Adrenal Metastasis In Patients Research Articles

Clinical‑imaging‑radiomic nomogram based on unenhanced CT effectively predicts adrenal metastases in patients with lung cancer with small hyperattenuating adrenal incidentalomas

Clinical‑imaging‑radiomic nomogram based on unenhanced CT effectively predicts adrenal metastases in patients with lung cancer with small hyperattenuating adrenal incidentalomas

Adrenal tumors in patients with neuroendocrine neoplasms

PurposeTo study the prevalence of primary adrenal tumors and adrenal metastases in patients with neuroendocrine neoplasms (NENs) and describe these in detail. NENs can be further divided into neuroendocrine tumor (NET) and neuroendocrine carcinoma (NEC).MethodsA review of medical files was conducted for all patients who underwent a 68Gallium-DOTATOC-PET/CT during 2010−2023 or adrenalectomy during 1999-2023 at the Karolinska University Hospital.ResultsIn total, 68Gallium-DOTATOC-PET/CT was performed on 1750 individuals with NEN, among whom 12 (0.69%) had adrenal tumors. Of these, 9 (0.51%) were NEN metastases. Out of 1072 adrenalectomies, 4 (0.37%) showed evidence of NEN metastases. Thus, 16 patients with NEN exhibited adrenal tumors. The adrenal tumors were found on average 5 years after the NEN diagnosis and 19% of the adrenal tumors with simultaneous NEN were benign. Few had all adrenal hormones measured. None had an adrenal insufficiency nor an adrenal biopsy. Another synchronous metastasis was found in 69% at the time of the adrenal tumor discovery. During the median 2-year follow-up, 38% of the subjects had deceased (with the exclusion of individuals presenting supposedly benign adrenal tumors 31%) all due to tumor complications. A comparison between individuals identified through 68Gallium-DOTATOC-PET/CT and those who underwent adrenalectomy revealed a higher prevalence of NETs in the former group and NECs in the latter group.ConclusionAdrenal primary tumors and adrenal metastases are infrequent occurrences in patients with NEN. Most cases involved the presence of NEN metastasis upon the initial discovery of adrenal tumors. The overall prognosis was found to be favorable.

Adrenal Metastases Are Associated with Poor Outcomes in Patients with Metastatic Clear Cell Renal Cell Carcinoma Treated with Nivolumab in the GETUG-AFU-26 NIVOREN Phase 2 Trial

BackgroundGlandular metastases (GMs; adrenal gland, pancreas, thyroid, ovary, breast, or prostate) are rare in metastatic clear cell renal cell carcinoma (mccRCC). Previous studies have indicated that GM patients treated with antiangiogenic therapy experience significantly longer overall survival (OS). ObjectivesTo assess outcomes for mccRCC with or without GMs treated with nivolumab. Design, setting, and participantsThe GETUG-AFU-26 NIVOREN phase 2 trial evaluated the activity and safety of nivolumab in patients with mccRCC who experienced failure of antiangiogenic therapies (NCT03013335). In this ancillary study, patients were divided into two groups according to the presence or absence of at least one GM. Outcome measurements and statistical analysisThe primary outcome was OS; secondary outcomes were progression-free survival (PFS) and the objective response rate (ORR). Survival was estimated using the Kaplan-Meier method. Univariate and multivariable Cox regression models are used to estimate the hazard ratio (HR) with 95% confidence interval (CI) for survival outcomes. Subgroup analyses were performed for patients with pancreatic metastases and patients with adrenal metastases. Results and limitationsAmong 720 patients treated with nivolumab between February 2016 and July 2017, 217 had GMs, of whom 151/217 had adrenal metastases and 86/217 had pancreatic metastasis. Patients with adrenal metastases had worse 12-mo OS (64% vs 71.1%) and 6-mo PFS (27.2% vs 36.6%) and a lower objective response rate (12.5%, 95% CI 7.6%–19.0%, vs 23.2%, 95% CI 19.8–27.0%; p = 0.005) than patients without adrenal metastases. Conversely, univariate analysis showed that patients with pancreatic metastases had significantly better 12-mo OS (82.3% vs 67.9%; HR 0.59, 95% CI 0.40–0.85) in comparison to patients with nonpancreatic GMs. On multivariable analysis, only adrenal metastasis remained associated with adverse prognosis. ConclusionsAdrenal metastasis is an independent prognostic factor for poor response and survival in the GETUG-AFU-26 NIVOREN trial. Limited activity with nivolumab was observed for patients with mccRCC with adrenal metastases. These results warrant an evaluation of the prognostic value of adrenal metastases in patients treated with immunotherapy combinations with ipilimumab or tyrosine kinase inhibitors. Patient summaryOur study showed that metastasis in the adrenal glands could be an independent factor associated with poor response to immunotherapy and survival for patients with metastatic kidney cancer. It would be useful to evaluate the prognostic value of adrenal gland metastasis in patients treated with immunotherapy combinations or immunotherapy agents combined with drugs called tyrosine kinase inhibitors.

