Laparoscopic adrenalectomy for solitary adrenal metastasis from lung cancer

Abstract

Background and objectives: Several studies have been reported on the problem of determining when laparoscopic adrenalectomy is indicated for solitary adrenal metastasis of malignant tumors. Our efforts at answering this question constitute the basis of this report.

Methods: From June 2010 to June 2011, laparoscopic adrenalectomy was performed in 10 lung cancer patients with solitary adrenal metastases (5 adenocarcinomas, 1 squamous cell carcinoma, 1 large cell carcinoma, 1 small cell carcinoma, and 2 pleomorphic carcinomas). The surgical results of all 10 patients were examined.

Results: Adrenal swelling was detected by computed tomography in all patients except 1 case of pleomorphic carcinoma. The findings of positron emission tomography-computed tomography were positive in 8 patients, including the 2 cases with pleomorphic carcinomas. Laparoscopic surgery was successfully performed in 9 cases. In the eighth patient (a case of pleomorphic carcinoma with adrenal swelling), laparoscopic adrenalectomy was attempted but conversion to open surgery was required because of clear evidence of pancreatic invasion.

Conclusion: The results obtained in this study, along with other published reports, support 4 criteria as operative indications for laparoscopic adrenalectomy in solitary adrenal metastasis from the lung: (1) the primary lung cancer is resected or can be cured by radical chemotherapy, (2) metastasis is limited to the adrenal gland only, (3) adrenal metastasis does not invade the surrounding organs, and (4) the size of the adrenal tumor does not exceed 10 cm. In cases of pleomorphic carcinoma, laparoscopic adrenalectomy should be performed when positron emission tomography-computed tomography results are positive.

Keywords: Adrenal metastasis; Laparoscopic adrenalectomy; Lung cancer; Pleomorphic carcinoma.

Figure 1.

(a) Case 1. Left adrenalectomy (asterisk) by transperitoneal approach. (b) Case 9. Left adrenalectomy (asterisks) by lateral retroperitoneal approach. The Gerota fascia was removed from the upper pole of the left kidney (square).

Figure 2.

CT and PET-CT findings obtained from a patient with pleomorphic carcinoma in whom complete laparoscopic adrenalectomy was performed. CT showed an adrenal gland (solid triangle) that was normal in size (no swelling). PET-CT of the adrenal gland indicated a positive result (dashed triangle).

Figure 3.

Histologic analysis of the lung and adrenal gland of the patient with pleomorphic carcinoma in whom complete laparoscopic adrenalectomy was performed. The left panel shows the histology of the lung. The upper panel shows hematoxylin-eosin (HE) staining of the primary lung cancer. A ductal structure can be seen in the center (square). The lower left panel is a 400× magnification of the square in the upper panel (HE staining). The lower right panel shows thyroid transcription factor 1 (TTF-1) staining of the ductal structure. TTF-1–positive cells are evident around the duct. The right panel shows the histology of the adrenal gland extracted by laparoscopic surgery. A ductal structure is evident in the center of the adrenal gland, as well as in the primary lung lesion (square) (upper panel, HE staining, original magnification ×100). The lower left panel is a 400× magnification of the square in the upper panel (HE staining). The lower right panel shows thyroid transcription factor 1 (TTF-1) staining of the ductal structure. TTF-1–positive cells are evident around the duct.