She was eligible for the IMpassion131 clinical trials, a Phase 3 randomized, double-blind, placebo-controlled trial under treatment with atezolizumab/palcebo plus paclitaxel as adjuvant-therapy.

OUTCOMES

She was still undergoing the therapy and waiting for the further evaluation.

LESSONS

In order to better understand metastatic pathways of breast carcinoma, publications of individual patient cases diagnosed with rare metastatic sites should be encouraged, especially for the simultaneous rare metastatic sites. This might improve our understanding of metastatic behavior of breast cancer and promote further clinical research.

Adrenal insufficiency due to recurrent renal cell carcinoma in the left adrenal gland 3 years after right radical nephrectomy for renal cell carcinoma

Primary adrenal insufficiency due to tumor involvement is very rare. We herein report a case of adrenal insufficiency caused by cancer metastasis to a remaining single adrenal gland in a renal cell carcinoma patient who had undergone radical nephrectomy including removal of the right adrenal gland. The patient presented with abdominal discomfort, nausea, and vomiting which had begun about 3 months earlier. A rapid adrenocorticotropic hormone (ACTH) test showed no cortisol response with upper normal level of baseline ACTH. The patient was treated with prednisolone after diagnosis of primary adrenal insufficiency due to adrenal metastasis. The symptoms improved after prednisolone replacement. The case reminds clinicians the diagnosis of primary adrenal insufficiency due to tumor metastasis should be considered in patients with nonspecific gastrointestinal symptoms.

Lung Carcinoma Presenting as a Superior Vena Cava Syndrome, Burnt and Twice Reborn as Adrenal and Facial Tumors

Eighty-five percent of all lung cancers are Non-Small-Cell Lung Carcinoma (NSCLC) with common sites of metastasis to the adrenal glands and liver. Onset is insidious, and seventy-five percent of patients have either regional or distant metastases at initial presentation. The five-year relative survival rate is four and a half percent with a distantly spread disease based on recent studies. Here we present a unique case of a ten-year survival with NSCLC initially presenting as a Superior Vena Cava Syndrome and reoccurring with adrenal gland, bone, and CNS lesions. The patient presented with SVC caused by lung cancer and underwent chemo and radiotherapy with complete response in 2010. Five years later, the same cancer returned disguised as an adrenal tumor. In 2017, the patient came in with facial neuropathy, shooting pains, sinus headaches, eyelid concerns, and active tumoral activity was detected in the middle cranial fossa, involving parotid glands and the vertebral column. Craniotomy revealed a metastatic poorly differentiated adenocarcinoma that extended through foramen ovale and rotundum to the infratemporal fossa and caused left-sided facial paralysis, hearing loss and numbness in CN V2 - V3 distribution. Considering that the patient has experienced several recurrences of disease on standard protocols and is not a candidate for targeted molecular therapies, an immunotherapy trial was suggested as the next step. The natural history of this disease is remarkable in terms of metastatic sites, paraneoplastic manifestations, and a substantially prolonged lifespan. Thus, more studies of similar cases will advance our understanding of tumor genetics and immunotherapy allowing the greater benefit to future patients.

Solitary adrenal metastasis from advanced gastric cancer invading duodenal bulb with situs inversus totalis: A case report

RATIONALE

Situs invsersus totalis (SIT) is a rare anomaly featured by complete inversion of abdominal and thoracic organs. Adrenal metastasis is often encountered as part of advanced systemic dissemination, which is usually unresectable. Few published cases reported the adrenal metastasis from gastric cancer with SIT and the treatment of gastrectomy combined with adrenalectomy, especially with intraoperative radiotherapy (IORT).

PATIENT CONCERNS

A 61-year-old SIT man found a mass on the right clavicle and the biopsy revealed a metastatic cancer. Around 14 years ago, he had a rectal cancer resection surgery and no sign of occurrence. Five months later, the patient had a pain in his right low abdomen and abdominal CT found a right adrenal mass.

DIAGNOSES

Gastroscopy and the pathology revealed the gastric antrum cancer invading the duodenal bulb. Abdominal enhanced CT suspected the adrenal mass as a hematoma, but positron emission tomography computed tomography suspected it as the metastases of gastric cancer which is consistent with the pathology results. Finally, the SIT patient was diagnosed with primary gastric cancer invading duodenal bulb with solitary right adrenal metastasis.