Laparoscopic management of isolated metachronous adrenal metastases in a patient with esophageal cancer: a case report

BackgroundThe presence of isolated metachronous adrenal metastasis in patients with esophageal cancer is rare. There is significant controversy regarding the management of such patients. Adrenal metastasectomy has been shown to be of benefit in some reports. Minimally invasive approach, although the gold standard for adrenalectomy, has not been used commonly in a postesophagectomy setting owing to the anticipated technical difficulties. We describe one such case wherein this approach helped in early recovery and long-term survival.Case presentationA 59-year-old male of Asian ethnicity presented with an isolated left adrenal nodule, 3 years after an Ivor Lewis esophagectomy for a lower esophageal adenocarcinoma. The biopsy of the nodule was suggestive of metastatic adenocarcinoma. The patient underwent laparoscopic excision of the left adrenal gland.ConclusionAdrenal metastasectomy, in postesophagectomy patients can provide good oncological control. Laparoscopic approach, though technically challenging, can provide results equivalent to those of open surgery, albeit with less morbidity.

Adrenal malignancy: still a contraindication for laparoscopy?

Minimally invasive adrenalectomy represents the gold standard for benign adrenal diseases, while its role in the management of malignant primary and secondary adrenal tumors remains controversial because of the risk of tumor spillage at manipulation, incomplete removal and subsequent recurrences. However, advances in imaging have improved early detection of primary and metastatic adrenal tumors, that might be theoretically removed by minimally invasive adrenalectomy without capsular disruption. Minimally invasive surgical approaches seem to be useful in selected patients with isolated, moderately sized adrenal metastases in patients with good performance status and controlled primary tumor with favorable biology. The open laparotomic approach is still considered the preferred surgical strategy for large and invasive adrenocortical cancer albeit emerging data suggest that laparoscopic surgery might be equivalent for moderately sized and localized primary adrenocortical cancers in terms of oncological benefits. However, the predominant endpoint remains the oncological radicality rather than the surgical approach itself. Multicenter randomized controlled trials with long follow-up time periods evaluating oncological outcomes are required to determine the benefits of the minimally invasive over the open approach in adrenal malignancies.

Predictive factors for adrenal metastasis in extra-adrenal malignancy patients with solitary adrenal mass.

The adrenal gland is a frequent site for metastasis, and a solitary adrenal mass is often observed during staging workup or imaging follow-up in patients with extra-adrenal malignancy. To create an appropriate management plan, it is essential to distinguish between benign adrenal lesions and metastasis in patients with extra-adrenal cancer having solitary adrenal masses. Therefore, here we evaluated the predictive factors for adrenal metastasis in patients with extra-adrenal malignancy having solitary adrenal mass. From September 2003 to June 2016, we retrospectively reviewed patients with extra-adrenal malignancy having solitary adrenal mass on a cancer staging workup or follow-up study who subsequently underwent adrenalectomy at our institution. All patients underwent preoperative functional studies; those with positive results were excluded from this study. Characteristics of oncology patients with adrenal mass including age, sex, body mass index, smoking, mass location, mass size, hypertension, diabetes mellitus, precontrast Hounsfield unit (HU), and synchronous or metachronous adrenal mass based on the time of the extra-adrenal cancer diagnosis were analyzed. Of the total 68 patients with extra-adrenal cancer having solitary adrenal mass, 22 had pathologically confirmed adrenal metastasis. Primary cancers consisted of hepatocellular cell carcinoma (n = 7), renal cell carcinoma (n = 7), lung cancer (n = 4), colon cancer (n = 3), and breast cancer (n = 1). On multivariate analysis, a higher precontrast HU (P = 0.001, odds ratio [OR] = 1.105, 95% confidence interval [CI] = 1.042-1.172), male sex ( P = 0.019, OR = 9.782, 95% CI = 1.462-65.461), and metachronous adrenal mass ( P = 0.007, OR = 11.090, 95% CI = 1.937-63.490) were observed as predictive factors for adrenal metastasis in patients with extra-adrenal cancer having solitary adrenal mass. The cut-off value of precontrast HU to distinguish between metastasis and benign lesions was 36.2 (sensitivity = 81.8%; specificity = 91.3%). High precontrast HU (> 36), male sex, and metachronous adrenal mass are predictive factors for adrenal metastasis in patients with extra-adrenal malignancy having solitary adrenal mass.

