The need for routine adrenalectomy during surgical treatment for renal cell cancer: the Hannover experience

Abstract

Objectives To further clarify the need for routine adrenalectomy during the surgical treatment of renal cell cancer, as in the absence of clinically overt metastatic disease, tumorous lesions within the adrenal gland are found in only 2-10% of patients, with most being over-treated by adrenalectomy. Patients and methods The medical records of 819 patients undergoing adrenalectomy combined with nephrectomy, irrespective of the local extension of the primary tumour or the clinical stage at first diagnosis, were reviewed to determine the reliability of currently available imaging methods in predicting adrenal gland metastases. Several patient and tumour characteristics were correlated with the presence of intra-adrenal metastases, and their possible independent prognostic value was determined by a multivariate logistic regression model. Results There was metastatic spread into the adrenal gland in 27 of 819 (3.3%) patients. In only three of eight patients in whom the adrenal was identified as the only metastatic site were preoperative abdominal computed tomography scans interpreted as falsenegative. On multivariate statistical analysis only the presence of distant metastases, vascular invasion within the primary tumour and multifocal growth of renal cell cancer within the tumour-bearing kidney were identified as independent predictors of the presence of intra-adrenal metastases. Conclusions None of the patient or tumour characteristics evaluated reliably predicted the likelihood of adrenal metastases in patients with no evidence of disseminated metastatic spread. However, previously published data indicate that the frequency of metachronous metastases within the contralateral kidney (1.8-3.8%) is significantly higher than the risk of a preoperatively undetected isolated intra-adrenal metastatic lesion when currently available imaging modalities are applied. Therefore, routine adrenalectomy should not be recommended if the preoperative radiological examinations are normal.

A population based study of surgeon characteristics associated with the uptake of contemporary techniques in renal surgery

“…17 Recent data have challenged this notion and now demonstrate that removal of the adrenal gland is not necessary unless specific risk factors for adrenal involvement are present. Indications for ipsilateral adrenalectomy include high-risk tumour characteristics (higher T-stage, 18 larger diameter, 19 and upper pole location 20 ) or concern for adrenal involvement on preoperative imaging. 21 In appropriately selected patients, 10-year cancer-specific survival is equivalent whether or not the adrenal gland is removed.…”

Metachronous adrenal metastasis from operated contralateral renal cell carcinoma with adrenalectomy and iatrogenic Addison’s disease

“…4,5 The reason is that there is no difference in overall survival. Only 3 of 2065 patients who underwent concurrent ipsilateral adrenalectomy had direct invasion of the adrenal gland by RCC or renal cell carcinoma metastasis.…”

Aktuelle chirurgische Aspekte des Nierenzellkarzinoms

“…Auf dieser Basis wurde dogmatisch über ein Vierteljahrhundert die radikale Tumornephrektomie als Standardtherapie des NZK in Stein gemeißelt. Erst in den späten 80er Jahren wurde begonnen, dieses Dogma zu hinterfragen, und es wurden prospektiv randomisierte chirurgische Studien in Angriff genommen [7][8][9][10]. [10].…”

“…Erst in den späten 80er Jahren wurde begonnen, dieses Dogma zu hinterfragen, und es wurden prospektiv randomisierte chirurgische Studien in Angriff genommen [7][8][9][10]. [10]. Sowohl die routinemäßige Lymphadenektomie als auch die Adrenalektomie gelten heute nicht mehr als Standard [1].…”