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Eur J Cardiothorac Surg 2005;27:753-756
© 2005 Elsevier Science NL

Metachronous adrenal masses in resected non-small cell lung cancer patients: therapeutic implications of laparoscopic adrenalectomy

Marco Lucchia,*, Paolo Dinia, Marcello Carlo Ambrogia, Piero Bertib, Gabriele Materazzib, Paolo Miccolib, Alfredo Mussia

a Division of Thoracic Surgery, Cardiac and Thoracic Department, University of Pisa, Via Paradisa 2, Pisa 56124, Italy
b Division of Endocrine Surgery, Department of Surgery, University of Pisa, Pisa, Italy

Received 4 December 2004; received in revised form 6 January 2005; accepted 10 January 2005.

* Corresponding author. Tel.: +39 50 995228; fax: +39 50 577239. (E-mail: m.lucchi{at}med.unipi.it).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: In literature only few reports focused on the resection of solitary adrenal gland metastasis in patients operated on for non-small cell lung cancer (NSCLC). We report our experience on laparoscopic adrenalectomy for suspected or confirmed metachronous solitary adrenal metastasis from NSCLC and discuss its therapeutic role. Methods: From June 1993 to March 2003, 14 patients (pts), who had been undergone lung resection for NSCLC, with suspected or confirmed solitary adrenal gland metastasis at the follow-up, underwent 15 laparoscopic adrenalectomy (in 1 patient it was bilateral). All the patients had enlarged adrenal glands at the abdominal ultrasound or CT. All but 2 pts underwent at least 1 adrenal fine needle aspiration. All the patients underwent a careful staging to exclude other sites of metastasis. The adrenal gland was in 6 cases the right, in 9 cases the left. Results: In 7 cases we had a preoperative cytological diagnosis of metastasis. In 1 case adrenalectomy was not performed because of infiltration of vena cava and in 1 case it was necessary to perform a small laparotomy because of bleeding. The pathologic examination confirmed in 11 cases a NSCLC metastasis while in 4 cases it was a cortical adenoma. Regarding the 10 patients with NSCLC metastases, 3 are still alive and well at 37–80 months from the lung resection. One patient (who underwent bilateral adrenalectomy) is still alive at 44 months with local relapse. Two patients died 5 and 6 months after the adrenalectomy for other causes, 1 died at 14 months for local and systemic relapse and the remaining 3 patients died at 12 to 38 months for systemic relapse. Conclusions: Laparoscopic adrenalectomy in patients resected for NSCLC is a safe mini-invasive procedure. Even though this series is still too small, laparoscopic adrenalectomy should be considered an effective therapeutic tool in case of progressive adrenal gland enlargement, also with negative cytological examinations. A bigger series and other institution experiences will clarify its oncological value.

Key Words: NSCLC • Adrenal metastasis • Surgery • Laparoscopic adrenalectomy • Follow-up • Prognosis


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Even though it is commonly accepted that laparoscopic adrenalectomy is the treatment of choice for benign adrenal lesions [1], still controversial are the indications to adrenalectomy in case of primary or metastatic adrenal cancer and the opportunity of approaching malignant lesions by this mini-invasive procedure [2–3]. Moreover, it has been claimed that a laparoscopic exploration can also be necessary in order to confirm both the neoplastic nature of the lesion and the feasibility of the operation [4]. Adrenal gland is a common site of metastasis from lung carcinoma but rarely the patients are suitable to a surgical resection [5–6]. Despite that some long-term survivors of resection of a solitary adrenal metastasis from NSCLC are reported in the literature [7–11]. Since 1993, we started a planned policy on patients, resected for a NSCLC, with the suspicion or citological diagnosis of solitary adrenal metastasis. We present our data, aiming to debate the role of laparoscopy in the treatment of solitary adrenal metastasis from NSCLC.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
From June 1993 to March 2003, out of 197 patients who underwent a laparoscopic adrenalectomy for various pathologies, 14 were treated (1 patient bilaterally) with the diagnosis or suspicion of a solitary adrenal metastasis from NSCLC. There were 13 males and 1 female. Mean age was 65.7 (50–78) years. All the patients had been radically resected for lung carcinoma and the characteristics of the tumors are listed in Table 1.