Adrenal metastases: clinical manifestations and surgical outcomes

Background. The adrenal glands are one of the most common sites of metastases in malignant disease, particularly lung cancer. The frequency of adrenal metastasis in patients with breast cancer and lung cancer reaches 39 and 35 % respectively.Materials and methods. A total of 156 patients with adrenal tumors underwent surgical treatment in the Siberian State Medical University between December 1998 and July 2017. The study included 16 (10.2 %) patients (9 males and 7 females) with adrenal metastases. The mean age of study participants was 57.6 years (range: 44–73 years).Results. By the moment of surgery, the mean metastatic adrenal tumor size was 4.9 ± 3.0 cm (range: 1.0–10.2 cm). Thirteen out of 16 patients had adrenal metastases from renal cell carcinoma, one patient – from colon cancer, one patient – from lung cancer, and one patient – from breast cancer. Nine patients had left-sided adrenal metastases, whereas six patients had right-sided adrenal metastases. Synchronous adrenal metastasis was detected in two cases: one patient had adrenal metastasis at the side of the renal tumor; the other one had bilateral renal cell carcinoma with both adrenal glands affected.We identified three main variants of the disease course according to prevailing clinical manifestations of adrenal metastasis: no manifestations, pain syndrome, and arterial hypertension.Seven participants had no clinical manifestations; of them, 6 patients had renal cell carcinoma, whereas 1 patient had breast cancer. The mean time between surgical removal of the primary tumor and detection of adrenal metastases was 24.1 months; the mean tumor size was 4.5 cm.Pain syndrome was observed in 5 patients. In three of them, adrenal metastases derived from renal cell carcinoma, in one patient – from lung cancer, and in one patient – from colon cancer. The mean time between removal of the primary tumor and detection of adrenal metastases was 19.8 months; the mean tumor size was 5.4 cm.Arterial hypertension was diagnosed in four patients. The mean time between removal of the primary tumor and identification of adrenal metastases was 27.3 months; the mean tumor size was 4.1 cm. The five-year overall survival rate in operated patient was 47.8 %.Conclusion. Regular examinations of patients after surgical treatment of malignant tumors are needed to detect adrenal metastases; surgery can extend the patient’s life. can extend the patient’s life.

Factors related to improved clinical outcomes associated with adrenalectomy for metachronous adrenal metastases from solid primary carcinomas

BackgroundSurgery for metachronous adrenal metastases from solid primary carcinoma has increased with the development of technical skills. Here we analyzed the postoperative clinical outcomes of patients who underwent adrenalectomy for metachronous adrenal metastases from solid primary carcinomas. MethodsPatients who underwent adrenalectomy for metachronous adrenal metastases after initial treatment of primary carcinoma at Asan Medical Center from 2000 to 2010 were included. Clinicopathological parameters were analyzed to evaluate prognostic outcomes. ResultsA total of 30 patients with 19 hepatocellular carcinomas and 11 lung carcinomas were included. The mean age was 54.3 years. The mean time until adrenalectomy was 23 months. The size of the metastatic adrenal tumor and the disease status of the primary carcinoma at the time of adrenalectomy were associated with second recurrence after adrenalectomy (P < 0.05). There was no significant difference in disease-specific recurrence-free survival between patients who underwent open adrenalectomy and laparoscopic adrenalectomy (P = 0.646). ConclusionsSurgical treatment should be recommended for metachronous adrenal metastases in patients with no evidence of primary carcinoma and/or in those having metastatic adrenal tumors ≤4.4 cm. This approach may increase the recurrence-free interval related to second recurrence. Further, laparoscopic adrenalectomy appears sufficient for the treatment of such patients.

DIAGNOSIS OF ENDOCRINE DISEASE: The diagnostic performance of adrenal biopsy: a systematic review and meta-analysis.

