Adrenalectomy For Solitary Metastasis

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Metastases to the adrenal gland are more common than primary adrenocortical carcinoma. Such metastases tend to originate from pulmonary, renal, mammary, and gastrointestinal carcinomas (3). Adrenal metastasis has been noted in 10% to 27% of autopsies of patients with known malignancy (4,5). Patients with metastasis to the adrenal gland commonly have disseminated cancer. Rarely does the clinician diagnose a patient suspected of harboring an isolated adrenal metastasis. The management of such a patient presents a challenging dilemma. Having already undergone definitive treatment for the primary malignancy, the physician is faced with counseling the patient on the best treatment strategy for the presumed metastasis. Unfortunately, the treatment of such lesions is controversial. Although some reports support the surgical treatment of isolated adrenal metastases with long-term survivors, identifying the most suitable surgical candidate is less clear. The ideal study would involve a prospective comparison of patients with adrenal metastasis randomized to receive surgical treatment or observation or another form of treatment (chemotherapy/radiation). However, the accrual period of such a study would be extraordinarily long given the rare subset of patients in question. As such, clinical decisions must rely on larger retrospective studies, addressing a heterogeneous group of patients with a wide array of primary malignancies that have metastasized to the adrenal gland.

Several studies supporting the role of adrenalectomy for isolated adrenal metastasis have been reported. Several case reports have highlighted survival for solitary adrenal metastasis from colorectal cancers in carefully selected patients (6-8). These case reports consist of patients with solitary adrenal metastasis noted after primary colorectal resection. With intermediate follow-up, a survival advantage has been noted in patients with solitary adrenal metastasis of primary colorectal surgery undergoing adrenalectomy. Interestingly, the serum carcinoembryonic antigen was found to be elevated in patients with colorectal recurrence in the adrenal gland, although this elevation has not been noted in all reports (9).

Patients with metastatic lung cancer typically have a poor prognosis. Only 7% of patients present with solitary metastasis (10). Although still controversial, a survival advantage has been noted in patients with solitary adrenal metastasis from a non-small cell lung malignancy, whether synchronous or metachronous (11-15). These published series, with relatively small numbers and intermediate follow-up, have reported survival in this very select subset of patients. Luketich and Burt (11) compared the median survival of eight patients with isolated adrenal metastases from lung cancer who underwent adrenalectomy and chemotherapy with six patients who underwent chemotherapy alone. The median survival in the surgical group was found to be significantly increased (31 months) versus the chemotherapy alone group (8.5 months, p = 0.03). In another study, survival was noted in a multicenter trial of 43 patients with isolated adrenal metastases (32 synchronous, 11 metachronous) for patients with primary non-small cell lung cancer who underwent adrenalectomy (12). Median overall survival was 11 months, with three patients surviving over five years.

The survival of patients with metastatic renal cell carcinoma and multiple metastatic sites is poor. Although the overall number of patients is limited, those with solitary metastatic sites have been shown to possibly benefit from resection of the metastatic site, in particular, solitary metastasis to the lung (16-20). Lau et al. reported the largest series of 11 patients at Mayo Clinic with contralateral adrenal metastasis from renal call carcnone who underwent adrenalectomy. In this series, 2 of 11 patients (18%) were alive at last follow-up. Seven patients died at a mean of 3.9 years after adrenalectomy. Their review of the literature reveals that of 56 patients treated surgically for adrenal metastasis from RCC, 27 (48%) patients showed no evidence of disease on last follow-up. The median follow-up time is unfortunately not provided.

The primary therapy for adrenocortical carcinoma is surgical en bloc removal of the tumor. However, even with complete resection, local recurrence is seen in 35% to 85% of reported cases.

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