CASE REPORT
Laparoscopic adrenalectomy for a late solitary renal cell cancer metastasis to the ipsilateral adrenal gland
D. McGrogan . M. McCavert . M. E. O’Donnell . S. Dolan
Received: 26 November 2009 / Accepted: 1 December 2010/Published online: 14 December 2010 @ Royal Academy of Medicine in Ireland 2010
Abstract
Background Metastases to the adrenal gland are the second most common type of adrenal mass lesion after adrenocortical adenomas [1, 2]. However, less than 2% of those patients who develop a metachronous metastasis after resection of a primary renal tumour will present with a solitary adrenal tumour [3]. Most of these patients present within several years of the primary diagnosis [4].
Case report A 66-year-old man with a history of left nephrectomy for renal cell carcinoma 18 years previously was investigated for recent weight loss. Computed tomography scanning identified a lesion in the ipsilateral adrenal gland. Hormonal investigations were consistent with a non-functioning mass. Magnetic resonance imaging and positron emission tomography scans suggested a malignant lesion. Laparoscopic adrenalectomy was per- formed without complication and histopathological exam- ination confirmed metastatic renal cell carcinoma. The patient remains well with no evidence of recurrence at 6 months.
D. McGrogan . M. McCavert · M. E. O’Donnell · S. Dolan Department of Surgery, Ward 6C, Royal Victoria Hospital, Belfast BT12 6AB, Northern Ireland, UK
e-mail: markmccavert@doctors.org.uk
D. McGrogan e-mail: damianmcg@gmail.com
S. Dolan e-mail: Seamus.dolan@westerntrust.hscni.net
M. E. O’Donnell
Faculty of Life and Health Sciences, University of Ulster, Newtownabbey BT37 0QB, Northern Ireland, UK e-mail: modonnell904@hotmail.com
Conclusion Laparoscopic adrenalectomy is a safe, effective treatment in the treatment of late solitary renal cell cancer metastasis to the ipsilateral adrenal gland.
Keywords Adrenalectomy . Laparoscopic . Metastasis . Nephrectomy · Renal cell carcinoma
Introduction
Approximately, one-third of patients with renal cell carci- noma (RCC) have metastatic disease at the time of diag- nosis, while 50% of patients undergoing attempted curative surgery have relapse at distant sites [1]. The lungs, lymph nodes and bones are common sites for metastasis. Although metastasis to the adrenal gland in patients with dissemi- nated RCC is common, metachronous isolated adrenal metastasis is rare. Radical nephrectomy includes resection of the adjacent adrenal gland, but ipsilateral adrenalectomy is no longer routinely performed [2]. Recently, laparo- scopic resection of solitary adrenal metastases has been associated with improved outcomes [3-5]. We present a case of laparoscopic adrenalectomy for a late solitary RCC metastasis to the ipsilateral adrenal gland.
Case report
A 66-year-old gentleman presented with a history of 2-stone weight loss over a period of 1 year. There were no associated symptoms. He had a left nephrectomy 18 years previously for a 10-cm adenocarcinoma, which had extended into the left renal vein, followed by post-opera- tive radiotherapy to the renal bed. He had remained well during follow-up and was working as a gardener. His past
medical history included a partial gastrectomy for a duo- denal ulcer at age 36 years. He was a lifelong smoker of 30 cigarettes per day (pack years, 75). Abdominal examina- tion revealed scars from previous gastric and renal surgery, but was otherwise unremarkable. Blood tests including a full blood picture (FBP), electrolytes, liver function tests (LFTs) and erythrocyte sedimentation rate (ESR) were all within normal ranges. An oesophagogastroduodenoscopy (OGD) revealed mild gastritis only.
A computed tomography (CT) scan identified a 5.6 cm × 3.1 cm × 4.2 cm heterogeneously enhancing left adrenal tumour (Fig. 1). Functional assessment of this lesion, using urinary cortisol and catecholamine levels along with plasma renin and aldosterone levels, was nor- mal. Magnetic resonance imaging (MRI) confirmed a 4 cm × 3 cm × 4 cm left adrenal gland mass, which did not have the signal characteristics of an adrenal adenoma or phaeochromocytoma (Fig. 2). A positron emission tomo- graphy (PET) scan confirmed the presence of a metaboli- cally active left adrenal mass with a maximum standardised uptake value (SUVmax) of 20.1.
