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had a benign pathology, six (0.8%) were directly infiltrated by the tumour and 26 (2.7%) were metastatic. For both benign and metastatic ipsilateral adrenal pathology, CT had sensitivity, specificity and positive/ negative predictive values of 47%, 99%, 73% and 96%, respectively. Of 29 contralateral glands removed because of suspicious CT findings (15 at diagnosis of renal cancer, 14 during the follow-up) there was no abnormality in one (3.4%), a benign pathology in seven (24%) and a metastasis in 21 (72%). Thus there were 32 synchronous (incidence 2.7%; ipsilateral to the renal tumour in 24, contralateral in six and bilateral in two), and 13 metachronous adrenal metastases (incidence 1.0%; contralateral in 11 and bilateral in two). The metachronous metastases were diagnosed at a mean (range) interval of 30.6 (8-73) months after renal surgery. No ipsilateral adrenal metastases were discovered at diagnosis or during the follow-up in the 382 patients with an organconfined renal tumour of < 4 cm in diameter. Twenty-seven patients with an isolated adrenal metastasis (synchronous in 14, metachronous in 13) had statistically significantly ( P < 0.001) better survival than the 18 (all synchronous) with multiple sites of metastatic disease. In particular, there was long-term survival (mean 83 months) in 10 patients with an isolated adrenal metastasis. CONCLUSIONSparing the ipsilateral adrenal is advisable only for organ-confined renal tumours of < 4 cm in diameter; clinical local staging of renal cancer is the best predictor of the risk of adrenal metastasis. Conversely, CT had good diagnostic ability for the contralateral adrenal gland, especially during the follow-up. Some patients with isolated adrenal metastasis could be treated by metastasectomy, with long-term survival free of disease and confirming that, even if in a few and unselectable patients, removing all the neoplastic bulk can be curative. Nevertheless, the high rate of relapse underlines the need for an effective systemic therapy, and more so for widespread metastatic disease that currently cannot be cured. KEYWORDSadrenal metastasis, renal cell carcinoma, metastasectomy, survival OBJECTIVETo report, in a retrospective study, the diagnostic problems and oncological results of surgery in patients with either synchronous or metachronous adrenal metastasis, which are uncommon in renal cancer, at 2-10% of patients. PATIENTS AND METHODSOf 1179 patients treated for renal cancer between 1987 and 2003, 914 had renal surgery with concomitant ipsilateral adrenalectomy (routinely in 875 and for abnormal findings on computed tomography, CT, in 39) and 15 contralateral adrenalectomy (all after suspicious findings on CT). During the follow-up after renal surgery, another 14 patients had adrenalectomy for CT evidence of an abnormal adrenal gland, contralateral to the previous renal tumour in 12 and bilaterally in two. RESULTSOf 914 ipsilateral adrenal glands removed during renal surgery, 854 (93.5%) were normal on pathological examination, 28 (3%)

OBJECTIVE To define a follow‐up protocol based on the University of California Los Angeles Integrated Staging System (UISS) for patients undergoing surgery for N0M0 renal cell carcinoma (RCC). PATIENTS AND METHODS The clinical records of patients treated with radical surgery for N0/NXM0 RCC and monitored through periodic follow‐up studies (≥24 months in disease‐free patients) were reviewed retrospectively from 1399 patients surgically treated for renal neoplasms between 1983 and 2005. Each case was assigned a UISS risk category; recurrence features, time and site were recorded. In particular, recurrence sites were categorized into local, renal (ipsilateral or contralateral) and distant (single‐site or disseminated). RESULTS The records were reviewed of 814 patients with a mean follow‐up of 75.6 months. UISS risk categories were distributed as follows: high‐risk (HR) 17.2%, intermediate‐risk (IR) 51.6% and low‐risk (LR) 31.2%. Disease‐free survival rates at 5 years were 63.9%, 88.3% and 96.5% (log‐rank test P < 0.001), respectively. The disease recurred in 193 patients (23.7%), at distant sites (73.0% of recurrences), locally (11.9%), in the contralateral kidney (10.9%) and in the ipsilateral kidney (4.1%). There was a significant correlation between UISS category and risk of distant or local (both P < 0.001) recurrences, whereas there was no correlation of recurrences in the operated kidney (P = 0.372) or contralateral kidney (P = 0.898). CONCLUSIONS The prognostic accuracy and applicability of the UISS for distant and local recurrences is confirmed, whereas renal relapses have an independent course. A follow‐up scheme tailored to the recurrence patterns observed in each UISS risk group is recommended.

