RESULTS OF SURGICAL TREATMENT OF KIDNEY CANCER WITH SOLITARY METASTASIS TO CONTRALATERAL ADRENAL JANUSZ PLAWNER, M.D. From the Urology Department, New York University Medical Center, New York, New York
•n ,
T
R
A
C
T
-
-
A
large series of patients were reviewed in two major teaching institutions, and pawith a carcinoma of the kidney with a solitary metastatic deposit in the contralateral adrenal ~ ~dentified. Their survival was analyzed and compared with the survival of those patients ~ n g a solitary metastatic deposit in other organs.
~llenN cell cancer presents frequently with disi~tmtmetastasis. At the tlme of initial presenta~on 20~50 percent of cases are beyond surgical ae majority of patients die of prorant metastatic spread rather than rring disease. 1-s Less than 5 percent five years. a small percentage of patients (1present with solitary metastasis to ~one survive longer after removal of metastatic lesion along with the pri~Na~y:tumor; 30-35 percent of these aggres~e[y: treated l~atients were alive after five ~ s f i : i ° P a t i e n t s w i t h solitary metastatic lesions N ? h r:soft tissues also survive longer when the nd secondary deposits are exent our experience with 7 paitary metastatic lesion in an :eral to a kidney bearing the Dnly patients treated aggresrectomy and c o n t r a l a t e r a l vere evaluated for survival. iterature from 1965 to 1985 ii![°undan additional 7 similar cases also treated ~iir~ally (Table I). Material and Methods ~ts A fifty-seven-year-old man was s having a left adrenal mass eighty-
/
MARCH 1991
/
two months post right nephrectomy for a renal cell carcinoma. He underwent a left adrenalectomy and at thirty-two months has no evidence of disease. Pathologic examination of the adrenal showed metastatic renal cell cancer, the same type as in the previously removed kidney. Of significance is that seventy-six months post nephreetomy a solitary metastasis to the left humerus developed which disappeared after radiation therapy. Case 2. A sixty-three-year-old man was found to have a bilateral kidney carcinoma and a mass in the left adrenal. He underwent a right radical nephrectomy and a simultaneous left p a r t i a l n e p h r e c t o m y c o m b i n e d w i t h left adrenalectomy. He remained with no evidence of disease for one hundred twelve months when he was found to have a recurrence in the stump of the right ureter which was then excised. Metastatic deposits were also found in the mediastinum and in the thyroid gland. These were incompletely removed, and he survived another sixty months with evidence of disease and eventually succumbed to metastatic spread one hundred seventy-two months after the initial treatment.
Case 3. A seventy-one-year-old man with right renal tumor involving the ipsilateral adrenal and a mass in the contralateral adrenal underwent a right radial nephrectomy and a simultaneous left adrenalectomy. One positive
VOLUME XXXVII, NUMBER 3
233
TABLE I. Case (Age, Sex)
Site
Stage
Summary o/14 cases o/ renal cell cancer
Treatment
Extraadrenal Extention
Adrenal Involvement
None
S.R.A.
None
S.L.A.
None
S.R.A.
None
S.R.A.
None
S.L.A.
4 + LN/7
S.L.A.
None
S.L.A.
Follow-up
GROUP 1 (9 eases) Ref. 12 (56, F) Ref. 13 (54, F) Ref. 13 (53, F) Ref. 14 (54, M) Ref. 14 (57, F) Case 5* (48, M)
L.K.
IV
L. R. R. L. L. R. L. R. R. L. L. R.
R.K.
IV
L.K.
IV
L.K.
IV
R.K.
IV
L.K.
IV
Case 7* (55, M) Case 2~ (63, M)
R.K.
IV
II.K. L.K.
IV
Case 3T (71, M)
R.K.
IV
R. nephrectomy L. adrenalectomy
R. L. R. L. L.
nephreetomy adrenalectomy nephreetomy adrenaleetomy nephrectomy adrenalectomy nephrectomy adrenaleetomy nephreetomy adrenalectomy nephreetomy adrenaleetomy + 1 MAS nephrectomy adrenalectomy nephrectomy part. nephrect, adrenalectomy
+ 112 mo. ureteral stump + 160 mo. mediastinum 1 + LN/7
S.L.A.