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  		Table 1. Characteristics of the resected NSCLC patients who underwent laparoscopic adrenalectomy
 
All patients presented at the follow-up enlargement of an adrenal gland suspicious for metastasis and underwent an accurate work-up consisting of: a chest and upper abdomen CT scan, an abdominal ultrasonography, a complete staging (brain CT and bone scan) to exclude other sites of metastasis. Whenever an adrenal mass was discovered, adrenal function was studied (serum cortisol and potassium, and 24-h urinalyses for catecholamines, 17-hydroxycorticosteroids and 17-ketosteroids). An ultrasound or CT-guided fine needle aspiration (FNAB) was performed in all but 2 patients. In these patients the FNAB was not performed because the mass had shown a significant growth in between two CT examinations. In 2 cases of negative FNAB a magnetic resonance imaging (MRI) was performed but, in both cases MRI did not add useful informations for the differential diagnosis. In cases no. 13 and 14 a PET scan was performed. In all the cases of negative FNAB we proceeded to operation whenever we assisted to a mass growth during the follow up (more than 1cm in 4 months). All patients had a good performance status (ECOG 0-1) and had signed an informed consent. One patient, operated on for a solitary left adrenal metastasis, developed a right adrenal metastasis and was operated on again.

The adrenal lesion was on the left in 9 cases and on the right in 6 cases. No adrenal mass was symptomatic. Mean size of the lesion was 4,6 (range: 2, 5–10)cm. Median time between thoracic surgery and adrenalectomy was 13 (range: 4–34) months.

The exeresis was always preceded by a diagnostic laparoscopy with intraoperative ultrasonography to exclude other abdominal metastatic nodules or an extra-capsular invasion of the adrenal gland which would have been considered a contraindication for adrenalectomy. The technique of laparoscopic adrenalectomy has been extensively described in our previous reports [12–13].

All the patients underwent a strict follow-up every 3 months.

The statistical analysis has been performed by the Stat-Soft software. Results are expressed as mean±standard deviation. Survival was evaluated from the date of surgical treatment (thoracotomy and laparoscopic adrenalectomy) until death or the last follow-up (October, 2003). No patient was lost at follow-up. Survival curves were estimated by the Kaplan–Meyer's product-limit method and were compared by using the log-rank test.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Among the cases submitted to FNAB, 7 were true positive, 3 true negative, and 3 false negative. In cases no. 13 and 14, despite a negative FNAB, a remarkable uptake of the adrenal gland at the PET scan, prompted us to surgical indication.

All patients were operated through a laparoscopic transperitoneal approach in flank position. All but 1 underwent an adrenalectomy, in this case just an explorative laparoscopy was performed because of infiltration of the vena cava. Mean operative time of the laparoscopic procedures was 97min (80–110). Conversion to open surgery was necessary in only one case for an intra-operative bleeding in the patient who underwent staged bilateral adrenalectomies. We did not experience any important post-operative complication. The pathologic examination confirmed in 11 cases a NSCLC metastasis while in 4 cases it was a cortical adenoma. One patient underwent a left adrenalectomy for a solitary adrenal gland metastasis and 14 months later the controlateral adrenalectomy for a new solitary metastasis. Regarding the 10 patients with NSCLC metastases, 3 are still alive and well at 37–80 months from the lung resection. One patient (who underwent bilateral adrenalectomy) is still alive at 44 months with local relapse. Two patients died 5 and 6 months after the adrenalectomy for other causes, 1 died at 14 months for local and systemic relapse and the remaining 3 patients died at 12–38 months for systemic relapse. Survival curves from thoracic operation and laparoscopic adrenalectomy are shown in Fig. 1. We did not observe any significant difference of survival according to the interval between the thoracic operation and laparoscopic adrenalectomy (Fig. 2).



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  		Fig. 1. Survival curves of the NSCLC patients who underwent laparoscopic adrenalectomy for solitary adrenal metastasis. (A) Survival time from thoracotomy (B) from laparoscopic adrenalectomy.

 


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  		Fig. 2. Survival curves of the NSCLC patients who underwent laparoscopic adrenalectomy for solitary adrenal metastasis according to the interval between thoracotomy and laparoscopic adrenalectomy (<median vs>median). Median time was 13 months. (A) Survival time from thoracotomy (B) from laparoscopic adrenalectomy.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Even before the introduction of laparoscopic adrenalectomy the opportunity of operating patients presenting with a solitary metastasis to the adrenal gland from lung cancer had been explorated [7,8]. However, laparoscopic adrenalectomy, providing a quicker and better surgical outcome, contributed to extend the current indication to adrenalectomy in case of patients resected for lung cancer and the experiences of some institutions have been recently published [14–16]. In some way, we may formulate a similitude with what happened for metachronous single brain metastasis from lung cancer which is now always evaluated for surgical exeresis [17–18]. Similarly to what happened for solitary brain metastasis also for solitary adrenal metastasis from lung cancer, we are moving from reports of some long-term survivors [7,10] to trials showing a better outcome in patients who underwent adrenalectomy compared to chemotherapy alone [19], looking at some interesting trials combining chemotherapy and surgery [20].

