Eur J Cardiothorac Surg 2006;30:194-195
© 2006 Elsevier Science NL
Combined lung resection and transdiaphragmatic adrenalectomy in patients with non-small cell lung cancer and homolateral solitary adrenal metastasis
Ian Hunt
a
,
Sheila C. Rankin
b
,
Loic Lang-Lazdunski
a
,
*
a Department of Thoracic Surgery, Guy's Hospital, London, United Kingdom
b Department of Radiology, Guy's Hospital, London, United Kingdom
Received 10 February 2006;
accepted 29 March 2006.
* Corresponding author. Address: Cardiothoracic Surgery Centre, St Thomas’ Hospital, London SE1 7EH, United Kingdom. (Email: Loic.Lang-Lazdunski{at}gstt.nhs.uk).
 |
Abstract
|
|---|
Surgery may offer a long-term survival benefit to a small proportion of patients with operable non-small cell lung cancer (NSCLC) and solitary adrenal metastasis. Several approaches to lung resection with a separate open or laparoscopic adrenalectomy have been advocated. We describe a technique that allows a single incision, single operation through a transdiaphragmatic approach to the ipsilateral adrenal gland following a standard lung resection through a postero-lateral thoracotomy. By using this approach, along with the harmonic scalpel to aid adrenal dissection, both lobectomy and adrenalectomy can be carried out safely and effectively with minimal perioperative and postoperative morbidity.
Key Words: Lung cancer • Adrenal metastases • Thoracic surgery
|
1. Introduction
|
|---|
Metastasis from non-small cell lung cancer (NSCLC) is traditionally regarded as a contraindication to surgical resection of the primary tumour and is associated with very poor survival. Solitary adrenal metastasis from a resectable NSCLC is rare despite a relatively common predilection of adrenal metastases detected at autopsy [1]. Several groups have reported in small series favourable long-term survival following staged lung resection and resection of metachronous or synchronous isolated adrenal metastasis [2,3].
Considering the high retroperitoneal location of the adrenal gland, its fragile parenchyma and rich, variable blood supply, the transthoracic approach, through a postero-lateral thoracotomy [4] offers an attractive alternative to standard approaches to adrenal tumours. We describe a technique of simultaneously completing a curative lung resection and adrenalectomy safely and effectively through the transdiaphragmatic approach using the harmonic scalpel, a device that uses ultrasonic energy to achieve both cutting and coagulation and minimises collateral thermal damage [5].
|
2. Technique
|
|---|
Before operation, all patients must undergo thorough staging with CT, PET-CT, mediastinoscopy and CT or MRI of the brain to exclude distant metastases or N2 disease. A standard postero-lateral thoracotomy through the fifth intercostal space is made and a lobectomy followed by hilar and mediastinal lymphadenectomy is completed. Through the same incision a second thoracotomy in the eighth interspace is completed.
On the right, the diaphragm is incised posteriorly as a pedicle-sparing phrenotomy starting 2 cm from the inferior vena cava (IVC) (Fig. 1
). On the left, the incision is started left of the descending aorta and extended posteriorly.The peritoneum and retroperitoneal fat are exposed. Adrenal arteries tend to lie in a coronal plane and enter the adrenal gland medially, meticulous division of the arteries with the harmonic scalp is important to avoid complications of bleeding. Conversely, the adrenal glands have a single venous drainage; the right adrenal vein is short (0.5 cm) and drains directly into the IVC. Careful dissection and clipping or ligation is required to avoid injury to the IVC or avulsion of the short adrenal vein itself.
View larger version (130K):
[in this window]
[in a new window]
|
Fig. 1. Diaphragm is incised posteriorly, starting 2 cm from the IVC orifice and preserving the pedicle.
|
|
The adrenal gland is typically presented in the incision along with the surrounding retroperitoneal fat. It is grasped carefully and separated from the kidney using the harmonic scalpel and extracted en-bloc (Fig. 2
). We routinely leave a small surgicel© mesh in the adrenalectomy bed and the diaphragm is closed using continuous 0-prolene. The patient is recovered according to unit policy following standard lung resection.