INTERVENTIONS

The patient was treated with curative distal gastrectomy and Billroth-II anastomosis with D2 lymphadenectomy. A total 18 Gy intraoperative radiotherapy (IORT) using low energy x-rays by Intrabeam were given after resection.

OUTCOMES

The patient had liver metastasis in the seventh month after surgery but there is no sign of local recurrence until now.

LESSONS

Gastric cancer with adrenal metastasis, especially with SIT is rare and intractable. The result suggested that active surgical treatment for resectable gastric cancer and solitary adrenal metastatic tumor, especially in combination with IORT may be an option in controlling local relapse and prolonging survival in selected patients.

Long-term Local Control of Primary Non-small Cell Lung Cancer and Adrenal Oligometastasis with Stereotactic Body Radiotherapy: A Case Report

Treatment options for non-small cell lung cancer (NSCLC) patients presenting with synchronous adrenal oligometastases (stage IV disease) include local treatment such as surgery, stereotactic body radiotherapy (SBRT) or systemic treatment such as chemotherapy. A case of successful SBRT treatment to a primary NSCLC with a synchronous left adrenal oligometastasis achieving long-term local control of both lesions is reported.

Adrenal incidentalomas: are they being worked up appropriately?

INTRODUCTION

Adrenal incidentalomas are defined as masses picked up on imaging studies that were done for apparently different reasons. With frequent use of imaging modalities, incidental adrenal masses are commonly encountered in clinical practice. Guidelines are currently available for the diagnosis and management of adrenal incidentalomas, but the appropriateness of initial work-up and subsequent follow-up of incidental adrenal masses in the community hospital setting is unknown.

OBJECTIVE

We studied the appropriateness of initial work-up and follow-up of incidental adrenal masses discovered on abdominal computerized tomography (CT).

METHODS

In our retrospective study, we reviewed sequential CT scans of the abdomen performed in the month of January 2010 at a community hospital. Once patients with one or more adrenal masses were identified, outpatient charts for initial biochemical testing and follow-up imaging were obtained either through directly accessing the electronic medical records or through contacting primary care physician's offices. Patient charts were reviewed to assess the data for the next 2 years following the discovery of an adrenal abnormality.

RESULTS

Twenty adrenal masses were incidentally discovered on 723 abdominal CTs performed within the month of January 2010 resulting in an overall incidence of 2.76%. Of the patients with incidentally discovered adrenal masses, appropriate biochemical and follow-up imaging were only performed in patients referred to an endocrinologist (2 of 20 patients). Thirty percent of patients with incidental masses received a repeat CT scan for non-adrenal reasons, and no change in the mass size was noted.

CONCLUSION

Despite published guidelines, the initial work-up and follow-up of patients with an incidentally discovered adrenal mass is unsatisfactory. There is a desperate need for education of providers regarding appropriate work-up of incidental adrenal masses.

Long-term outcome of adrenalectomy for metastasis resulting from colorectal cancer with other metastatic sites: A report of 3 cases

Metastasis to the adrenal glands is a relatively frequent observation at autopsy of patients that have succumbed to cancer. Long-term disease-free survival has been reported in patients following the resection of solitary adrenal metastasis resulting from colorectal cancer. In addition, following primary resection for colorectal cancer, solitary metastasis to the adrenal glands is rare, even in outpatients at routine follow-ups. Therefore, adrenal metastasis is usually detected in combination with multiple synchronous metastases at other sites in the terminal stages of cancer. Between 1998 and 2002, 3 patients with adrenal metastasis and other synchronous metastatic sites underwent surgery for adrenal metastasis at the Department of Gastroenterological Surgery at Osaka University. The other synchronous metastatic sites observed in the 3 patients consisted of lung and para-aortic lymph nodes. In total, 2 out of the 3 patients experienced long-term disease-free survival for >5 years following surgery and 1 patient underwent curative resection for recurrence of metastases in the liver and right adrenal gland 79 months subsequent to the initial resection for adrenal metastasis. All 3 patients survived for >90 months. In conclusion, aggressive surgical resection for adrenal metastasis and other metastatic sites resulting from colorectal cancer may result in a survival benefit in selected patients.