To perform a systematic review of published literature on adrenal biopsy and to assess its performance in diagnosing adrenal malignancy. Medline In-Process and Other Non-Indexed Citations, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trial were searched from inception to February 2016. Reviewers extracted data and assessed methodological quality in duplicate. We included 32 observational studies reporting on 2174 patients (39.4% women, mean age 59.8 years) undergoing 2190 adrenal mass biopsy procedures. Pathology was described in 1621/2190 adrenal lesions (689 metastases, 68 adrenocortical carcinomas, 64 other malignancies, 464 adenomas, 226 other benign, 36 pheochromocytomas, and 74 others). The pooled non-diagnostic rate (30 studies, 2013 adrenal biopsies) was 8.7% (95%CI: 6-11%). The pooled complication rate (25 studies, 1339 biopsies) was 2.5% (95%CI: 1.5-3.4%). Studies were at a moderate risk for bias. Most limitations related to patient selection, assessment of outcome, and adequacy of follow-up. Only eight studies (240 patients) could be included in the diagnostic performance analysis with a sensitivity and specificity of 87 and 100% for malignancy, 70 and 98% for adrenocortical carcinoma, and 87 and 96% for metastasis respectively. Evidence based on small sample size and moderate risk of bias suggests that adrenal biopsy appears to be most useful in the diagnosis of adrenal metastasis in patients with a history of extra-adrenal malignancy. Adrenal biopsy should only be performed if the expected findings are likely to alter the management of the individual patient and after biochemical exclusion of catecholamine-producing tumors to help prevent potentially life-threatening complications.

Metabolic and anatomic characteristics of benign and malignant adrenal masses on positron emission tomography/computed tomography: a review of literature.

PET/CT with (18)F-fluorodeoxyglucose (FDG) or using different radiocompounds has proven accuracy for detection of adrenal metastases in patients undergoing cancer staging. It can assist the diagnostic work-up in oncology patients by identifying distant metastases to the adrenal(s) and defining oligometastatic disease that may benefit from targeted intervention. In patients with incidentally discovered adrenal nodules, so-called adrenal "incidentaloma" FDG PET/CT is emerging as a useful test to distinguish benign from malignant etiology. Current published evidence suggests a role for FDG PET/CT in assessing the malignant potential of an adrenal lesion that has been 'indeterminately' categorized with unenhanced CT, adrenal protocol contrast-enhanced CT, or chemical-shift MRI. FDG PET/CT could be used to stratify patients with higher risk of malignancy for surgical intervention, while recommending surveillance for adrenal masses with low malignant potential. There are caveats for interpretation of the metabolic activity of an adrenal nodule on PET/CT that may lead to false-positive and false-negative interpretation. Adrenal lesions represent a wide spectrum of etiologies, and the typical appearances on PET/CT are still being described, therefore our goal was to summarize the current diagnostic strategies for evaluation of adrenal lesions and present metabolic and anatomic appearances of common and uncommon adrenal lesions. In spite of the emerging role of PET/CT to differentiate benign from malignant adrenal mass, especially in difficult cases, it should be emphasized that PET/CT is not needed for most patients and that many diagnostic problems can be resolved by CT and/or MR imaging.

Unusual Adrenal Gland Metastasis in a Patient with Follicular Carcinoma of the Thyroid Evidenced by (18)F-FDG PET/CT and Confirmed by Biopsy.

Follicular thyroid carcinoma (FTC) is a relatively rare form of differentiated thyroid carcinoma, but it is important to recognise that FTC may be very aggressive, may not respond to radioiodine treatment and may cause life-threatening complications [1, 2]. The use of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) has rapidly grown in the latest years in patients with differentiated thyroid carcinoma (DTC) with a negative radio-iodine scan despite clearly elevated levels of thyroglobulin [3]. The biological pattern of DTC, which loses its thyroid-specific iodide-trapping properties and becomes FDG-avid, reflects enhanced aggressiveness and is related to a worse prognosis than FDG-negative tumours [4]. In addition, there is evidence that several factors associated with FDG positivity (tumour size, lymph node metastasis, and glucose transporter expression and differentiation) are related to a poor prognosis in patients with FTC [5]. A 78-year-old woman with a history of FTC came under our observation to undergo an 18F-FDG PET/CT scan for the first time for restaging purpose. Total thyroidectomy had been performed 19 years previously and radio-iodine treatment reached a total activity level of 1.8 Ci (66.6 GBq) over 10 years. The aggressive treatment did not prevent the development of a widespread metastatic disease involving lymph nodes and bones. The most painful bone metastases were treated with external beam radiation therapy, with effective relief of the symptoms. A suppressive therapy with L-thyroxine was started. Thyroglobulin levels were checked yearly, and were relatively high but under control (maximum value, 32.3 ng/ml). However, the thyroglobulin levels suddenly rose up to 117.5 ng/ml 6 months previously. A 131I whole-body scan was requested but the result was negative (Fig. 1). Therefore the patient was referred to our department to undergo an 18FDG-PET/CT scan. Fig. 1 131I whole-body scan images Sixty minutes following intravenous injection of 138 MBq of 18F-FDG, low-dose CT and PET images from the skull base to mid-thigh were acquired using a hybrid Biograph mCT TOF PET/CT scanner (Siemens Medical Solutions, Erlangen,Germany). Images revealed FDG-avid lesions in the sternum (SUVmax 3.5), L1 (SUVmax 8) and in the lower lobe of the right lung (SUVmax 6.3) (Fig. 2a). Moreover, there was evidence of another pathological uptake (SUVmax 7.3) in the left adrenal gland (Fig. 2b-d). The adrenal lesion was surgically removed and pathological examination revealed metastasis from the FTC (Fig. 3). Fig. 2 a Maximum intensity projection (MIP) image; b transaxial PET image; c transaxial CT image; d transaxial fused PET/CT image. Arrows FDG-avid lesions Fig. 3 Haematoxylin and eosin stained section of the surgically removed adrenal lesion The patient was then referred to the clinical oncologist to evaluate possible further therapies. The adrenal gland is a very uncommon site of metastatic spread from thyroid carcinoma. Only a few cases have been reported in the literature, describing adrenal metastases in patients affected by papillary thyroid carcinoma [6–8] or anaplastic thyroid carcinoma [9]. Although a case of iodine-avid adrenal lesion has been described previously [10], to our knowledge, this is the first case report of an adrenal gland metastasis imaged by 18F-FDG PET/CT in a patient affected by FTC with high thyroglobulin levels and negative 131I whole-body scan.