View larger version (136K):
[in this window]
[in a new window]
|
Fig. 2. Adrenal gland is grasped and mobilised to extract en-bloc, the metastatic deposit is clearly seen (arrow).
|
|
|
3. Results
|
|---|
This technique was used electively in three patients with right-sided lesions. The length of the operation is increased by on average of 1 h, though perioperative blood loss, particularly when using the harmonic scalpel was comparable to a lobectomy alone. The length of stay was comparable to patients undergoing lobectomy alone. There were no local complications related to the transdiaphragmatic adrenalectomy, with no in-hospital or 30-day mortality.
|
4. Comment
|
|---|
As highlighted by Porte et al. [3] the value of operations to ‘cure’ patients with metastatic disease has previously been overlooked. Furthermore, in patients with a single site of metastatic disease that is resectable without significant morbidity and who have a primary lesion that can be (or has been) completely resected, resection of the metastatic deposit should be considered. Despite the small number of patients, increasingly several centres having experience of lung resection and adrenalectomy for metastatic NSCLC have shown in selected patient a long-term survival benefit [6]. Often the solitary adrenal metastases are on the same side as the primary lung lesion and may reflect lymphatic connections between the lung and the retroperitoneum and a relationship between ipsilateral adrenal metastases and limited metastatic spread [7].
The technique described allows a single incision, single operation ‘curative’ resection in a subset of patients, albeit small, who otherwise would face a dismal prognosis. The postoperative recovery is again comparable to a standard lobectomy and though a double thoracotomy is theoretically more painful, through meticulous surgical attention including avoiding over-retraction of rib cage and use of an epidural catheter, problems have not been reported.
A transdiaphragmatic approach with a carefully placed phrenotomy provides excellent exposure to the adrenal gland with no excess postoperative morbidity and should be the preferred approach in this small subset of patients with resectable primary lung cancer.
|
References
|
|---|
- Beitler AL, Urschel JD, Velagapudi SR, Takita H. Surgical management of adrenal metastases from lung cancer. J Surg Oncol 1998;69:54-57.[CrossRef][Medline]
- Luketich JD, Burt ME. Does resection of adrenal metastases from non-small cell lung cancer improve survival?. Ann Thorac Surg 1996;62:1614-1616.[Abstract/Free Full Text]
- 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;71:981-985.[Abstract/Free Full Text]
- Halachmi S, Best LA, Moskovitz B, Madjar S, Nativ O. Transthoracal approach for the removal of adrenal tumors. Early experience with 10 cases. Eur Urol 1996;30:480-483.[Medline]
- Valeri A, Borrelli A, Presenti L, Lucchese M, Manca G, Tonelli P, Bergamini C, Borrelli D, Palli M, Saieva C. The influence of new technologies on laparoscopic adrenalectomy: our personal experience with 91 patients. Surg Endosc 2002;16:1274-1279.[CrossRef][Medline]
- Mercier O, Fadel E, de Perrot M, Mussot S, Stella F, Chapelier A, Dartevelle P. Surgical treatment of solitary adrenal metastasis from non-small cell lung cancer. J Thorac Cardiovasc Surg 2005;130:136-140.[Abstract/Free Full Text]
- Karolyi P. Do adrenal metastases from lung cancer develop by lymphogenous or hematogenous route?. J Surg Oncol 1990;43:154-156.[Medline]
This article has been cited by other articles:
|
|
|
|
 
T. Tanvetyanon, L. A. Robinson, M. J. Schell, V. E. Strong, R. Kapoor, D. G. Coit, and G. Bepler
Outcomes of Adrenalectomy for Isolated Synchronous Versus Metachronous Adrenal Metastases in Non-Small-Cell Lung Cancer: A Systematic Review and Pooled Analysis
J. Clin. Oncol.,
March 1, 2008;
26(7):
1142 - 1147.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
1. Introduction
