Journal of Surgical Oncology 44:32-34 (1990)

Adrenalectomy for Adrenal Metastasis From Lung Carcinoma LUIS REYES,

ZAFAR PARVEZ, MD, TAKUMA NEMOTO, MD, A.-M. REGAL, MD, AND HlROSHl TAKITA, MD From the Department of Thoracic Surgery and Oncology, Roswell Park Cancer institute (L.R., Z.P., A,-M.R., H.T.; and Sisters of Charity Hospital (T.N.), Buffalo, New York MD,

In the past 3 years, five patients with lung carcinoma were found to have enlarged adrenal glands without any evidence of distant metastasis. The patients were treated with adrenalectomy. The cases are presented in order to discuss optimal methods of diagnosis and treatment for this condition. KEY WORDS:computed tomography, fine-needle aspiration, lung resection

INTRODUCTION Adrenal metastasis from lung cancer is not an infrequent finding in the patient with this disease. Since the CT scan became available, enlarged adrenal glands have been found by CT scan of the upper abdomen during routine staging work-up of lung cancer patients. We present five patients with lung cancer who had adrenal enlargement detected by the CT scan without any evidence of metastasis, and we will discuss problems related to the diagnosis and treatment. CASE REPORTS Case 1 A 35-year-old female, a smoker, was diagnosed in 1986 to have adenocarcinoma of the right upper lobe of the lung with mediastinal node metastasis. CT scan of the upper abdomen revealed a 2 cm left adrenal mass. A CT-guided needle biopsy was, however, negative for tumor cells (Fig. 1). Following a 4 month course of neoadjuvant chemotherapy, the patient had a radical right pneumonectomy in August 1986. The patient was followed by periodic CT scan of the chest and upper abdomen. A gradual increase in size of the left adrenal gland was noted. and by May 1989 it measured 7 cm in diameter (Fig. 2). There was no evidence of metastasis. At this time, the patient underwent a left adrenalectomy and removal of retroperitoneal lymph nodes for metastatic adenocarcinoma (Fig. 3). Postoperatively, she received 4,000 rads of external radiation therapy to the adrenal bed and is doing well presently. 0 1990 Wiley-Liss, Inc.

Case 2 A 43-year-old man had a right upper lobectomy for T,N, large-cell lung carcinoma in April 1987. CT scan of the chest and upper abdomen in August 1987 showed enlarged adrenal glands, particularly on the left. CTguided needle aspiration of the left adrenal gland was done twice, but no malignant cells were demonstrated. In September 1987, the patient underwent bilateral adrenalectomy for metastatic large-cell carcinoma to both adrenals. Postoperatively, he received three courses of cisplatin combination chemotherapy. The patient is free of disease at present. Case 3 A 41-year-old man saw a physician because of right flank pain. CT scan revealed a left upper lobe lung lesion, mediastinal adenopathy , and enlarged right adrenal gland (7 cm in diameter). A right adrenalectomy revealed metastatic large-cell lung carcinoma. One month later, left upper lobectomy and mediastinal node dissection were done for T,N, large-cell lung carcinoma. Postoperatively, the patient received three courses of cisplatin combination chemotherapy. The patient was able to return to his work but died because of brain and retroperitoneal metastases 13 months postoperatively.

Accepted for publication December 5 . 1989 Address reprint requests to Dr. H. Takita, Department of Thoracic Surgery and Oncology, Roswell Park Cancer Institute, 666 Elm Street, Buffdo, NY 14263.

Adrenalectorny for Lung carcinoma


Fig. I . Case I . Enlareed left adrenal sland measured 2 cm i n tlianietcr

I:ig. 3. Casc I . Removed left adrenal metastasis

Pancoast type, with metastasis to right adrenal gland. which measured 6 cm in diameter. The patient underwent an adrenalectomy followed by systemic cheniotherapy and preoperative radiation therapy. The primary lung lesion was then resected together with the chest wall. He died of local recurrence of the primary tumor 10 months later.


f i g . 2. Caw I . Three years later the left adrenal gland became enl;irgzd to 7 x 1 cni.

Case 4 A 69-year-old man was found to have bilateral lung carcinomas and a L cni left adrenal mass. The left upper lobe lung lesion was removed by a left thoracotoniy. and left adrenalectomy was done simultaneously. The removed adrenal lesion was a benign adenoma. Two months later, the patient had a right upper lobectomy for another primary lung carcinoma T,N,. The patient has been doing well without recurrence for 3 years.

Case 5 A 54-year-old man presented with right shoulder pain and was diagnosed to have poorly differentiated squarnous cell lung carcinoma of the right upper lobe.