PD1-10 ROLE OF POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY (PET/CT) IN THE EVALUATION OF THE METASTATIC ADRENAL MASSES

You have accessJournal of UrologyAdrenal1 Apr 2014PD1-10 ROLE OF POSITRON EMISSION TOMOGRAPHY/COMPUTED TOMOGRAPHY (PET/CT) IN THE EVALUATION OF THE METASTATIC ADRENAL MASSES Onur KAYGISIZ, Gokhun Ozmerdiven, Yakup Kordan, Burhan Coskun, Hakan Vuruskan, and Ismet Yavascaoglu Onur KAYGISIZOnur KAYGISIZ More articles by this author , Gokhun OzmerdivenGokhun Ozmerdiven More articles by this author , Yakup KordanYakup Kordan More articles by this author , Burhan CoskunBurhan Coskun More articles by this author , Hakan VuruskanHakan Vuruskan More articles by this author , and Ismet YavascaogluIsmet Yavascaoglu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.129AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To investigate the role of PET/CT imaging in the diagnosis of the patients with suspected non small cell lung cancer (NSCLC) metastases in the adrenal gland. METHODS Forty-one patients with suspected metastases Laparoscopic Adrenalectomy was performed in our clinic between March 2004 and July 2013. Fourteen patients without PET imaging were excluded from the study. The primary tumors in 22 were NSCLC. The parameters of the patients and peak standardized uptake values (SUVmax) were compared between the groups with benign and malignant pathologies. RESULTS Metastases were found in 17 adrenal masses (74%). Sex of the patient, sub-type of the lung cancer and the size of the adrenal mass were ineffective for the prediction of the metastasis (table). Together with this, the SUVmax value was found as significantly higher in the metastatic group (table). If the threshold value of SUV max for metastatic were taken as 3, sensitivity would be 100% and specificity would be 50%; whereas if the same value were taken as 4 or 5, sensitivity would be 88.2% and 76.5, respectively, and specificity would be 82.4% and 100%, respectively. CT or MRI were ineffective in determining the metastases (p=0,179). Specificity was 83.3%, while sensitivity was only 60%. However, in case we accepted the presence of suspicious metastasis based on CT or MRI as the criterion in the group we took the SUV max threshold value as 4, one patient more would be diagnosed to increase sensitivity to 94.11% and to decrease specificity to 66%. Likewise, taking the threshold SUV max value as 5 would allow diagnosing of 2 more patients and diagnosis of only 1 patient would be missed increasing sensitivity to 94.1% and lowering specificity to 83.3%. CONCLUSIONS In our series, PET/CT appears as an effective imaging modality to determine the adrenal metastases in patients with NSCLC as the primary disease. Follow-up may be considered in the first place for patients with SUV max values smaller than 3. SUVmax threshold value 5 sensitivity can be increased by combining with CT or MRI. Table. Comparison of the patients with primary NSCLC tumors in groups with and without metastasis Benign Grup 1 (n=6) Metastasis (Grup 2) (n=17) P Age (year)a 64,3±7,4 56,2± 7,8 0,047 SUVmaxa 2,8± 1,3 9,3±4,9 <0,001 Adrenal mass diameter (mm)a 26,0± 9,5 29± 15,5 0,617 Gender male 4 16 (80%) 0,155 female 2 1 (33,3%) Lung cancer subtypes Squamoz 3 7 (70%) 0,708 Adenocancer 3 10 (76,9%) CT/MRI benign 5 6 0,149 metastasis 1 9 SUV maxb ≤3 3 0 (0%) 0,011 > 3 3 17 (85%) SUV maxb ≤4 5 2 (28,6%) 0,003 > 4 1 15(93,8%) SUV maxb ≤5 6 3 (33,3%) 0,001 >5 0 14 (100%) SUVmax/ MRI-CT ≤5, benign 5 1 (16,7%) 0,001 > 5, metastasis 1 16 (94,1%) © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e13-e14 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Onur KAYGISIZ More articles by this author Gokhun Ozmerdiven More articles by this author Yakup Kordan More articles by this author Burhan Coskun More articles by this author Hakan Vuruskan More articles by this author Ismet Yavascaoglu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Evaluation of Adrenal Metastases from Renal Cell Carcinoma and Hepatocellular Carcinoma: Use of Delayed Contrast-enhanced CT

