| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
EDITORIALS |
VA Medical Center, San Francisco, California.
Correspondence: Address correspondence to: Quan-Yang Duh, MD, VA Medical Center, Surgical Service, 4150 Clement Street, San Francisco, CA 94121; Fax: 415-750-2181; E-mail: Quan-Yang.Duh{at}med.va.gov
Metastasis to the adrenal gland is common in patients with disseminated cancer, but isolated metastasis to the adrenal gland is rare. Whether isolated adrenal metastasis should be resected is controversial. Numerous reports exist of patients who are cancer-free many years after a resection of isolated adrenal metastasis. Skeptics argue that this long-term survival is the result of selecting a subgroup of patients who have less aggressive cancers with limited spread and slow growth. These patients may have survived just as long without resection of their adrenal metastasis. Enthusiasts, in contrast, argue that resecting isolated metastases to other organs (e.g., the liver, brain, and lung) can achieve long-term, disease-free survival; and that resecting isolated metastasis to the adrenal gland should be no different. Because isolated metastasis to the adrenal gland is rare, it is unlikely that this controversy will be resolved by a prospective, randomized study comparing the long-term outcome of resection versus observation. Thus, analysis of results of large series of patients who have had adrenalectomy for isolated metastasis is most useful.
Sarela et al.,1 in this issue of Annals of Surgical Oncology, updated the excellent series from the Memorial Sloan Kettering Cancer Center (MSKCC), published previously in 1998 by Kim et al.2 In that series of 37 patients, the 5-year actuarial survival rate was 24%. In the current series of 41 patients, the 5-year actuarial survival rate is similar at 29%. Other surgeons have also published similarly excellent survival results after resection of isolated adrenal metastasis.3–5
Clinically, isolated adrenal metastasis can be synchronous or metachronous; the former is found at the time or within 6 months of diagnosis of the primary cancer and the latter is found after a disease-free period of more than 6 months. The previous finding that patients with metachronous adrenal metastasis (versus synchronous metastasis) survive longer after adrenalectomy is confirmed by the current study. All four long-term survivors (>4 years) had metachronous metastasis. Interestingly, almost all the synchronous isolated adrenal metastases in this series were found in patients with non–small-cell lung cancer, which account for more than half of the primary cancers.
The improving survival of patients after adrenalectomy for isolated metastasis may also result from improvement in patient selection by better imaging studies. By detecting smaller adrenal metastasis that previously may have been missed, the more sensitive techniques (e.g., positron emission tomography [PET] scan, magnetic resonance imaging [MRI], and spiral or thin-cut computed tomography [CT] scan, may be contributing to the improving prognosis of these patients who have adrenalectomy for isolated adrenal metastasis. Some patients with multiple metastases, now detected by the more sensitive studies, who would likely develop recurrences, are now excluded from adrenalectomy, whereas other patients with smaller adrenal metastasis, now detectable, become candidates for adrenalectomy.
An important area of controversy that is addressed by Sarela et al. is the role of laparoscopic adrenalectomy for adrenal metastasis. Laparoscopic adrenalectomy has become the standard treatment for small benign adrenal tumors (e.g., aldosteronoma) and for most pheochromocytomas. Compared with open adrenalectomy, laparoscopic adrenalectomy is associated with significantly less pain and morbidity and shorter hospital stay and recovery time. Although short-term morbidity was not addressed in this series, one would expect a similar lower rate of morbidity for those who had laparoscopic adrenalectomy than those who had open adrenalectomy.
The long-term issue is whether laparoscopic resection is oncologically inferior to open resection and leads to a higher recurrence rate or shorter survival time. This controversy stems from the debate by colorectal surgeons in laparoscopic resection of colon cancer, where earlier reports showed an increased port-site and regional recurrences after laparoscopic resection. Current evidence from several large studies has convinced most colorectal surgeons that inexperience and poor surgical technique were the likely causes of these recurrences, not laparoscopy or pneumoperitoneum. Achieving adequate margins and avoiding tumor fracture are keys to preventing local recurrence, whether the operation is performed open or laparoscopic.
Sarela et al. found no difference in the rate of positive resection margin between the 11 laparoscopic adrenalectomies and the 30 open adrenalectomies, and they concluded that no oncological disadvantage exists for patients who have laparoscopic adrenalectomy. In our own series of laparoscopic adrenalectomy in 13 patients with isolated adrenal metastasis (11 metachronous, 2 synchronous), none had positive resection margin and none developed local recurrence.4 Four of our patients died from disseminated metastases after resection, during followup of 3 years. Heniford et al. 5 also reported similarly excellent locoregional control after laparoscopic adrenalectomy for isolated adrenal metastasis. In contrast, laparoscopic resection for adrenal cortical carcinoma is associated with a high local recurrence rate similar to open resection.4,6
I congratulate Sarela et al. for their excellent results and I agree with their conclusions. Because more than one of four patients can achieve a 5-year disease-free survival, adrenalectomy should be offered to patients with isolated adrenal metastasis. Given the lower morbidity rate and similar oncologic results, laparoscopic adrenalectomy, if technically safe and feasible, should be offered to these patients. These are rare patients and operations; we need to continue to study them as the authors from Memorial Sloan-Kettering Cancer Center have done.
Received for publication October 14, 2003. Accepted for publication October 21, 2003.
REFERENCES
This article has been cited by other articles:
 |
|
 |
|
  Q.-Y. Duh Laparoscopic Adrenalectomy for Isolated Adrenal Metastasis: The Right Thing to Do and the Right Way to Do It Ann. Surg. Oncol., December 1, 2007; 14(12): 3288 - 3289. [Full Text] [PDF]
|
|
|
|
|
|
V. E. Strong, M. D'Angelica, L. Tang, F. Prete, M. Gonen, D. Coit, K. A. Touijer, Y. Fong, and M. F. Brennan Laparoscopic Adrenalectomy for Isolated Adrenal Metastasis Ann. Surg. Oncol., December 1, 2007; 14(12): 3392 - 3400. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C.-H. Liao, S.-C. Chueh, M.-K. Lai, P.-J. Hsiao, and J. Chen Laparoscopic Adrenalectomy for Potentially Malignant Adrenal Tumors Greater than 5 Centimeters J. Clin. Endocrinol. Metab., August 1, 2006; 91(8): 3080 - 3083. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