S.L.A.
+ 19, too. NED; pulmonary Ine~ died + 20 too. + 39 too. NED; bone, lung rnei died + 52 too. + 63 mo. NED + 36 mo. NED; mult. bone In! alive + 57 mo. + 24 mo. NED; pulmonary me alive at + 44 mo. Died + 7 mo. mets
+ 20 mo. NED; brain mets; died + 58 too. + 112 mo. NED; + 160 mo. mediastinal mets; died + 172 too. mets + 76 too. NED; pulmonary m died + 80 mo.
GRouP 2 (5 eases) Case 6* (55, M)
L.K.
III
L. nephreetomy R. adrenalectomy
Ref. 7 (58, M) Ref. 15 (53, M) Case 1~ (57, M)
R.K.
IV
L.K.
II
R.K.
III
L. R. L. R. R. L.
Case 4~ (70, M)
L.K.
III
adrenalectomy part. nephreet. nephrectomy adrenaleetomy nephreetomy adrenaleetomy
L. nephrectomy ]El. adrenaleetomy
+ 23 too. L. humerus amputation None None +76 mo. single met; L. humerus RTX; NED None
As.R.A. + 43 too.
Died + 9 mo. post
As.L.K. + 9 mo. As.R.A. + 24 too. As.L.A. + 82 too.
Died + 22 mo. mets
As.R.A. + 84 too.
+ 60 too. NED; total surviv + 144 too.
Died + 12 mo. mets + 32 too. NED post adrenalectomy; total surv + 144 too.
KEY: L.K. = left kidney; R.K. = right kidney; mets = metastasis; LN = lymph node; RTX = radiation therapy; NED i evidence of disease; S. = synchronous; R.A. = right adrenal; L.A. = left adrenal; As. = asynchronous; + 1 MAS = done one post left nephrectomy, i~ *Memorial Sloan-Kettering Cancer Center. ~New York University Medical Center. ::
lymph node was found. He remained with no evidence of disease for seventy-six months but pulmonary and mediastinal metastasis later developed. He died eighty months after the initial treatment. Case 4. A seventy-year-old man had a right adrenal mass eighty-four months after left nephrectomy done for renal cell carcinoma. He underwent a right adrenalectomy. Pathologic examination showed it to be a renal cell cancer of the same type as found in the left kidney seven years previously. Sixty months postoperative he has no evidence of disease.
234
Case 5. A f o r t y - e i g h t - y ( diagnosed as having a carcinoma ney and a right adrenal mass u n radical nephrectomy. Four of 7 were positive. A month later his was removed, and pathologic fin~ same as from the kidney. Rapid metastasis developed and he died later. Case 6. A fifty-five-year< found to have a right adrenal m months after left nephreetomy carcinoma. The pathologic find
UROLOGY
/
MARCH 1991 / VOLUME XXXVII,
Comparison of survivals Tolia and Whitmore6 Plawner Middleton3 Solitary Solitary Solitary Soft Tissue Contralat. Lung and Bone Adrenal Metastasis Metastasis Metastasis 45 % 58 % 78 % Gr. 1 40 % Gr. 2 34 % 35 % 56 % Gr. 1 20 % Gr. 2
TABLEII.
viral
5
"
ass were the same as for the kidney. progressed rapidly and he died nine ater. Interestingly, t w e n t y - t h r e e !ter the initial nephrectomy he was r a solitary metastasis to the left hu[ch required an amputation. A fifty-five-year-old man with carcinoma with bilateral suprarenal lerwent a right radical nephrectomy, f right suprarenal mass, and a simuleft adrenalectomy. Pathologic exrevealed the same histologic type of 'cinoma in all specimens. For twenty e patient remained with no evidence until brain metastasis developed. He nother thirty-eight months with evilisease before succumbing to his dis-
ISeven similar
!
cases were found reported in e~iiierature (Table I).