To retrospectively compare absolute and relative washout of adrenal metastases in patients with renal cell carcinoma (RCC) and hepatocellular carcinoma (HCC) to that of adrenal adenoma. Between November 1994 and August 2011, in this institutional review board-approved study (with waiver of informed consent), 16 patients with 19 adrenal metastases (16 in 13 RCC patients, three in three HCC patients) and 20 patients with 21 adrenal adenomas (16 in 15 RCC patients, five in five HCC patients) underwent dedicated adrenal protocol consisting of unenhanced, 1-minute contrast material-enhanced, and 15-minute delayed contrast-enhanced computed tomography (CT). The attenuation values and percentage enhancement washout, including absolute percentage washout (APW) and relative percentage washout (RPW), were calculated. If available, histologic findings and the change in the size of adrenal lesions were assessed. Statistical analyses were performed by using generalized estimating equation and coefficient of variation. The mean APW of the metastases (observer 1, 67% ± 11 [standard deviation]; observer 2, 63% ± 12) was not significantly different from that of adenomas (observer 1, 73% ± 9; observer 2, 72% ± 12) for observer 1 (P = .143) and was significantly different for observer 2 (P = .029). The mean RPW of the metastases (observer 1, 46% ± 11; observer 2, 43% ± 12) was significantly lower than that of adenomas (observer 1, 62% ± 19; observer 2, 60% ± 17) (all P < .001 for each observer). With a threshold of 60% for APW or 40% for RPW, 95% (18 of 19) and 89% (17 of 19), respectively, of the metastases were falsely diagnosed as lipid-poor adenomas by each observer. All nine metastases that were followed up at CT had a substantial growth in size. In patients with RCC and HCC who undergo dedicated adrenal CT imaging for known adrenal lesions, the percentage enhancement washout of adrenal metastases is similar to that of lipid-poor adrenal adenomas. Careful imaging follow-up or pathologic tissue confirmation is needed.

Adrenalectomy For Isolated Metastasis In Five Patients With Lung Cancer: Single Centre Experience and Review of the Literature

Isolated adrenal metastasis from non-small cell lung cancer (NSCLC) is a rare event. Nonsurgical treatment of a solitary adrenal me- tastasis is associated with poor survival. However, in the aspect of long-term survival, the role of adrenalectomy for isolated metas- tasis is unclear. Here, we reported our experience with surgical treatment of solitary adrenal metastasis in patients with NSCLC who- se primary tumor control were achieved and reviewed current literature. Between the 2001 and 2009, five patients underwent cura- tive adrenalectomy (in 1 patient it was bilateral) for suspected solitary adrenal metastasis after surgical treatment of NSCLC. The pat- hologic examination confirmed in 3 cases a NSCLC metastasis while in 2 cases it was a benign lesion. In the follow-up period, all of the 3 patients with adrenal metastasis had recurrence of NSCLC. Recurrence was local (in the operated adrenal bed) in 2 patients. Palliative radiotherapy focalized to adrenal bed was given to one of the patient with local recurrence. This patient is currently alive 51 months after the adrenalectomy. The other patient with local recurrence died 24 months after the adrenalectomy. Recurrence was systemic (brain and contralateral adrenal gland) in 1 patient who was treated with contralateral adrenalectomy and surgical resecti- on of the cranial metastasis followed by cranial radiotherapy. The patient who underwent bilateral adrenalectomy for metastatic lung cancer died of wide-spread metastatic disease, 79 months after the adrenalectomy. In conclusion, survival benefit can be obtained after complete resection of isolated adrenal metastasis in patients with NSCLC. Therefore, resection of isolated adrenal metastasis should be considered if the primary NSCLC is resectable.

