BERKELEY, CA (UroToday Inc.) - Laparoscopic adrenalectomy has become the gold standard approach for benign surgical adrenal disorders such as aldosteronoma, Cushing's disease and pheochromocytoma. However, laparoscopic adrenalectomy for solitary metastasis or primary adrenal cancer remains a matter of considerable debate. Adrenal cancer rightfully confers the possibility of carcinomatosis or port site metastasis, as noted in initial published case reports. Given the controversial nature of this topic, the group at Cleveland Clinic headed by Dr. Inderbir Gill reviewed their single center experience with laparoscopic adrenalectomies for malignancy. Their results are reported in the February, 2005 issue of the Journal of Urology.

Their cohort comprised 31 patients (33 adrenalectomies) with preoperative suspicion of a solitary metastasis to the adrenal gland, and those who were incidentally found to have primary adrenal malignancy. Selection criteria for the laparoscopic approach on pre-operative CT were an adrenal mass of 10 cm or less without evidence of peri-adrenal infiltration, caval thrombus or bulky locoregional adenopathy.

A closer look at the study population revealed a mean age of 59.8 years. Mean tumor size was 5 cm. The laparoscopic approach was transperitoneal in 17 cases, retroperitoneal in 15 and transthoracic in 1. Pathology reports indicated a diagnosis of adrenal metastasis in 26 patients; with the primary cancer being renal cell carcinoma (RCC) in 13 patients, colonic metastasis in 5, and lung metastasis in 4 patients. Six patients had primary adrenocortical carcinoma (ACC). Surgical margins of the adrenalectomy specimen were negative for cancer in 19 cases (56%), indeterminate in 2 (6%) and positive in 1 (3%). The pathology report made no mention of margin status in 11 patients (33%).

Analysis revealed a current median follow-up of 26 months. Overall, 15 patients (48%) died and 16 (52%) were alive. Of these 13 (42%) had no evidence of disease. Local recurrence was noted in 7 patients including 3 with metastatic RCC, 2 with metastatic colon cancer and 2 with primary ACC. Surgical margins had been positive in one patient with a local recurrence. One patient with bilateral metastatic adrenal masses from RCC developed carcinomatosis 7 months postoperatively. They noted no port site metastases. Survival was similar in patients with tumors less than 5 cm vs. 5 cm or greater. Survival was not associated with patient age, tumor size, operative time or surgical approach. Survival was compromised in patients who developed local recurrences, with a median survival of 17 months.

In conclusion, their study shows that laparoscopic radical adrenalectomy can be performed with acceptable outcomes in carefully selected patients with a small, organ confined, solitary adrenal metastasis or primary adrenal carcinoma. The results of this group from Cleveland Clinic compare favorably with a contemporary open series from Memorial Sloan Kettering Cancer Center.

J Urol. 2005 Feb; 173(2):519-25