~mmation oj findings i--±~lFifteen patients (10
males and 5 females) l~!fh a solitary metastasis to the contralateral ld~enal from a kidney cancer were treated agIr~sively by nephrectomy and contralateral ~ Iarenalectomy. In 9 eases the adrenal lesion Das diagnosed concurrently wth the kidney ~ncer and both lesions were removed in one !ler~tion (Group 1, Table I). In 4 eases the I ! ~ a l metastases appeared twenty-four to ~g~f~;four months after the initial nephrecI ~ a ~ and all were removed. In 2 eases the I drenal metastases were misdiagnosed as a prii~.ar~:kidney cancer and were removed first. A I !artial nephrectomy for a primary eontralatM tumor followed nine months later in 1 ease; ihe other the patient apparently refused arther treatment 7 and is excluded from our ya!uation (Group 2, Table I).
~OLOGy
/
MARCH 1991
/
Group 2 (5 cases) analysis of survival* With Alive NED Disease Dead
TABLE III. Year 1 2 3 4 5
8 2 2 1 1
(60) (40) (40) (20) (20)
2 2 2 1 1
(40) (40) (40) (20) (20)
1 0 0 0 0
(20) (0) (0) (0) (0)
2 (40) 1 (20) .. .. ..
*Figures in parentheses indicate percent. NED = no evidence of disease.
In the group of patients with synchronous contralateral adrenal metastasis the total survival time ranged from seven to one hundred seventy-two months (average, 20 months) and survival with no evidence of disease ranged from twelve to one hundred twelve months (average, 13 months). In the group with metachronous adrenal metastasis survival after a d r e n a l e c t o m y ranged from nine to sixty months (average, 14 months) with only 2 cases remaining with no evidence of disease at thirtytwo and sixty months postoperative. Survival from the time of first treatment (nephrectomy) in this group ranged from twenty-two to one h u n d r e d f o r t y - f o u r m o n t h s (average, 33 months). At the time of exploration in Group 1, 2 patients had positive lymph node involvement. One (Case 5) rapidly progressed with metastasis and died; the other (Case 3) survived for seventy-six months with no evidence of disease until metastases developed followed by death. In 2 patients from Group 2 (Cases 1 and 6) single metastasis to the humerus developed before development of adrenal lesions. In 1 case the bony lesion was excised by amputation and in the other it was irradiated. Both patients were considered NED after treatment. Comment Clinical experience indicates that involvement of the ipsilateral adrenal is considered as a local extension whereas metastasis in the contralateral gland is considered a manifestation of systemic spread. The adrenal is a frequent site for metastatic deposits as indicated by 40-45 percent positive findings in large autopsy series on patients dying of metastatic kidney cancer, s,° It also appears that nephreetomy does not influence the frequency of metastasis to the contralateral adrenal, s,° Why this group survives longer remains unclear. It has been postulated that perhaps this is a localized disease limited to
VOLUME XXXVII, NUMBER 3
235
ACKNOWLEDGMENT. To M. Golimbu, M.D., M. MorS~ M.D., E Sogani, M.D., and W. Whitmore, M.D., f~ contributing their cases to this article.
one site and complete removal of the tumor is feasible. Another explanation has implicated immune mechanisms in combating and controlling microscopic disease after d e b u l k i n g . Finally it has been postulated that this may be a naturally selected group of patients with slowgrowing cancer which is not very aggressive and does not metastasize readily. The search for factors predicting the outcome of treatment led Golimbu and others 1° to establish a prognostic score and to correlate it with the length of survival. Since nephrocarcinoma is insensitive to irradiation and to a variety of chemotherapeutic agents, surgical excision of the primary tumor and/or excision of the solitary metastatic deposit remains the most widely used treatment. T M Patients without massive nodal involvement in Group 1 survived longer than the group with metachronous metastases: 56 percent versus 20 percent five-year survival (Table II). Fifty-six percent five-year survival (33% with NED) in the group with synchronous metastases in patients without massive nodal involvement and 20 percent five-year survival (20 % with NED) in the group with metachronous metastases (Table III) seem to justify aggressive surgical treatment in this selected group of patients in an attempt to render them cancer-free. It is comparable to survival in the group with solitary lung or bone metastasis treated similarly (Table II).