Surgical Resection of Isolated Adrenal Metastases in Patients with Non-Small Cell Lung Cancer: A Single-Institution Experience and Review of the Literature

Background: In non-small cell lung cancer (NSCLC), the benefits of resection of solitary adrenal metastases for survival and the identification of patients most likely to benefit from adrenalectomy are unknown. Patients and Methods: We retrospectively reviewed clinico-pathological factors and outcomes in 4 NSCLC patients treated with adrenalectomy at our centre. We reviewed the published literature with a focus on long-term survivors in order to formulate treatment recommendations. Results: Local pathological staging showed stages IA–IIA. All had a performance status (PS) of 0. The median age was 56 years (range: 53–58 years). Adrenal metastases were detected by positron emission tomography-computed tomography (PET-CT) in 3 patients. Median time from lobectomy to occurrence of metachronous adrenal metastases was 12.3 months (11–14 months). The perioperative mortality was zero. All patients recurred systemically after adrenalectomy within 2–49 months. 3 patients died due to systemic progression 6–15 months after adrenalectomy. 1 patient is alive with pulmonary relapse 49 months after adrenalectomy. Conclusions: Resection of solitary adrenal metastases in selected good-PS NSCLC patients with minimal local nodal involvement from the primary tumour is associated with low morbidity and may offer a chance for long-term disease-free survival in a small subset of patients. Careful pre-operative staging including PET-CT is warranted.

FDG PET/CT in Detection of Adrenal Metastasis in Patients With Renal Cell Carcinoma

Adrenal metastasis in renal cell carcinoma (RCC) is uncommon. The present study was aimed to evaluate the role of fluoro-deoxy-glucose positron emission tomography (FDG PET)/computed tomography (CT) in the detection of adrenal metastasis in patients with RCC. A total of 9 FDG PET/CT scans were performed in 4 patients (3 males, 1 female; median age: 53.5 years, range: 52-73 years). Of 9 PET/CT scans, 2 scans were done for initial staging, 2 for restaging, and 5 for evaluation of treatment response. PET/CT image interpretation and analysis was performed qualitatively (visually) and semiquantitatively. Absence of uptake in postchemotherapy PET/CT scan was considered as complete response and a fall in SUV by more than 50% of baseline value, as significant response. Patients 1 and 2 underwent staging FDG PET/CT. Patient 1 had undergone left radical nephrectomy 13 years back for left-sided RCC. Current FDG PET/CT revealed appearance of right RCC with adrenal metastasis. PET/CT of patient 2 demonstrated right adrenal and distant metastases. PET/CT done for restaging in patient 3, revealed right adrenal and abdominal lymph nodal metastasis. In patient 4, PET/CT revealed solitary adrenal metastasis. Magnetic resonance imaging findings were consistent with adrenal metastasis in this patient. Patient 1 received sunitinib and interferon chemotherapy along with radiotherapy and showed partial response on PET/CT scans done at 6, 17, 23, and 33 months from the initial study. PET/CT of patient 3 demonstrated the progression of disease (nonresponder). FDG PET/CT appears to be useful for staging, treatment response evaluation, and recurrence detection in patients with RCC having adrenal metastasis.

EUS-FNA for the detection of left adrenal metastasis in patients with lung cancer

In patients with lung cancer, enlarged or (18)Fluoro-deoxyglucose positron emission tomography ((18)FDG-PET) positive left adrenal glands are suspected for distant metastases and require tissue confirmation for a definitive assessment. The aim of this study was to assess the sensitivity of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for left adrenal metastases in lung cancer patients with a suspect adrenal gland based on imaging. EUS-FNA findings of patients with (suspected) lung cancer and CT enlarged or (18)FDG-PET positive left adrenal glands were retrospectively evaluated. In the absence of metastases at EUS, clinical and radiological follow-up was obtained. In 85 patients, EUS-FNA demonstrated left adrenal metastases of lung cancer in 53 (62%), benign adrenal tissue in 25 (29%), a metastasis from colon carcinoma in 1 (1%) and a primary adrenocortical carcinoma in 1 (1%) patient. In five patients (5.9%), the aspirates contained non-representative material. EUS outcomes were false negative in two patients. Sensitivity and negative predictive value (NPV) for EUS-FNA of the left adrenal gland were at least 86% (95% CI 74-93%) and 70% (95% CI 50-85%). No complications occurred. EUS-FNA is a sensitive, safe and minimally invasive technique to provide tissue proof of left adrenal metastases in patients with (suspected) lung cancer and enlarged or (18)FDG-PET positive adrenal glands. Therefore, EUS-FNA qualifies as the staging test of choice for patients with lung cancer with suspected left adrenal metastases.

Evaluation of Adrenal Masses in Lung Cancer Patients Using F-18 FDG PET/CT.

