Surgical Managementof Adrenal Metastases• Introduction • Prevalence • Origin • Clinical manifestations• Imaging techniques...
Percutaneous biopsy• Rationale                            Should we puncture all these lesions?              If negative t...
Percutaneous biopsy• Rationale• Utility                                      Should we puncture all these lesions?        ...
Percutaneous biopsy• Rationale• Utility• Complications                         Should we puncture all these lesions?      ...
Percutaneous biopsy                   Should we puncture all these lesions?                             Non contrast CT   ...
Surgical Managementof Adrenal Metastases• Introduction • Prevalence • Origin • Clinical manifestations• Imaging techniques...
Surgical Treatment• Indications                       Who should be operated on ?       1) Control of extra-adrenal diseas...
Surgical Treatment• Indications                                           Who should be operated on ?       1) Control of ...
Surgical Treatment• Indications                                           Who should be operated on ?       1) Control of ...
Surgical Treatment• Indications                       Who should be operated on ?       1) Control of extra-adrenal diseas...
Surgical Treatment• Indications                       Who should be operated on ?       1) Control of extra-adrenal diseas...
Surgical Treatment• Indications• Prognostic                                     What are we offering to them ?       • Two...
Surgical Treatment• Indications• Prognostic                                    What are we offering to them ?  •   NSCLC  ...
Surgical Treatment• Indications• Prognostic                                       What are we offering to them ?   37 pati...
Surgical Treatment• Indications• Prognostic                                       What are we offering to them ?       Sar...
Surgical Treatment• Indications• Prognostic                                       What are we offering to them ?   94 pati...
Surgical Treatment• Indications• Prognostic                          What are we offering to them ?                       ...
Surgical Treatment• Indications• Prognostic                          What are we offering to them ?                       ...
Surgical Treatment• Indications• Prognostic                          What are we offering to them ?                       ...
Surgical Treatment• Indications• Prognostic                          What are we offering to them ?                       ...
Surgical Treatment• Indications• Prognostic                          What are we offering to them ?                       ...
Surgical Treatment• Indications• Prognostic                     What are we offering to them ?                      Sarela...
Surgical Treatment• Indications• Prognostic                                     What are we offering to them ?            ...
Surgical Treatment• Indications• Prognostic                        What are we offering to them ?                         ...
Surgical Treatment• Indications• Prognostic                     What are we offering to them ?                        3-10...
Surgical Treatment• Indications• Prognostic• Approach                              Is laparoscopy safe for this condition ...
Surgical Treatment• Indications• Prognostic• Approach                     Is laparoscopy safe for this condition ?        ...
Surgical Treatment• Indications• Prognostic• Approach                     Is laparoscopy safe for this condition ?        ...
Surgical Managementof Adrenal Metastases• Introduction • Prevalence • Origin • Clinical manifestations• Imaging techniques...
Non-surgical options                       What else can be done?                              Mayo-Smith WW, et al. State...
Introduction• Prevalence               Sir Godfrey Hounsfield                     1919-2004
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Surgical management of adrenal mets third part

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

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Surgical management of adrenal mets third part

  1. 1. Surgical Managementof 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. 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. 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. 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. 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. 6. Surgical Managementof 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 29. Surgical Managementof Adrenal Metastases• Introduction • Prevalence • Origin • Clinical manifestations• Imaging techniques• Percutaneous biopsy• Surgical Treatment • Indications • Prognosis • Approach• Non Surgical options
  30. 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. 31. Introduction• Prevalence Sir Godfrey Hounsfield 1919-2004

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