A transperitoneal laparoscopic adrenalectomy was per- formed using standardised port insertions. There were extensive adhesions at the site of the previous nephrec- tomy. Following careful mobilisation, the abnormal adre- nal gland was resected. Histopathological examination revealed a 6.5-cm nodule, contained within the adrenal gland, which was confirmed as a metastatic renal cell carcinoma of clear-cell type. The patient made a satisfac- tory post-operative recovery and was discharged well on the fourth post-operative day. He was referred to the on- cologists for consideration of adjuvant therapy, but it was decided that further treatment was not indicated. At the 2-month follow-up, the patient remained well. Surveillance
R
10cm
CT imaging 6 months post-surgery showed no evidence of recurrent disease.
Discussion
Metastases to the adrenal gland are the second most com- mon type of adrenal mass lesion after adrenocortical ade- nomas. Isolated RCC metastases to the adrenal gland are uncommon. In a retrospective review of 1,179 patients who underwent nephrectomy (with routine ipsilateral adrenal- ectomy in the majority of cases) for RCC, the incidence of adrenal metastases was 3.7%, which were ipsilateral in 1.9%, contralateral in 1.5% and bilateral in 0.3% patients [3]. Synchronous (within 6 months of the diagnosis of RCC) and metachronous adrenal tumours were present in 2.7 and 1% of patients, respectively [3]. An 18-year interval between nephrectomy and the detection of isolated metastatic disease is exceptionally rare [4]. However, in patients with a history of RCC, a solitary non-functional adrenal tumour is strongly suggestive of a metastatic lesion. Although cross-sectional imaging can now accu- rately determine adrenal involvement, it is still associated with a risk of false positives [2].
Despite improvements in adjuvant therapies, surgical resection remains the only potential curative treatment in patients with adrenal metastasis [3-5]. It has been sug- gested that patients are most likely to benefit from adre- nalectomy if there is a long disease-free interval after
nephrectomy, if the tumour is less than 4.5 cm in diameter and if the patient has good performance status [4]. There are only a few previous reports in literature describing laparoscopic adrenalectomy for metachronous RCC metastasis to the ipsilateral adrenal gland. In a review of 94 adrenalectomies (31 laparoscopic) in patients with an isolated adrenal metastasis, Strong et al. [4] found that laparoscopic adrenalectomy, compared with open adre- nalectomy, resulted in less morbidity and achieved similar oncological outcomes. It is generally advised that laparo- scopic adrenalectomy is performed with caution, particu- larly if the tumour is large, has a suspected primary adrenal carcinoma or if there is evidence of local invasion [5]. In this case, the size and location of the tumour on preoper- ative imaging suggested that laparoscopic resection was feasible.
Our patient may have benefited from ipsilateral adre- nalectomy at the time of his nephrectomy 18 years previ- ously. Until relatively recently, adrenalectomy was generally recommended along with nephrectomy because of the possibility of direct lymphatic and haematogenous spread and the high reported incidence of adrenal involvement in early radical nephrectomy series [2]. However, current guidelines from the European Associa- tion of Urology advise that adrenalectomy is not usually required if preoperative imaging and operative findings suggest a normal adrenal gland [6]. O’Malley et al. iden- tified no evidence for routine adrenalectomy in a recent systematic review. They advised that routine adrenalec- tomy should be considered when cross-sectional imaging suggests an isolated adrenal metastasis, if there is involvement of the adrenal vein or if the tumour is greater than 7 cm in diameter and localised to the upper pole [2].
Conclusion
We have presented an unusual case of a patient with an isolated RCC metastasis 18 years after nephrectomy. Laparoscopic adrenalectomy is a safe, effective treatment in patients with a metachronous RCC metastasis to the ipsilateral adrenal gland.
Acknowledgments Written informed consent was obtained from the patient for the publication of this study. No source of funding has been declared by the authors.
Conflict of interest The authors declare that they have no com- peting interests.
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