The aim of this study was to assess the diagnostic efficacy of PET/CT using various parameters for the characterization of adrenal nodules in lung cancer patients. Sixty-one adrenal nodules in 51 lung cancer patients were evaluated. The final diagnosis was based on histology (n = 2) or imaging follow-up (n = 59, range of follow-up: 7-57months, median 27months). Each adrenal nodule was analyzed using four parameters of PET/CT: the maximum standardized uptake value (SUVmax), the adrenal nodule/liver ratio of the SUV (SUV ratio), Hounsfield units (HU) and size. The optimal cutoff of each parameter for the identification of metastatic nodule was determined by ROC analysis and then the diagnostic efficacy was compared among the parameters. Of the 61 adrenal nodules, 45 (73%) were considered metastasis. The optimal cutoff values of the parameters were SUVmax >2.7, SUV ratio >1.3, HU >18 and size >20mm, respectively. The sensitivity, specificity and accuracy by SUVmax >2.7 were 88.9%, 87.5% and 88.5%, and those by SUV ratio >1.3 were 84.4%, 100% and 88.5%, respectively. The combination of SUV ratio >1.3 and HU >18 had sensitivity of 97.7%, specificity of 81.2% and accuracy of 93.4% to predict adrenal metastasis in patients with lung cancer. SUV ratio from F-18 FDG PET/CT could identify the adrenal metastasis in lung cancer patients. The combination of SUV ratio and HU can improve the accuracy of differentiating benign and metastatic adrenal lesions in lung cancer patients.

EUS-guided alcohol ablation of left adrenal metastasis from non-small-cell lung carcinoma

EUS presents an alternative access to the left adrenal, making it possible to perform echo-guided needle biopsies. We present a case of EUS-guided therapy as alcohol ablation of left adrenal metastases. A 52-year-old man was admitted to the hospital complaining of abdominal pain. CT scan revealed an invasive process in the left upper lobe of the lung and a mass in the left adrenal area that was considered highly suspicious for left adrenal metastases from the patient's lung carcinoma. Cytopathologic examination of EUS-guided FNA confirmed the diagnosis of left adrenal metastasis. Because the patient's main clinical symptom was disabling abdominal pain, we considered the possibility of injection of alcohol into the left adrenal metastases under EUS guidance to ablate the metastatic lesion and potentially relieve the abdominal pain. EUS-guided alcohol ablation was performed successfully. RESULTS AND MAIN OUTCOME MEASUREMENT: On follow-up 3 days after EUS-guided left adrenal ablation, the patient had no abdominal pain. He remained without abdominal pain after 30 and 60 days of follow-up. New technique with limited data. EUS-guided alcohol ablation of left adrenal metastases in patients with non-small-cell lung cancer may provide palliation of cancer-related abdominal pain. There may be potential for combining this (minimally invasive and easily performed EUS-guided therapeutic) technique for ablation of solitary adrenal metastasis in patients with lung cancer with other modalities (e.g., surgery, radiation, or chemotherapy) directed toward the primary pulmonary malignancy and adjacent mediastinal disease.

Adrenal metastasis in renal cell carcinoma: A recommendation for adjustment of the TNM staging system

To study the incidence of adrenal metastasis in patients with renal cell carcinoma (RCC) of all stages, its correlation with clinicopathological variables and its impact on survival. Furthermore, the need for adrenalectomy as part of the routine radical nephrectomy was assessed. The medical records of 321 patients with RCC of all stages who were operated on with the aim of performing adrenalectomy combined with radical nephrectomy between 1982 and 2000 were reviewed. The accuracy of the available preoperative radiological examinations was evaluated and any adrenal involvement was compared with other clinical and histopathological findings. Ipsilateral adrenal tumour involvement was detected in 17/321 patients (5.3%). In four of these patients, the adrenal gland was the only preoperatively found metastatic site. Factors predicting the presence of ipsilateral adrenal metastases were male gender, tumour size, vein invasion, renal capsule and perirenal fat invasion. Tumour location within the kidney and tumour side had no predictive value for the presence of adrenal metastasis. The presence of ipsilateral adrenal involvement was a significant adverse prognostic variable, indicating a short survival time (p<0.001). Ipsilateral adrenal metastasis is a highly adverse prognostic factor. In the TNM staging system, adrenal gland involvement should be staged as M1a. Ipsilateral adrenalectomy in conjunction with radical nephrectomy should be performed if an adrenal lesion cannot be cleared of suspicion after preoperative radiological imaging, as in locally advanced tumours. The adrenal gland can be left in situ if the ipsilateral adrenal gland is assessed as normal at the preoperative investigation and perioperatively by the surgeon.