Before focusing on the therapeutic value of adrenalectomy in case of solitary metastasis we should debate on the indication to surgery when an adrenal mass is discovered during the follow-up of patients resected for NSCLC. A preoperative diagnosis of the adrenal mass may be a difficult goal to achieve and the differential diagnosis between adenoma and metastasis is critical [21]. If, on one hand, the conservative approach, consisting of follow-up with the CT and ultrasonography of the adrenals, may lead to gravis delay in the treatment, on the other hand, surgery in case of adenoma may be considered an over treatment. Unfortunately FNAB, in most of the reported experiences, is quite disappointing in terms of accuracy of the technique with a sensitivity as low as 57% [4]. Though in our series we had no complications related to FNAB its sensitivity was quite low because the rate of false negative appeared to be too high (3 out of 6 cases); fortunately it did not exclude patients from surgical treatment because of other considerations (significant mass growth at follow up). In one patient (no. 14), who previously underwent a left adrenalectomy, after 3 negative FNAB we also performed a PET scan which showed the right adrenal gland as the only site with ipermetabolic activity. It is our opinion that in case of negative FNAB a PET scan may give further informations and help us in the decision making. Unfortunately when we treated the patients of our series a PET scan was not disposable and we could not test its diagnostic accuracy. We used MRI only in two cases but it did not add useful informations, and, consequently, we do not use it anymore for the differential diagnosis. Nowadays, at our institution, all the patients, with a confirmed or suspected solitary adrenal metastasis, undergo a PET scan with the aim of confirming that it is really a solitary metastasis. In any case it is our opinion that an adrenal mass (>3cm), appearing during the follow-up of a patient resected for NSCLC and not present before, whose nature is not clarified by the diagnostic tools (including FNAB and PET scan), deserves at least a laparoscopic exploration.

Unfortunately, only 7% of the patients developing metastatic disease from NSCLC have a solitary metastasis [5], so that only selected cases may be suitable to laparoscopic adrenalectomy and benefit from that. Moreover the dismal results provided by the chemotherapy and radiotherapy, emphasize the surgical resection as the best option for a potential cure [19,22]. As it was demonstrated with solitary brain metastasis [18] the stage of lung cancer (N0 vs N1–2) and the interval between the lung resection and the adrenalectomy may be prognostic factors. Our series is still too small to define possible prognostic factors, however, the 2 patients with N2 disease died 3 and 4 months after the adrenalectomy with systemic disease. As regards the disease free interval, it was identified as a prognostic factor by some authors [15,19]. Our data do not support this thesis, in agreement with other authors [14], even if we observed a trend of better survival in patients with longer disease free interval.

In conclusion, laparoscopic adrenalectomy in patients resected for NSCLC proved to be a safe mini-invasive procedure. Laparoscopic adrenalectomy should be considered an effective therapeutic tool in case of metachronous solitary adrenal metastasis or progressive adrenal gland enlargement, highly suspected for metastasis.

