Port site, retroperitoneal and intra-abdominal recurrence after laparoscopic acrenalectomy for apparently isolated metastasis.

Abstract

A 55-year-old woman who had previously undergone resection of stage IIB nonsmall cell lung cancer followed by chemotherapy and irradiation was found to have a 2.5 cm. left adrenal nodule suspicious for solitary metastasis on computerized tomography (CT) (fig. 1). Subsequent evaluation with positron emission tomography, head CT and spine magnetic resonance imaging demonstrated no additional disease. The patient was advised that resection of the isolated metastasis might produce a long-term disease-free outcome. At transperitoneal laparoscopic adrenalectomy (standard instrumentation, 4 ports) the mass was considerably larger than suspected. As such, the wide field of dissection included the margins of the kidney laterally, aorta medially, lumbar musculature posteriorly, renal vein inferiorly and spleen superiorly. The specimen was dissected free without gross violation and was removed intact in an entrapment sack through the primary port site (mid clavicular line 2 cm. cephalad to the umbilicus) enlarged to 4 cm. Postoperative course was uneventful, and the patient was discharged home on postoperative day 1. On the self-reported questionnaire she indicated a return to normal nonstrenuous activity on postoperative day 3. The surgical specimen weighed 72 gm. and measured 8.0 6.0 3.0 cm. Pathological examination revealed a 5.0 1.5 1.5 cm. normal adrenal gland and an immediately adjacent 5.0 5.0 3.5 cm. mass consistent with metastatic adenocarcinoma. The specimen was not inked for margins, but there was cautery artifact at the edge of the malignant mass. A bowel obstruction developed 5 months postoperatively. A large mass was palpable at the port site used for extraction. CT showed advanced disease in the retroperitoneum, abdomen and anterior abdominal wall (fig. 2). After receiving palliative external beam radiotherapy, the patient died 10 months following laparoscopic adrenalectomy secondary to multiple metastases.