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

Abstract

INTRODUCTION AND OBJECTIVES Concurrent adrenalectomy during renal surgery for RCC was once routine. More recent data suggest that adrenalectomy should be reserved for tumors ≥7cm, particularly those involving the upper pole. We evaluated the radiographic and pathologic incidence of adrenal involvement in patients undergoing renal surgery for RCC ≥7cm. METHODS Patients undergoing renal surgery for tumors ≥7cm between 1999 and 2008 were identified from our kidney cancer registry. Fisher’s exact test was used to determine whether radiographic tumor location predicted adrenal involvement. Kaplan-Meier method and Cox proportional hazard regression models were used to analyze the impact of adrenal resection on outcome. RESULTS Of 1,650 patients, we identified 179 patients who underwent surgery for RCC ≥7 cm. Of these 91 underwent concurrent total ipsilateral adrenalectomy at the time of renal surgery with pathological adrenal involvement confirmed in 4.4% (4/91). Upper pole location did not predict involvement (p=0.83). Preoperative adrenal imaging was 100% sensitive and 92% specific for detection of adrenal involvement by RCC with a 100% NPV. No survival advantage was noted on multivariable analysis comparing those who underwent adrenal resection to the cohort (n=88) whose adrenal was spared (p=0.38). CONCLUSIONS Synchronous ipsilateral adrenal involvement with RCC is rare, even in cases of large and/or upper pole tumors making routine adenalectomy unnecessary. Pre-operative adrenal imaging is highly sensitive and should inform the decision regarding adrenalectomy more than tumor size or location.

Routine adrenalectomy in renal cancer—an antiquated practice

“…Similar to the study by Kutikov and colleagues, 1 Weight et al 2 from the Mayo Clinic reported on a large cohort of 4,018 patients, and found ipsilateral adrenal involvement in only 88 patients (2.2%). Adrenal involvement was present in 42 (3.4%) of 1,229 patients with upper-pole tumors versus 46 (1.6%) of 2,789 patients with renal tumors in other locations.…”

“…Recent articles by Kutikov et al 1 from the Fox Chase Cancer Center and Weight et al 2 from the Mayo Clinic examine the role of a routine adrenalectomy for patients with renal cell carcinoma (RCC). Both articles provide compelling arguments against the routine removal of the adrenal gland and present strong data supporting their points.…”

“…Evaluating the influence of tumor size and location on adrenal involvement, Kutikov and colleagues 1 examined the outcomes of patients with large (>7cm) tumors located within or outside the upper pole who underwent adrenalectomy. They found adrenal involvement to be present in only 4 (4.4%) of 91 patients: 3 of 46 patients with upper-pole tumors (6.5%) and 1 of 45 patients (2.2%) with non-upper-pole tumors ( P = 0.83).…”

“…They found adrenal involvement to be present in only 4 (4.4%) of 91 patients: 3 of 46 patients with upper-pole tumors (6.5%) and 1 of 45 patients (2.2%) with non-upper-pole tumors ( P = 0.83). 1 …”

Surgical management of large renal tumors

“…However, several studies have questioned the role of routine adrenalectomy during radical nephrectomy. The most recent series of 179 patients with tumors greater than 7 cm demonstrated that adrenal involvement is quite rare and was observed in only 4.4% of these patients [7]. In those who had adrenal involvement, preoperative imaging was 100% specific in detecting this preemptively, with 100% negative predictive value.…”