A bigger series and other institution experiences will clarify its oncological value.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Smith CD, Weber CJ, Amerson JR. Laparoscopic adrenalectomy: new gold standard. World J Surg 1999;23:389-396.[CrossRef][Medline]
  2. Heniford BT, Arca MJ, Walsh RM, Gill IS. Laparoscopic adrenalectomy for cancer. Semin Surg Oncol 1999;16:293-306.[CrossRef][Medline]
  3. Wells SA, Merke DP, Cutler GB, Norton JA, Lacroix A. Therapeutic controversy: the role of laparoscopic surgery in adrenal disease. J Clin Endocrinol Metab 1998;83:3041-3049.[Free Full Text]
  4. Kebebew E, Siperstein AE, Clark OH, Duh QY. Results of laparoscopic adrenalectomy for suspected and unsuspected malignant adrenal neoplasms. Arch Surg 2002;137:948-953.[Abstract/Free Full Text]
  5. Albain KS, Crowley JJ, LeBlanc M, Livingston RB. Survival determinants in extensive-stage non-small cell lung cancer: the Southwest oncology group experience. J Clin Oncol 1991;9:1618-1626.[Abstract]
  6. Schuchert MJ, Luketich JD. Solitary sites of metastatic disease in non-small cell lung cancer. Curr Treat Options Oncol 2003;4(1):65-79.[Medline]
  7. Twomey P, Montgomery C, Clark O. Successful treatment of adrenal metastases from large-cell carcinoma of the lung. J Am Med Assoc 1982;248(5):581-583.[Abstract/Free Full Text]
  8. Reyes L, Parvez Z, Nemoto T, Regal AM, Takita H. Adrenalectomy for adrenal metastasis from lung carcinoma. J Surg Oncol 1990;44(1):32-34.[Medline]
  9. Urschel JD, Finley RK, Takita H. Long-term survival after bilateral adrenalectomy for metastatic lung cancer: a case report. Chest 1997;112(3):848-850.[Abstract/Free Full Text]
  10. de Perrot M, Licker M, Robert JH, Spiliopoulos A. Long-term survival after surgical resections of bronchogenic carcinoma and adrenal metastasis. Ann Thorac Surg 1999;68(3):1084-1085.[Abstract/Free Full Text]
  11. Tsuji Y, Yasuhuku M, Haryu T, Watanabe Y, Ataka K, Okada M. Laparoscopic adrenalectomy for solitary metachronous adrenal metastasis from lung cancer: report of a case. Surg Today 1999;29(12):1277-1279.[CrossRef][Medline]
  12. Miccoli P, Raffaelli M, Berti P, Materazzi G, Massi M, Bernini G. Adrenal surgery before and after the introduction of laparoscopic adrenalectomy. Br J Surg 2002;89(6):779-782.[CrossRef][Medline]
  13. Bendinelli C, Lucchi M, Buccianti P, Iacconi P, Angeletti CA, Miccoli P. Adrenal masses in non-small cell lung carcinoma patients: is there any role for laparoscopic procedures?. J Laparoendosc Adv Surg Tech A 1998;8(3):119-124.[Medline]
  14. Porte H, Siat J, Guibert B, Lepimpec-Barthes F, Jancovici R, Bernard A, Foucart A, Wurtz A. Resection of adrenal metastases from non-small cell lung cancer: a multicenter study. Ann Thorac Surg 2001;71(3):981-985.[Abstract/Free Full Text]
  15. Kim SH, Brennan MF, Russo P, Burt ME, Coit DG. The role of surgery in the treatment of clinically isolated adrenal metastasis. Cancer 1998;82(2):389-394.[CrossRef][Medline]
  16. Beitler AL, Urschel JD, Velagapudi SR, Takita H. Surgical management of adrenal metastases from lung cancer. J Surg Oncol 1998;69(1):54-57.[CrossRef][Medline]
  17. Wronski M, Arbit E, Burt M, Galicich JH. Survival after surgical treatment of brain metastases from lung cancer: a follow-up study of 231 patients treated between 1976 and 1991. J Neurosurg 1995;83(4):605-616.[Medline]
  18. Mussi A, Pistolesi M, Lucchi M, Janni A, Chella A, Parenti G, Rossi G, Angeletti CA. Resection of single brain metastasis in non-small-cell lung cancer: prognostic factors. J Thorac Cardiovasc Surg 1996;112(1):146-153.[Abstract/Free Full Text]
  19. Higashiyama M, Doi O, Kodama K, Yokouchi H, Imaoka S, Koyama H. Surgical treatment of adrenal metastasis following pulmonary resection for lung cancer: comparison of adrenalectomy with palliative therapy. Int Surg 1994;79(2):124-129.[Medline]
  20. Downey RJ, Ng KK, Kris MG, Bains MS, Miller VA, Heelan R, Bilsky M, Ginsberg R, Rusch VW. A phase II trial of chemotherapy and surgery for non-small cell lung cancer patients with a synchronous solitary metastasis. Lung Cancer 2002;38(2):193-197.[CrossRef][Medline]
  21. Porte HL, Ernst OJ, Delebecq T, Metois D, Lemaitre LG, Wurtz AJ. Is computed tomography guided biopsy still necessary for the diagnosis of adrenal masses in patients with resectable non-small-cell lung cancer?. Eur J Cardiothorac Surg 1999;15(5):597-601.[Abstract/Free Full Text]
  22. Soffen EM, Solin LJ, Rubenstein JH, Hanks GE. Palliative radiotherapy for symptomatic adrenal metastases. Cancer 1990;65:1318-1320.[CrossRef][Medline]



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