Massive renal urothelial carcinoma with renal vein tumor thrombus, pancreatic infiltration and adrenal metastasis: A case report

A 49-year-old female patient presented with a massive left renal tumor, recurrent left flank pain and gross hematuria. The tumor was accompanied by a renal vein tumor thrombus, pancreatic infiltration and a solitary adrenal metastasis. Radical nephrectomy, distal pancreatectomy, ipsilateral adrenalectomy and splenectomy were performed. Histopathological examination suggested high-grade urothelial carcinoma (UC); however, tumor recurrence and multiple metastases were detected only 3 months after the surgery, and the patient succumbed during follow-up 1 month later. To the best of our knowledge, this is the first case of renal UC of such advanced stage with renal vein tumor thrombus, pancreatic infiltration and a solitary adrenal metastasis.

Contralateral adrenal metastasis from renal cell carcinoma with tumor thrombus in the adrenal vein: a case report

A 64-year-old woman presented with contralateral right adrenal metastasis with adrenal vein thrombus, which was diagnosed many years after left nephrectomy with adrenalectomy due to renal cell cancer. The patient underwent right adrenalectomy with adrenal vein tumor thrombectomy for treatment. The pathologic examination confirmed metastatic clear cell carcinoma. The remote but existing risk of developing contralateral adrenal metastasis (CAM) after primary radical nephrectomy supports the idea of sparing the adrenal gland in suitable patients who undergo radical nephrectomy. Contralateral adrenal metastasis from RCC is a rare finding with the potential benefit of cure after resection. Care must be taken in preoperative diagnostics, as this metastasis is capable of causing inferior vena cava tumor thrombus via the suprarenal venous route. According to our knowledge, our case is the second similar entity described in literature so far.

Emerging applications of stereotactic body radiotherapy

Stereotactic body radiotherapy (SBRT) has been used extensively in patients with lung, liver and spinal tumors, and the treatment outcomes are very favorable. For certain conditions such as medically inoperable stage I non-small-cell lung cancer, liver and lung oligometastases, primary liver cancer and spinal metastases, SBRT is regarded as one of the standard therapies. In the recent years, the use of SBRT has been extended to other disease conditions and sites such as recurrent head and neck cancer, renal cell carcinoma, prostate cancer, adrenal metastasis, pancreatic cancer, gynecological malignancies, spinal cord compression, breast cancer, and stage II-III non-small-cell lung cancer. Preliminary data in the literature show promising results but the follow-up intervals are short for most studies. This paper will provide an overview of these emerging applications.

Bilateral synchronous adrenal metastases of renal cell carcinoma: A case report and review of the literature

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.

Bilateral synchronous adrenal metastasis of invasive ductal carcinoma treated with multimodality therapy including adrenalectomy and oophorectomy

A 38-year-old woman presented with a mass in the left breast. Biopsy of the lesion revealed invasive ductal carcinoma. Bilateral adrenal metastasis was detected in whole body positron emission tomography scanning. Needle biopsy of the left adrenal lesion proved infiltration of malignant cells from breast carcinoma. After eight cycles of neoadjuvant (preoperative) chemotherapy, mastectomy, bilateral adrenalectomy, and bilateral oopherectomy were performed. No further hormonal treatment was recommended due to the resection of both adrenal glands and ovaries. The patient is still followed without any sign of progression. To our knowledge, this is the first case representing multimodality approach to breast cancer with bilateral synchronous adrenal metastasis. Patients with oligometastatic disease may benefit from aggressive treatment including local therapies.

Dedifferentiated endometrial cancer: an atypical case diagnosed from cerebellar and adrenal metastasis: case presentation and review of literature

Dedifferentiated endometrial cancer (DEC) is microscopically characterized by the presence of high-grade areas emerging from low-grade tumour. DEC is an aggressive tumour even when the dedifferentiated component represents only 20% of the entire neoplasm. A proper histological diagnosis is essential to define the most appropriate therapeutic approach for these tumors, since they are characterized by a particularly aggressive trend and by an extremely poor prognosis. We report a single case of DEC associated with dedifferentiated and adrenal metastasis, for which the patient underwent both abdominal-pelvic and cerebellar surgery. Dedifferentiated carcinoma of the endometrium is a poorly recognized neoplasm since they have not been clearly defined the histological features discriminating this neoplasm from high-grade endometrioid adenocarcinoma. Revising existing literature we found 79 described cases of central nervous system secondary involvement and 13 cases where the onset of the disease was characterized by neurological signs and symptoms. We could only find two reported cases of adrenal metastases originating from endometrial neoplasia but in no case of dedifferentiated endometrial carcinoma previously described has been reported the concomitant adrenal-cerebellar involvement.