References
;?i!~
205 East 78th Street New York, New York 10021
236
1. Fuselier HA, et al: Renal cell carcinoma: Ochsner Medi Institution experience, J Urol 130:445 (1983). 2. Hajdu S, and Thomas A: Renal cell carcinoma at autops Urol 97:978 (1967). 3. Middleton RG: Surgery for metastatic renal cell carcinolr J Urol 97:973 (1967). 4. Rafla S; Renal cell carcinoma--natural history and resu of treatment, Cancer 25:26 (1970). 5. Wright FW: Adrenal metastases from renal earcin0~ diagnosed by selective renal angiography, Br J Urol 46; (1974). 6. Tolia BM, and Whitmore WF Jr: Solitary metastasis renal cell carcinoma, J Urol 14:836 (1975). 7. Foucar E, and Dehner LP: Renal cell carcinoma occult with contralateral adrenal metastasis. A clinical and patholo~ trap, Arch Surg 114:959 (1979). ;:o!,~°~ 8. Saitoh H, et al: Metastatic process and potential indicati~ for treatment of metastatic lesions of renal adenocarcinoma~ Urol 128:915 (1982). i'~i~ 9. Saitoh H, Nakayama M, Nakamura K, and Satoh T: Dis metastasis of renal adenocareinoma in nephreetomized easl)~,~:~ Urol 114:836 (1975). 10. Golimbu M, Askari S, Tessler A, and Morales P: A g g r ' ~ treatment of metastatic renal cancer, J Urol 136:805 (1986) 11. DeKernion J: Treatment of advanced renal c e l l ~ einoma--traditional methods and innovative approaches, J ~ 130:2 (1983). :~i;~?~i~! 12. Campbell CM, Middleton RG, and Rigby OF: A d r ~ i metastasis in renal carcinoma, Urology 21:403 (1983). 13. Previte SR, Willscher MK, and Burke CR: Renal c e l l . ~ cinoma with solitary contralateral adrenal metastasis: e x p e r i ~ with 2 cases, J Urol 128:132 (1982). ~ 14. Neal PM, Leach GE, Kaswick JA, and Lieber M M i ~ cell carcinoma: recognition and treatment of synchronous soi~.:~ eontralateral adrenal metastasis: experience with 2 cases, ~' ~ 128:132 (1982). ~$~ 15. Goldenberg SL, Wright JE, and McLoughlin M G : ~ static renal cell carcinoma: unusual cause of Addison's di Urology 22:408 (1983).
UROLOGY / MARCH 1991 / VOLUME XXXVII,
•n ,
T
R
A
C
T
-
-
A
large series of patients were reviewed in two major teaching institutions, and pawith a carcinoma of the kidney with a solitary metastatic deposit in the contralateral adrenal ~ ~dentified. Their survival was analyzed and compared with the survival of those patients ~ n g a solitary metastatic deposit in other organs.
~llenN cell cancer presents frequently with disi~tmtmetastasis. At the tlme of initial presenta~on 20~50 percent of cases are beyond surgical ae majority of patients die of prorant metastatic spread rather than rring disease. 1-s Less than 5 percent five years. a small percentage of patients (1present with solitary metastasis to ~one survive longer after removal of metastatic lesion along with the pri~Na~y:tumor; 30-35 percent of these aggres~e[y: treated l~atients were alive after five ~ s f i : i ° P a t i e n t s w i t h solitary metastatic lesions N ? h r:soft tissues also survive longer when the nd secondary deposits are exent our experience with 7 paitary metastatic lesion in an :eral to a kidney bearing the Dnly patients treated aggresrectomy and c o n t r a l a t e r a l vere evaluated for survival. iterature from 1965 to 1985 ii![°undan additional 7 similar cases also treated ~iir~ally (Table I). Material and Methods ~ts A fifty-seven-year-old man was s having a left adrenal mass eighty-
/
MARCH 1991
/
two months post right nephrectomy for a renal cell carcinoma. He underwent a left adrenalectomy and at thirty-two months has no evidence of disease. Pathologic examination of the adrenal showed metastatic renal cell cancer, the same type as in the previously removed kidney. Of significance is that seventy-six months post nephreetomy a solitary metastasis to the left humerus developed which disappeared after radiation therapy. Case 2. A sixty-three-year-old man was found to have a bilateral kidney carcinoma and a mass in the left adrenal. He underwent a right radical nephrectomy and a simultaneous left p a r t i a l n e p h r e c t o m y c o m b i n e d w i t h left adrenalectomy. He remained with no evidence of disease for one hundred twelve months when he was found to have a recurrence in the stump of the right ureter which was then excised. Metastatic deposits were also found in the mediastinum and in the thyroid gland. These were incompletely removed, and he survived another sixty months with evidence of disease and eventually succumbed to metastatic spread one hundred seventy-two months after the initial treatment.