Adrenal glands are known to be a common site of metastasis from carcinoma of the lung and breast ( 11. It has been found from autopsy reports that between 28 and 57% of patients with lung cancer had adrenal metastasis [2,3). The mechanisms of metastasis are still uncertain. even though studies suggest an early ipsilateral lymphatic spread by lymph channels connecting mediastinal lymph nodes with adrenal glands, which is then followed by a late hematogcnous spread [4,5]. There have been various attempts in the past to detect adrenal metastasis in lung cancer by measuring the stcroid levels of blood and urine or by radionucleotidc scanning (6.71. However. since CT became available, CT scans of the upper abdomen has become an essential part of the initial staging work-up of lung carcinoma to rule out metastasis to the liver, adrenals, and the retroperitcineal nodes. The observation that enlargement of the adrenals can be produced by a benign condition, knowing that 2% of the population has benign adenomas of the adrenal glands, has introduced the use of fine-needle aspiration for cytological confirmation of malignancy. Attempts were made to diagnose the adrenal metastasis noninvasively by measuring the size of the adrenal on CT scan, but they were not successful [8,9].


Reyes et al.

There are several studies showing that the use of CTguided fine-needle aspiration, in the hands of experienced investigators, appears to be the best way to diagnose adrenal gland metastasis from lung carcinoma [ 101. This is an important step in the work-up of patients with lung cancer for correct staging of the disease; even though the involvement of the adrenal gland will put the patient in an inoperable stage, the bad prognosis of these patients justifies the use of aggressive treatment in order to improve the prognosis. There is one report in which adrenalectomy was performed in patients with large-cell carcinoma of the lung, offering symptom relief and longterm survival [ 1 11. In case 1, detection of the adrenal metastasis was delayed because CT-guided needle biopsy initially produced a false-negative result. Although percutaneous needle biopsy is indicated for confirmation of adrenal metastasis, we feel that negative results do not completely rule out the metastasis, as illustrated in case 1 . We recommend a close follow-up by repeated CT scans in such cases. There have been reports of aggressive surgical therapy of solitary brain metastasis from lung cancers producing acceptable survival results. However, analysis of the cases showed that the best results were obtained when the primary lung lesion was in stages I or I1 and was completely resectable [ 12,131. From our limited experience, we believe that adrenalectoniy for metatasis from lung cancers may offer good therapeutic results when the primary lung lesion is controlled by a curative lung resection and when there is no other evidence of metastasis elsewhere (as in case 2). Finally, adrenalectomy may offer good palliation when a patient has severe pain from an enlarged metastatic adrenal mass (case 3 ) .

REFERENCES 1. Payne DK. Levine SN, Franco DP, Giyanayi VL: Adrenal insufficiency due to metastatic lung carcinoma and shown by abdominal CT scan. South Med J 77:1592-1593, 1984. 2. Marabella P, Takita H: Adenocarcinoma of the lung: Clinicopathological study. J Surg Oncol 7:205-212, 1975. 3. Quraishi MA, Constanzi JJ. Balauchandran S: Idocholesterol adrenal scanning for the detection of adrenal metastasis in lung cancer and its clinical significance. Cancer 48:714-716, 1981. 4. Mitchell ML, Ryan IP, Shermer RW: Pulmonary adenocarcinoina metastatic to the adrenal gland mimicking normal adrenal cortical epithelium on fine needle aspiration. Acta Cytol 29:994-995, 1985. 5 . Libshitz HI, McKenna RJ, Mountain CF: Patterns of mediastinal metastasis in bronchogenic carcinoma. Chest 90:229-232, 1986. 6. Shagain E.4, Holland JF: Metastatic carcinoma to the adrenal glands with cortical hypofunction. Cancer 7: 1242-1248. 1954. 7. Zimm S, Gardener DF, Walsh JW: Addison’s disease as the sole clinical manifestation of recurrent bronchogenic carcinoma. South Med J 74:1016-1018, 1981. 8. Kaneko K , Hirata H. Nishitani H. Onitsuka H. Ono M. Matsura K: Computed tomographic evaluation of adrenal glands in patients with bronchogenic carcinoma. Radiat Med 2:353-355, 1981. 9. Nielsen ME. Heaston DK, Dunnick NR, Korobkin M: Preoperative CT evaluation of adrenal glands in non-small cell bronchogenic carcinoma. AJR 139:317-320, 1982. 10. Pagani JJ: Non-small cell lung carcinoma adrenal metastasis: Computed tomography and percutaneous needle biopsy in their diagnosis. Cancer 53: 1058-1060. 1984. 11. Twomey P, Montgomery C, Clark 0: Successful treatment of adrenal metastasis from large-cell carcinoma of the lung. JAMA 248581-583, 1982. 12. Magilligan DJ, Duvernoy C. Malik G , Lewis WJ, Knighton R. Ausman JI: Surgical approach to lung cancer with solitary cerebral metastasis: Twenty-five years experience. Ann Thorac Surg 421360-364, 1986. 13. Hankins JR, Miller JE. Salcman M, Ferraro F. Green DC. Attar S, McLaughlin JS: Surgical management of lung cancer with solitary cerebral metastasis. Ann Thorac Surg 46:24-28. 1988.

Adrenalectomy for adrenal metastasis from lung carcinoma.

In the past 3 years, five patients with lung carcinoma were found to have enlarged adrenal glands without any evidence of distant metastasis. The pati...
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