Adrenalectomy: Defining Its Role in the Surgical Treatment of Renal Cell Carcinoma

Abstract

Objectives: With the recent widespread use of modern imaging techniques, the frequency of small low-stage renal cell carcinomas (RCC) has grown considerably, giving rise to more conservative surgical approaches. We evaluated the characteristics of adrenal involvement and the accuracy of computerized tomography (CT) in the diagnosis of RCC, defining the real need for adrenalectomy during surgical treatment. Methods: The medical records of 201 patients undergoing radical nephrectomy and ipsilateral adrenalectomy for localized or advanced RCC, from 1996 to 2002, were analyzed, retrospectively. We considered 76 with stage T1–2 disease and 125 with T3–4N0–1M0–1 disease. In all cases a blinded review of the preoperative abdominal CT was performed. Histopathology records of the surgical specimens were examined to determine the accuracy of the CT in identifying adrenal involvement by RCC. Results: The overall incidence of adrenal metastasis was 4.4%. The mean renal tumor size in patients with adrenal involvement was 7.8 cm. The tumor stage correlated with a probability of adrenal spread (p < 0.05), with T1–2 tumors accounting for 1.3% of cases only. The adrenal gland was diagnosed as abnormal on preoperative CT in 21 patients (10.4%). CT scan demonstrated 88.8% sensitivity, 92.1% specificity, 99.4% negative predictive value and 34.7% positive predictive value for adrenal involvement by RCC. Conclusions: Adrenal involvement is not likely in patients with localized early stage RCC and adrenalectomy can be omitted in such cases, particularly when CT is negative. However, in selected patients with large high-risk tumors, radical nephrectomy, including removal of the ipsilateral adrenal gland, should be performed.

Routine Adrenalectomy Is Unnecessary During Surgery for Large and/or Upper Pole Renal Tumors When the Adrenal Gland Is Radiographically Normal

“…As such, the PPV of imaging in our cohort was 33.3% and specificity was calculated at 90.1%. Although a handful of investigators have reported more impressive PPV’s 8, 20 , our data are consistent with reports from other centers in patients with smaller tumors 3, 13, 17, 25, 27, 28 and demonstrate the rigor with which we looked for any radiographic adrenal abnormality. 62.5% (5 of 8) false positive results in our cohort were due to radiographic suspicion of direct tumor invasion into the adrenal rather than an adrenal mass.…”

“…Such low incidence of adrenal involvement in our cohort of large tumors is consistent with the rates of ~1% to ~5% reported in series that include renal masses of all sizes. 4, 8, 13–18 Indeed, conflicting data exist regarding whether size alone – independent of the tumor’s ability to invade perinephric tissues or renal vein – is a predictor of adrenal involvement by RCC. 4, 19, 20 …”

“…Indeed, the data upon which the recommendation for routine adrenalectomy for upper pole tumors has been made are at best inconclusive, suggesting that this recommendation is based more on the possible than the probable. 4, 7, 8, 13, 15, 20, 24–26 The majority of these manuscripts make subjective conclusions in their discussion, advocating the potential use of routine adrenalectomy for large upper pole renal tumors, perhaps in an effort to not overstate their call to spare most adrenals. In fact, only two publications contain data that allow for a statistical analysis of a relationship between upper pole location and adrenal involvement (Supplementary Material).…”

“…25, 27, 28 The excellent performance of cross-sectional radiography of the adrenal has been confirmed prospectively by at least one group. 17 While some authors have reported rare adrenal lesions that are missed by pre-operative imaging, 8, 13, 20 it appears inaccurate radiological interpretation is to blame. 22 Of note, it has been suggested that when in the setting of RCC an adrenal gland cannot be appropriately visualized on pre-operative imaging, the gland should be presumed infiltrated by the renal mass and removed.…”

Papel actual de la linfadenectomía y la adrenalectomía en la cirugía radical del cáncer renal

“…La afectación de la glándula ipsilateral habitualmente se relaciona con la proximidad al riñón así como por la existencia de un drenaje venoso y linfático común, principalmente en el lado izquierdo 21 . La incidencia de afectación suprarrenal en el cáncer renal oscila entre el 1,2 y el 10% en las series quirúrgicas 20,[22][23][24][25][26][27] . Este porcentaje se incrementa en las series autopsias de pacientes con enfermedad diseminada, situándose entre el 7 y el 23 % 22,28 .…”