Case 3. A seventy-one-year-old man with right renal tumor involving the ipsilateral adrenal and a mass in the contralateral adrenal underwent a right radial nephrectomy and a simultaneous left adrenalectomy. One positive
VOLUME XXXVII, NUMBER 3
233
TABLE I. Case (Age, Sex)
Site
Stage
Summary o/14 cases o/ renal cell cancer
Treatment
Extraadrenal Extention
Adrenal Involvement
None
S.R.A.
None
S.L.A.
None
S.R.A.
None
S.R.A.
None
S.L.A.
4 + LN/7
S.L.A.
None
S.L.A.
Follow-up
GROUP 1 (9 eases) Ref. 12 (56, F) Ref. 13 (54, F) Ref. 13 (53, F) Ref. 14 (54, M) Ref. 14 (57, F) Case 5* (48, M)
L.K.
IV
L. R. R. L. L. R. L. R. R. L. L. R.
R.K.
IV
L.K.
IV
L.K.
IV
R.K.
IV
L.K.
IV
Case 7* (55, M) Case 2~ (63, M)
R.K.
IV
II.K. L.K.
IV
Case 3T (71, M)
R.K.
IV
R. nephrectomy L. adrenalectomy
R. L. R. L. L.
nephreetomy adrenalectomy nephreetomy adrenaleetomy nephrectomy adrenalectomy nephrectomy adrenaleetomy nephreetomy adrenalectomy nephreetomy adrenaleetomy + 1 MAS nephrectomy adrenalectomy nephrectomy part. nephrect, adrenalectomy
+ 112 mo. ureteral stump + 160 mo. mediastinum 1 + LN/7
S.L.A.
S.L.A.
+ 19, too. NED; pulmonary Ine~ died + 20 too. + 39 too. NED; bone, lung rnei died + 52 too. + 63 mo. NED + 36 mo. NED; mult. bone In! alive + 57 mo. + 24 mo. NED; pulmonary me alive at + 44 mo. Died + 7 mo. mets
+ 20 mo. NED; brain mets; died + 58 too. + 112 mo. NED; + 160 mo. mediastinal mets; died + 172 too. mets + 76 too. NED; pulmonary m died + 80 mo.
GRouP 2 (5 eases) Case 6* (55, M)
L.K.
III
L. nephreetomy R. adrenalectomy
Ref. 7 (58, M) Ref. 15 (53, M) Case 1~ (57, M)
R.K.
IV
L.K.
II
R.K.
III
L. R. L. R. R. L.
Case 4~ (70, M)
L.K.
III
adrenalectomy part. nephreet. nephrectomy adrenaleetomy nephreetomy adrenaleetomy
L. nephrectomy ]El. adrenaleetomy
+ 23 too. L. humerus amputation None None +76 mo. single met; L. humerus RTX; NED None
As.R.A. + 43 too.
Died + 9 mo. post
As.L.K. + 9 mo. As.R.A. + 24 too. As.L.A. + 82 too.
Died + 22 mo. mets
As.R.A. + 84 too.
+ 60 too. NED; total surviv + 144 too.
Died + 12 mo. mets + 32 too. NED post adrenalectomy; total surv + 144 too.
KEY: L.K. = left kidney; R.K. = right kidney; mets = metastasis; LN = lymph node; RTX = radiation therapy; NED i evidence of disease; S. = synchronous; R.A. = right adrenal; L.A. = left adrenal; As. = asynchronous; + 1 MAS = done one post left nephrectomy, i~ *Memorial Sloan-Kettering Cancer Center. ~New York University Medical Center. ::
lymph node was found. He remained with no evidence of disease for seventy-six months but pulmonary and mediastinal metastasis later developed. He died eighty months after the initial treatment. Case 4. A seventy-year-old man had a right adrenal mass eighty-four months after left nephrectomy done for renal cell carcinoma. He underwent a right adrenalectomy. Pathologic examination showed it to be a renal cell cancer of the same type as found in the left kidney seven years previously. Sixty months postoperative he has no evidence of disease.
