Third Part. (Second part -radiology diagnosis- not available on line)

1. Surgical Management
of Adrenal Metastases
• Introduction
• Prevalence
• Origin
• Clinical manifestations
• Imaging techniques
• Percutaneous biopsy Should we puncture all these lesions ?
• Surgical Treatment
• Indications
• Prognosis
• Approach
• Non Surgical options

2. Percutaneous biopsy
• Rationale
Should we puncture all these lesions?
If negative then
Metastasis is EXCLUDED
Anxiety is REDUCED
Unnecesary surgery is AVOIDED
If positive then
Consider surgery
End If

3. Percutaneous biopsy
• Rationale
• Utility
Should we puncture all these lesions?
Table 1 Utility of adrenal biopsy in the diagnosis of adrenal metastasis in retrospective series.
Authors Year N Accuracya Sensitivity Specificity PPV NPV Notes
Welch 1994 277 90% 81% 99% 99% 80% Majority of lung cancer
NSCLC and renal cancer
Harisinghani 2002 225 -c -c -c -c 100%
had the highest yield
Paulsen 2004 50 94% 94% 90% 97% 82% Majority of lung cancer
Mazzaglia 2009 127b -c Pooled FNA and C-B
a. Overall accuracy. b. Out of 163 biopsies including incidentalomas. c. Insufficient data to calculate. FNA: Fine needle
aspiration biopsy; C-B: Core-biopsy

4. Percutaneous biopsy
• Rationale
• Utility
• Complications
Should we puncture all these lesions?
Complications: 3% to 13%
• Abdominal pain
• Adrenal hematoma
• Pneumothorax
• Hematuria
• Acute pancreatitis
• Retroperitoneal abscess
• Tumour recurrence along the tract
• Severe hypertension
• Myocardial infarction
• Cerebrovascular accident
Islam A, Nwariaku FE. Adrenal Metastases and Rare Adrenal Tumors. In: Endocrine Surgery. London: Springer-Verlag; 2009. p. 427-38

5. Percutaneous biopsy
Should we puncture all these lesions?
Non contrast CT
HU < 10 HU ≥ 10
Benign
Chemical shift Delayed Contrast
Magnetic Resonance OR Enhancement CT (10’)
Signal NO Signal HU≥30 HU<30
dropoff dropoff OR AND
Washout ≤ 50% Washout > 50%
Benign Biopsy Biopsy Benign
Mayo-Smith WW, et al. State-of-the-art adrenal imaging. Radiographics 2001;21:995-1012.

6. Surgical Management
of Adrenal Metastases
• Introduction
• Prevalence
• Origin
• Clinical manifestations
• Imaging techniques
• Percutaneous biopsy
• Surgical Treatment
• Indications Who should be operated on ?
• Prognosis What are we offering to them ?
• Approach Is laparoscopy safe for this condition ?
• Non Surgical options

7. Surgical Treatment
• Indications
Who should be operated on ?
1) Control of extra-adrenal disease and metastasis isolated
to the adrenal gland
2) Biochemical evaluation is performed and addressed
appropriately
3) Adrenal image highly suggestive of metastasis
or
Biopsy-proven adrenal metastasis
and
appears resectable on imaging studies
4) Performance status warrants an aggressive approach

8. Surgical Treatment
• Indications
Who should be operated on ?
1) Control of extra-adrenal disease and metastasis isolated
to the adrenal gland
• CT scan
• Chest
• Abdominal
• Cerebral
• [PET scan]
Marangos IP, et al. Should we use laparoscopic adrenalectomy for metastases? Scandinavian multicenter study. J Surg Oncol 2009;100:43-7.

9. Surgical Treatment
• Indications
Who should be operated on ?
1) Control of extra-adrenal disease and metastasis isolated
to the adrenal gland
2) Biochemical evaluation is performed and addressed
appropriately
• Prevalence of pheochromocytoma 5-9%
… up to 25% !
Adler JT, et al. Isolated adrenal mass in patients with a history of cancer: remember pheochromocytoma. Ann Surg Oncol 2007;14(8):2358-62.