From July 1, 1979 to June 30, 1983, 136 consecutive patients from 5 centers in Lombardy entered a prospective randomized study to compare 500 mg. adjuvant medroxyprogesterone acetate 3 times a week for 1 year to no treatment following radical nephrectomy for category M0 renal cancer. After a median followup of 5 years (range 42 to 90 months) 40 of 120 evaluable patients (33.3 per cent) experienced relapse after a median interval free of disease of 17 months (range 2 to 74 months). Relapses occurred in 19 of 58 evaluable patients in the adjuvant treatment group (32.7 per cent) and in 21 of the 62 evaluable controls (33.9 per cent). Sex steroid hormone receptors were studied in 102 of the 120 evaluable patients with the dextran-coated charcoal technique. No significant correlation could be found among receptors, relapses and treatment. On the other hand, 33 (56.9 per cent) of the 58 treated patients experienced 39 complications related to the long-term hormonal therapy. Three patients had to discontinue medroxyprogesterone acetate for severe toxicity after 2 to 3 months. Medroxyprogesterone acetate cannot be recommended as adjuvant therapy to radical nephrectomy in patients with renal cell carcinoma.

E 5 5 9What ' s known on the subject? and What does the study add? The interest in metastatic renal cell carcinoma has increased in the last few years, mainly due to the advent of targeted therapies, but metastasectomy remains the sole therapy that can lead to a complete and durable regression, even if only in a minority of patients. The literature reports quite large series of metastasectomies for the most common sites of metastasis, e.g. lung, liver, bone, adrenal and brain, whereas little is known about the management of metastasis in ' atypical ' sites.The prognosis of patients submitted to metastasectomy for a metastasis in an atypical site is equivalent to patients with lung metastasis. The characteristics of the primary tumour in these patients are not indicative, but atypical metastasis (AM) are often located in superfi cial sites and frequently associated with other metastases. So, physical examination should be included in all follow-up regimens and a complete re-staging should be performed after the diagnosis of an AM. OBJECTIVE• To review the clinical characteristics and oncological results in patients submitted to surgical removal of metastasis from renal cell carcinoma (RCC) in atypical sites (atypical metastasis [ AM ] , i.e. metastasis in sites other than the chest, liver, bone, adrenal, brain, kidney, and lymph nodes), compared with patients submitted to metastasectomy due to a lung metastasis (LM). PATIENTS AND METHODS• From an institutional database of ≈ 1800 patients surgically treated for a RCC, we retrospectively identifi ed 37 cases that had undergone metastasectomy for AM and 57 operated for LM.• Clinicopathological features of the primary RCC and metastasis, and cancerspecifi c survival (CSS) computed from the time of metastasectomy of patients with AM and LM, were compared.• A univariate and multivariable analysis applying a Cox regression model was used to evaluate CSS. RESULTS• The patients with AM and LM were followed for an average of 40.8 and 50.7 months from metastasectomy, respectively ( P = 0.372).• There were no signifi cant differences in the characteristics of the primary tumour between patients with AM and LM.• In the cases with AM and LM the diagnosis was simultaneous with that of the primary tumour in 32.4% and 24.6%, ( P = 0.40) respectively, and, when metachronous, occurred at an average delay of 53.4 and 44.3 months ( P = 0.370).• More frequently in the cases with AM other metastases had been diagnosed in the previous medical history (35.2 vs 8.8%, P = 0.001) or simultaneously (48.6 vs 8.8%, P = 0.001).• CSS from metastasectomy was affected by the synchronicity in diagnosis between metastasis and primary tumour, and by the simultaneous presence of other metastases, while the type of metastasis (AM vs LM) did not affect CSS. In fact, metastasectomy in AM was as effective as in LM. CONCLUSION• AM are an exceptional presentation of metastatic RCC, but the role of surgery is similar to that of pulmonary metastasis. In these cases, metastasectomy is accepted as possible care...