234
Case 5. A f o r t y - e i g h t - y ( diagnosed as having a carcinoma ney and a right adrenal mass u n radical nephrectomy. Four of 7 were positive. A month later his was removed, and pathologic fin~ same as from the kidney. Rapid metastasis developed and he died later. Case 6. A fifty-five-year< found to have a right adrenal m months after left nephreetomy carcinoma. The pathologic find
UROLOGY
/
MARCH 1991 / VOLUME XXXVII,
Comparison of survivals Tolia and Whitmore6 Plawner Middleton3 Solitary Solitary Solitary Soft Tissue Contralat. Lung and Bone Adrenal Metastasis Metastasis Metastasis 45 % 58 % 78 % Gr. 1 40 % Gr. 2 34 % 35 % 56 % Gr. 1 20 % Gr. 2
TABLEII.
viral
5
"
ass were the same as for the kidney. progressed rapidly and he died nine ater. Interestingly, t w e n t y - t h r e e !ter the initial nephrectomy he was r a solitary metastasis to the left hu[ch required an amputation. A fifty-five-year-old man with carcinoma with bilateral suprarenal lerwent a right radical nephrectomy, f right suprarenal mass, and a simuleft adrenalectomy. Pathologic exrevealed the same histologic type of 'cinoma in all specimens. For twenty e patient remained with no evidence until brain metastasis developed. He nother thirty-eight months with evilisease before succumbing to his dis-
ISeven similar
!
cases were found reported in e~iiierature (Table I).
~mmation oj findings i--±~lFifteen patients (10
males and 5 females) l~!fh a solitary metastasis to the contralateral ld~enal from a kidney cancer were treated agIr~sively by nephrectomy and contralateral ~ Iarenalectomy. In 9 eases the adrenal lesion Das diagnosed concurrently wth the kidney ~ncer and both lesions were removed in one !ler~tion (Group 1, Table I). In 4 eases the I ! ~ a l metastases appeared twenty-four to ~g~f~;four months after the initial nephrecI ~ a ~ and all were removed. In 2 eases the I drenal metastases were misdiagnosed as a prii~.ar~:kidney cancer and were removed first. A I !artial nephrectomy for a primary eontralatM tumor followed nine months later in 1 ease; ihe other the patient apparently refused arther treatment 7 and is excluded from our ya!uation (Group 2, Table I).
~OLOGy
/
MARCH 1991
/
Group 2 (5 cases) analysis of survival* With Alive NED Disease Dead
TABLE III. Year 1 2 3 4 5
8 2 2 1 1
(60) (40) (40) (20) (20)
2 2 2 1 1
(40) (40) (40) (20) (20)
1 0 0 0 0
(20) (0) (0) (0) (0)
2 (40) 1 (20) .. .. ..
*Figures in parentheses indicate percent. NED = no evidence of disease.
In the group of patients with synchronous contralateral adrenal metastasis the total survival time ranged from seven to one hundred seventy-two months (average, 20 months) and survival with no evidence of disease ranged from twelve to one hundred twelve months (average, 13 months). In the group with metachronous adrenal metastasis survival after a d r e n a l e c t o m y ranged from nine to sixty months (average, 14 months) with only 2 cases remaining with no evidence of disease at thirtytwo and sixty months postoperative. Survival from the time of first treatment (nephrectomy) in this group ranged from twenty-two to one h u n d r e d f o r t y - f o u r m o n t h s (average, 33 months). At the time of exploration in Group 1, 2 patients had positive lymph node involvement. One (Case 5) rapidly progressed with metastasis and died; the other (Case 3) survived for seventy-six months with no evidence of disease until metastases developed followed by death. In 2 patients from Group 2 (Cases 1 and 6) single metastasis to the humerus developed before development of adrenal lesions. In 1 case the bony lesion was excised by amputation and in the other it was irradiated. Both patients were considered NED after treatment. Comment Clinical experience indicates that involvement of the ipsilateral adrenal is considered as a local extension whereas metastasis in the contralateral gland is considered a manifestation of systemic spread. The adrenal is a frequent site for metastatic deposits as indicated by 40-45 percent positive findings in large autopsy series on patients dying of metastatic kidney cancer, s,° It also appears that nephreetomy does not influence the frequency of metastasis to the contralateral adrenal, s,° Why this group survives longer remains unclear. It has been postulated that perhaps this is a localized disease limited to
VOLUME XXXVII, NUMBER 3
235
ACKNOWLEDGMENT. To M. Golimbu, M.D., M. MorS~ M.D., E Sogani, M.D., and W. Whitmore, M.D., f~ contributing their cases to this article.