Solitary extrahepatic intraabdominal metastasis from hepatocellular carcinoma after liver transplantation

A liver transplantation is a treatment option in selected patients with hepatocellular carcinoma (HCC). Despite the adequate selection of candidates, recurrences of HCC may still develop. Solitary extrahepatic metastasis from HCC after a liver transplantation is rare. Here we report two cases of HCC demonstrated extrahepatic recurrence to the adrenal gland and spleen, respectively, within one year after a liver transplantation. Since the treatment of solitary extrahepatic metastasis from HCC after a liver transplantation is not standardized, surgical resection was performed. In the case of HCC adrenal metastasis, innumerable intrahepatic metastases were found two months after the adrenalectomy. And 16 months after adrenalectomy, the patient expired due to tumor progression and hepatic failure. In the case of HCC splenic metastasis, postoperative radiation therapy was performed. However, two recurrent HCC nodules were found 15 months after the splenectomy and received transarterial chemoembolization (TACE). And 29 month after the splenectomy, the patient also expired as same causes of former patient.

Asymmetric 18F-FDG Uptake in the Infradiaphragmatic Brown Adipose Tissue (BAT) Mimicking Adrenal Metastasis: A Relatively Rare Site of Brown Fat and a Potential Source for False Positive FDG-PET Study

FDG uptake in the metabolically active brown adipose tissue (BAT) is a source of significant concern while interpreting FDG-PET studies. It is also of great interest due to its potential implications for obesity research. In this communication, we describe hitherto unreported asymmetric BAT uptake in the abdomen, persisting after diazepam intervention in the repeat PET study on a separate day. The patient did not have any evidence of disease even at 24 months' follow up. The present case is a useful addition to the current body of literature of false positive FDG-PET due to BAT uptake in unusual location and underscores the importance of high index of suspicion and careful correlation, whenever one comes across an unusual PET finding in a given clinical situation. This assumes important diagnostic value particularly when it coexists in the setting of malignancy where the disease can be falsely upstaged by misinterpretation. The literature relevant to the report is discussed and a schema is suggested for correct interpretation.

Laparoscopic adrenalectomy for large adrenal metastasis from contralateral renal cell carcinoma

We present herein the case of a patient with solitary metachronous contralateral adrenal metastasis from renal cell cancer. The patient had undergone left radical nephrectomy and adrenalectomy for localized renal cancer 7 years previously. Laparoscopic transperitoneal right adrenalectomy was performed. The postoperative period was uneventful. Histology showed right adrenal metastasis from renal cancer. At 6-month follow-up, there was no evidence of recurrence.

Laparoscopic adrenalectomy for isolated adrenal metastasis

BACKGROUND

Laparoscopic adrenalectomy is accepted by many as the standard of care for the majority of adrenal masses less than 8 cm. The question exists whether laparoscopic removal of metastatic lesions to the adrenal is more difficult than laparoscopic removal of primary adrenal lesions.

METHODS

We performed a retrospective analysis of all laparoscopic adrenalectomies performed at a single institution from 1998 to 2001, comparing laparoscopic adrenalectomies for primary lesions of the adrenal gland versus isolated metastatic lesions to the adrenal gland.

RESULTS

Fourteen laparoscopic adrenalectomies were attempted, 10 for primary disease and 4 for metastatic disease. All 10 laparoscopic procedures were completed successfully for primary disease (average operative time=218 minutes, average tumor size=4 cm, median hospital stay=2 days). Only one of the 4 laparoscopic adrenalectomies for metastatic disease was completed successfully (average operative time=332 minutes, average tumor size=7.3 cm, median hospital stay=2 days). No major complications occurred in either group.

CONCLUSIONS

We feel laparoscopic adrenalectomy is the preferred approach for primary adrenal masses less than 8 cm. Based on our experience and a review of the literature, isolated metastatic lesions to the adrenal gland appear less amenable to laparoscopic removal than do primary lesions of the same size.