10. Surgical Treatment
• Indications
Who should be operated on ?
1) Control of extra-adrenal disease and metastasis isolated
to the adrenal gland
2) Biochemical evaluation is performed and addressed
appropriately
3) Adrenal image highly suggestive of metastasis
or
Biopsy-proven adrenal metastasis
and
appears resectable on imaging studies
4) Performance status warrants an aggressive approach

11. Surgical Treatment
• Indications
Who should be operated on ?
1) Control of extra-adrenal disease and metastasis isolated
to the adrenal gland
2) Biochemical evaluation is performed and addressed
appropriately
3) Adrenal image highly suggestive of metastasis
or
Biopsy-proven adrenal metastasis
and
appears resectable on imaging studies
4)Performance status warrants an aggressive
approach

12. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
• Two patients
• NSCLC
• Disease free
• 4 years
• 6 years
Twomey P, Montgomery C, Clark O. Successful treatment of adrenal metastases from large-cell carcinoma of the lung. JAMA 1982;248:581.

13. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
• NSCLC
• Based on brain metastases
resection (10%-30% 5-y)
Median survival:
• Chemo (n=6): 8.5 mo (max 21 mo)
• Chemo + ADX (n=8): 31 mo (3y actuarial: 38%)
“Resection of isolated adrenal metastases
should be considered if the primary NSCLC is resectable.”
Luketich JD, Burt ME. Does resection of adrenal metastases from non-small cell lung cancer improve survival? Ann Thorac Surg 1996;62:1614-6.

14. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
37 patients
• Lung
• Kidney
• Breast
• Gastrointestinal tract
Max Survival 108
Median survival 21
% Long term survivors (60 mo) 24%
Kim SH, Brennan MF, Russo P, Burt ME, Coit DG. The role of surgery in the treatment of clinically isolated adrenal metastasis. Cancer 1998;82:389-94.

15. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
Sarela AI, Murphy I, Coit DG, Conlon KC. Metastasis to the adrenal gland: the emerging role of laparoscopic surgery. Ann Surg Oncol 2003;10:1191-6.

16. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
94 patients
• Lung
• Kidney
• Breast Max Survival 126
• …. Median survival 29
• …. % Long term survivors (60 mo) 30%
Sarela AI, Murphy I, Coit DG, Conlon KC. Metastasis to the adrenal gland: the emerging role of laparoscopic surgery. Ann Surg Oncol 2003;10:1191-6.

17. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
Year
Author Year N Max Median % Long term Primary Observations
Survival Survival survivorsa type(s)
(months) (months)
Watatani 1993 3 12 7 2 Colorectal
Lo 1996 52 107 13 15%(b) Various
Kim 1998 37 108 21 24% Various
Heniford 1999 11 19 NR NR Various
Kebebew 2002 17 84 40(c) NR Various
Lam 2002 21 75 8 NR Various
Sarela 2003 6 62 28 30% Various
Miccoli 2004 16 108 39(c) NR Various
Sebag 2006 16 68 23 33% Various All laparoscopic
Castillo 2007 22 64 26 Various All laparoscopic
Okabe 2007 7 54 23 NR Hepatocellular
carcinoma
Popescu 2007 4 43 28.3(c) 0% Hepatocellular
carcinoma
Strong 2007 94 126 29 30% Various Compares open and laparoscopy.
Includes some of the Kim et al. and
Sarela et al. series.
Silvio-Estaba 2007 13 108 39.7 17% Various
Marangos 2009 31 70 29 18% Various Scandinavian multicentre study
De Haas 2009 10 29 23 32% Colorectal All with previous resection(s) of
colorectal liver metastases
Fumagalli 2010 5 50 24(c) 20%(d) Oesophageal Oesophago-gastric junction
adenocarcinoma
Muth 2010 30 120 23 20% Various

18. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
Year
Author Year N Max Median % Long term Primary Observations
Survival Survival survivorsa type(s)
(months) (months)
Watatani 1993 3 12 7 2 Colorectal
Lo 1996 52 107 13 15%(b) Various
Kim 1998 37 108 21 24% Various
Heniford 1999 11 19 NR NR Various
Kebebew 2002 17 84 40(c) NR Various
Lam 2002 21 75 8 NR Various
Sarela 2003 6 62 28 30% Various
Miccoli 2004 16 108 39(c) NR Various
Sebag 2006 16 68 23 33% Various All laparoscopic
Castillo 2007 22 64 26 Various All laparoscopic
Okabe 2007 7 54 23 NR Hepatocellular
carcinoma
Popescu 2007 4 43 28.3(c) 0% Hepatocellular
carcinoma
Strong 2007 94 126 29 30% Various Compares open and laparoscopy.
Includes some of the Kim et al. and
Sarela et al. series.
Silvio-Estaba 2007 13 108 39.7 17% Various
Marangos 2009 31 70 29 18% Various Scandinavian multicentre study
De Haas 2009 10 29 23 32% Colorectal All with previous resection(s) of
colorectal liver metastases
Fumagalli 2010 5 50 24(c) 20%(d) Oesophageal Oesophago-gastric junction
adenocarcinoma
Muth 2010 30 120 23 20% Various

19. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
Year
Author Year N Max Median % Long term Primary Observations
Survival Survival survivorsa type(s)
(months) (months)
Watatani 1993 3 12 7 2 Colorectal
Lo 1996 52 107 13 15%(b) Various
Kim 1998 37 108 21 24% Various
Heniford 1999 11 19 NR NR Various
Kebebew 2002 17 84 40(c) NR Various
Lam 2002 21 75 8 NR Various
Sarela 2003 6 62 28 30% Various
Miccoli 2004 16 108 39(c) NR Various
Sebag 2006 16 68 23 33% Various All laparoscopic
Castillo 2007 22 64 26 Various All laparoscopic
Okabe 2007 7 54 23 NR Hepatocellular
carcinoma
Popescu 2007 4 43 28.3(c) 0% Hepatocellular
carcinoma
Strong 2007 94 126 29 30% Various Compares open and laparoscopy.
Includes some of the Kim et al. and
Sarela et al. series.
Silvio-Estaba 2007 13 108 39.7 17% Various
Marangos 2009 31 70 29 18% Various Scandinavian multicentre study
De Haas 2009 10 29 23 32% Colorectal All with previous resection(s) of
colorectal liver metastases
Fumagalli 2010 5 50 24(c) 20%(d) Oesophageal Oesophago-gastric junction
adenocarcinoma
Muth 2010 30 120 23 20% Various

20. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
Year
Author Year N Max Median % Long term Primary Observations
Survival Survival survivorsa type(s)
(months) (months)
Watatani 1993 3 12 7 2 Colorectal
Lo 1996 52 107 13 15%(b) Various
Kim 1998 37 108 21 24% Various
Heniford 1999 11 19 NR NR Various
Kebebew 2002 17 84 40(c) NR Various
Lam 2002 21 75 8 NR Various
Sarela 2003 6 62 28 30% Various
Miccoli 2004 16 108 39(c) NR Various
Sebag 2006 16 68 23 33% Various All laparoscopic
Castillo 2007 22 64 26 Various All laparoscopic
Okabe 2007 7 54 23 NR Hepatocellular
carcinoma
Popescu 2007 4 43 28.3(c) 0% Hepatocellular
carcinoma
Strong 2007 94 126 29 30% Various Compares open and laparoscopy.
Includes some of the Kim et al. and
Sarela et al. series.
Silvio-Estaba 2007 13 108 39.7 17% Various
Marangos 2009 31 70 29 18% Various Scandinavian multicentre study
De Haas 2009 10 29 23 32% Colorectal All with previous resection(s) of
colorectal liver metastases
Fumagalli 2010 5 50 24(c) 20%(d) Oesophageal Oesophago-gastric junction
adenocarcinoma
Muth 2010 30 120 23 20% Various

21. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
Year
Author Year N Max Median % Long term Primary Observations
Survival Survival survivorsa type(s)
(months) (months)
Watatani 1993 3 12 7 2 Colorectal
Lo 1996 52 107 13 15%(b) Various
Kim 1998 37 108 21 24% Various
Heniford 1999 11 19 NR NR Various
Kebebew 2002 17 84 40(c) NR Various
Lam 2002 21 75 8 NR Various
Sarela 2003 6 62 28 30% Various
Miccoli 2004 16 108 39(c) NR Various
Sebag 2006 16 68 23 33% Various All laparoscopic
Castillo 2007 22 64 26 Various All laparoscopic
Okabe 2007 7 54 23 NR Hepatocellular
carcinoma
Popescu 2007 4 43 28.3(c) 0% Hepatocellular
carcinoma
Strong 2007 94 126 29 30% Various Compares open and laparoscopy.
Includes some of the Kim et al. and
Sarela et al. series.
Silvio-Estaba 2007 13 108 39.7 17% Various
Marangos 2009 31 70 29 18% Various Scandinavian multicentre study
De Haas 2009 10 29 23 32% Colorectal All with previous resection(s) of
colorectal liver metastases
Fumagalli 2010 5 50 24(c) 20%(d) Oesophageal Oesophago-gastric junction
adenocarcinoma
Muth 2010 30 120 23 20% Various

22. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
Sarela AI, et al. Metastasis to the adrenal gland: the emerging role of laparoscopic surgery. Ann Surg Oncol 2003;10:1191-6.

23. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
Prognostic factors
Positive effect on survival
Origin renal cell carcinoma
DFI > 12 months
Unique metastasectomy
(a)
Adrenalectomy for potential cure achieved
Positive or no apparent effect on survival
Tumour histology adenocarcinoma
(b)
Presentation time (metachronous vs. synchronous)
Small size of metastasis
No apparent effect on survival
Gender
Age
Surgical approach (open vs. laparoscopy)
Origin other primary
(d)
Conflicting results regarding effect on survival
Origin Colorectal
Origin Non Small-Cell Lung Carcinoma
Origin Melanoma
Negative effect on survival
Incomplete resection
Disseminated disease to other sites
Previous metastasectomy

24. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
3-10 y 1-3 y 15-20%
Author Year N Max Mean Survival % Long terma Notes
Survival (months) survivors
(months)
Kirch 1993 12 183 36 25% Highly selected. Long DFI
Higashiyama 1994 5 40 9 NR Comparison of adrenalectomy with palliative
therapy
Ayabe 1995 12 168 47 NR Pooled analysis from 3 small series.
Luketich 1996 8 61 31 20% Compares with non-adrenalectomised
patients.
Porte 1998 11 66 6 9%
Wade 1998 47 86 20 9% 5-year survival rate of 13%.
Beitler 1998 32 92 24 30% Pooled analysis from 11 series.
Bretcha-Boix 2000 5 58 34 20%
Porte 2001 43 72 11 15% Multicentre retrospective. Does not include
previous series.
Lucchi 2005 10 80 31 10%
Pfannschmidt 2005 11 70 12.6 10%
Mercier 2005 23 110 13 18%
Itou 2006 6 36 24 16% Reviews also published data from 104
additional patients.
Strong 2007 29 127 28.6 22% Extracted from large multiorigin series.
Compares laparoscopic and open access

25. Surgical Treatment
• Indications
• Prognostic
What are we offering to them ?
3-10 y 1-3 y 15-20%
10-15 y 2-8 y 20-25%
4-12 y 0.5-1,2 y 5-8 % **

26. Surgical Treatment
• Indications
• Prognostic
• Approach
Is laparoscopy safe for this condition ?
Duh QY. Laparoscopic adrenalectomy for isolated adrenal metastasis: the right thing to do and the right way to do it. Ann Surg Oncol 2007;14:3288-9.

27. Surgical Treatment
• Indications
• Prognostic
• Approach
Is laparoscopy safe for this condition ?
Months of
Median
follow-up
Authors Year N Survival 5-year survival Notes
Max
(months)
(mean)
LAP OPEN LAP OPEN
Tumours by Lap
(1)
Sarela 2003 69 (16) 41 NR* 28 29% significantly smaller than
by Open.
Non-significant differences
Adler 2007 97 (13) 17 19 17 34% 54% in 5 year survival.
(2)
Strong 2007 125 (42) 94 30 29 25% 33%
(1) Non-significant differences
Muth 2010 35 (16) 30 23 22.5% in 5 year survival.

28. Surgical Treatment
• Indications
• Prognostic
• Approach
Is laparoscopy safe for this condition ?
Benefits:
• Less pain
• Shorter postop-stay
• Less scar
• Less postoperative complications
Dangers:
• Affected margins -> Local recurrence
• Port-recurrence

29. Surgical Management
of Adrenal Metastases
• Introduction
• Prevalence
• Origin
• Clinical manifestations
• Imaging techniques
• Percutaneous biopsy
• Surgical Treatment
• Indications
• Prognosis
• Approach
• Non Surgical options

30. Non-surgical options
What else can be done?
Mayo-Smith WW, et al. State-of-the-art adrenal imaging. Radiographics 2001;21:995-1012.

31. Introduction
• Prevalence
Sir Godfrey Hounsfield
1919-2004