one site and complete removal of the tumor is feasible. Another explanation has implicated immune mechanisms in combating and controlling microscopic disease after d e b u l k i n g . Finally it has been postulated that this may be a naturally selected group of patients with slowgrowing cancer which is not very aggressive and does not metastasize readily. The search for factors predicting the outcome of treatment led Golimbu and others 1° to establish a prognostic score and to correlate it with the length of survival. Since nephrocarcinoma is insensitive to irradiation and to a variety of chemotherapeutic agents, surgical excision of the primary tumor and/or excision of the solitary metastatic deposit remains the most widely used treatment. T M Patients without massive nodal involvement in Group 1 survived longer than the group with metachronous metastases: 56 percent versus 20 percent five-year survival (Table II). Fifty-six percent five-year survival (33% with NED) in the group with synchronous metastases in patients without massive nodal involvement and 20 percent five-year survival (20 % with NED) in the group with metachronous metastases (Table III) seem to justify aggressive surgical treatment in this selected group of patients in an attempt to render them cancer-free. It is comparable to survival in the group with solitary lung or bone metastasis treated similarly (Table II).
References
;?i!~
205 East 78th Street New York, New York 10021
236
1. Fuselier HA, et al: Renal cell carcinoma: Ochsner Medi Institution experience, J Urol 130:445 (1983). 2. Hajdu S, and Thomas A: Renal cell carcinoma at autops Urol 97:978 (1967). 3. Middleton RG: Surgery for metastatic renal cell carcinolr J Urol 97:973 (1967). 4. Rafla S; Renal cell carcinoma--natural history and resu of treatment, Cancer 25:26 (1970). 5. Wright FW: Adrenal metastases from renal earcin0~ diagnosed by selective renal angiography, Br J Urol 46; (1974). 6. Tolia BM, and Whitmore WF Jr: Solitary metastasis renal cell carcinoma, J Urol 14:836 (1975). 7. Foucar E, and Dehner LP: Renal cell carcinoma occult with contralateral adrenal metastasis. A clinical and patholo~ trap, Arch Surg 114:959 (1979). ;:o!,~°~ 8. Saitoh H, et al: Metastatic process and potential indicati~ for treatment of metastatic lesions of renal adenocarcinoma~ Urol 128:915 (1982). i'~i~ 9. Saitoh H, Nakayama M, Nakamura K, and Satoh T: Dis metastasis of renal adenocareinoma in nephreetomized easl)~,~:~ Urol 114:836 (1975). 10. Golimbu M, Askari S, Tessler A, and Morales P: A g g r ' ~ treatment of metastatic renal cancer, J Urol 136:805 (1986) 11. DeKernion J: Treatment of advanced renal c e l l ~ einoma--traditional methods and innovative approaches, J ~ 130:2 (1983). :~i;~?~i~! 12. Campbell CM, Middleton RG, and Rigby OF: A d r ~ i metastasis in renal carcinoma, Urology 21:403 (1983). 13. Previte SR, Willscher MK, and Burke CR: Renal c e l l . ~ cinoma with solitary contralateral adrenal metastasis: e x p e r i ~ with 2 cases, J Urol 128:132 (1982). ~ 14. Neal PM, Leach GE, Kaswick JA, and Lieber M M i ~ cell carcinoma: recognition and treatment of synchronous soi~.:~ eontralateral adrenal metastasis: experience with 2 cases, ~' ~ 128:132 (1982). ~$~ 15. Goldenberg SL, Wright JE, and McLoughlin M G : ~ static renal cell carcinoma: unusual cause of Addison's di Urology 22:408 (1983).
UROLOGY / MARCH 1991 / VOLUME XXXVII,
