Transcript Metachronous solitary left adrenal gland metastasis of right colon

Metachronous solitary left adrenal gland
metastasis of right colon cancer treated
with laparoscopic approach
Ann. Ital. Chir.
Published online (EP) 24 June 2014
pii: S2239253X14022762
www.annitalchir.com
Alberto Oldani, Manuela Monni, Enrica Soligo, Sergio Gentilli, Marcello Garavoglia
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Department of Surgery, University of Eastern Piedmont “A. Avogadro”
Hospital “Maggiore della Carità” Novara, Italy
Metachronous solitary left adrenal gland metastasis of right colon cancer treated with laparoscopic approach
AIM: Adrenal gland metastasis are the second most common type of adrenal mass lesions after adenomas and they could
be related to numerous malignancies; Literature shows that adrenal metastasis deriving from colorectal cancer are very
rare.
MATERIAL OF THE STUDY: A 71-year old - male patient, treated two years before with right colectomy and adjuvant
chemotherapy for right colon cancer, came to our attention after the diagnosis at follow up, of a left adrenal gland mass;
CT scan and CT – PET did not show other pathological findings.
RESULTS: The patient underwent left adrenalectomy with trans-peritoneal laparoscopic approach: the definitive histological examination diagnosed metastatic tissue of colonic cancer in left adrenal gland.
CONCLUSIONS: Adrenal gland metastases are common clinical entities, but which of them arise starting from colonic cancer are very rare and they are generally discovered about 1 year after the first diagnosis of cancer. Early diagnosis, laparoscopic radical excision when feasible and eventual adjuvant radio-chemotherapy are actually the proper clinical management of adrenal gland metastases finalized to better outcomes in terms of longer survival rate and quality of life.
KEY
WORDS:
Adrenal gland, Colorectal cancer, Laparoscopic, Metastasis
Introduction
Adrenal gland metastasis are the second most common
type of adrenal mass lesions after adenomas and they
could be related to numerous malignancies 1, even if isolated or solitary ones are uncommon especially when
related to colonic cancer 2.
Adrenal gland metastasis are generally discovered during
oncologic follow-up in patients with good performance
Pervenuto in redazione Febbraio 2014. Accettato per la pubblicazione
Aprile 2014.
Correspondence to: Alberto Oldani, Clinica Chirurgica, Università del
Piemonte Orientale “Amedeo Avogadro” Azienda Ospedaliero, Universitaria
“Maggiore della Carità”, Corso Mazzini 18, 28100 Novara
(E-mail: [email protected])
status; no symptoms are usually referred and there’s not
significant difference of incidence between those that
arise as bilateral (51%) to monolateral ones (49%);
Literature reports a 66% rate of metachronous adrenal
gland metastasis, discovered within one year after the
first diagnosis of primitive cancer 3.
Case report
In September 2011, a 71-year old - male patient required
right hemicolectomy for malignant right colonic cancer
(pT3 N1 M0), treated after surgery with adjuvant
chemotherapy; periodic oncologic follow-up with thoraxabdomen CT scan resulted completely clear until August
2013; the patients was completely asymptomatic and in
good general conditions.
The thorax–abdomen CT scan performed in August
2013, revealed the presence of dimensional increase of
left adrenal gland (27x23 mm) (Fig. 1).
Published online (EP) 24 June 2014 - Ann. Ital. Chir
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A. Oldani, et al.
Fig. 3: Left adrenal gland with metastatic mass.
Fig. 1: CT scan showing dimensional increase of left adrenal gland
(arrow).
Fig. 4: Histology: adrenal gland with
carcinoma (arrows).
Fig. 2: CT – PET showing increased FDG uptake in the left adrenal gland (arrow).
The subsequent PET-CT confirmed an increased FDG
uptake in the left adrenal gland and in colonic fields
(SUV max 9.89) (Fig. 2).
Completed colonoscopy not identified mucosal anomalies.
Results
The patient underwent left adrenalectomy with transperitoneal laparoscopic approach.
Histological examination diagnosed metastatic tissue of
colonic cancer in left adrenal gland (Figg. 3, 4).
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Ann. Ital. Chir - Published online (EP) 24 June 2014
metastatic colon adeno-
The patient was discharged in first post-operative day
with no pain; no complication occurred during hospitalization.
Discussion
Adrenal gland metastases are the second most common
type of adrenal mass lesion after adenomas, and which
of them arise starting from colonic cancer are very rare2,
and they are generally discovered about 1 year after the
first diagnosis of cancer. Metastases to the adrenal gland
are often revealed during regular oncologic follow-up
with thorax-abdomen CT-scan while the patient is completely asymptomatic, but it is necessary to perform a
PET-CT to confirm the neoplastic behavior of the lesion
[4]: about 66% of adrenal gland metastasis are metachro-
Metachronous solitary left adrenal gland metastasis of right colon cancer treated with laparoscopic approach
comunque che raramente tali lesioni derivano da tumori primitivi colo – rettali.
Un paziente di 71 anni di età, sottoposto due anni prima ad emicolectomia destra e chemioterapia adiuvante
per adenocarcinoma del colon ascendente, è giunto alla
nostra osservazione a seguito del riscontro, al follow up,
di una lesione surrenalica sinistra, indagata tramite TC
e PET –TC; le procedure di stadiazione non avevano
evidenziato ulteriori reperti patologici di rilievo.
Il paziente è stato sottoposto a surrenalectomia sinistra
laparoscopica con approccio trans peritoneale. Esame
istologico definitivo: metastasi surrenalica di adenocarcinoma del colon.
Le metastasi surrenaliche sono entità patologiche molto
comuni; le lesioni di questo tipo derivanti da neoplasie
colo–rettali risultano comunque molto rare, e sono in
genere diagnosticate entro l’anno dalla diagnosi della neoplasia primitiva.
La diagnosi precoce, l’escissione chirurgica radicale se
possibile ed una eventuale radio – chemioterapia risultano il gold standard per ottenere migliori risultati 3in
termini di sopravvivenza e qualità di vita.
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nous and about 49% 2-3 of them are monolateral as our
case exposes. Once adrenal gland metastases is diagnosed,
the proper treatment consists in radical surgical adrenalectomy, performing open versus laparoscopic surgical
approach, chosen after an accurate patient selection, especially when adrenal gland is the only site of secondary
neoplastic involvement.
Many authors referred that laparoscopic adrenalectomy
offers a minimally invasive approach 1-3, with better perioperative and post-operative parameters as decreased
blood loss, fewer complications, and shorter length of
hospital stay compared to open technique, that is however feasible for adrenal gland primitive cancers or for
giant metastatic lesions more than 9 cm. Actually adrenalectomy with complete exeresis of metastasis also
improves survival about 30 months, compared to
chemotherapy alone 3.
Conclusions
Early diagnosis, laparoscopic radical excision when feasible and eventual adjuvant radio-chemotherapy are actually the proper clinical management of adrenal gland
metastases finalized to better outcomes in terms of longer
survival rate and quality of life: the case that we have
described exposes an isolated metachronous right colonic
cancer metastasis on left adrenal gland : our case demonstrates the fundamental role of periodic oncologic follow-up even in complete absence of local either systemic
symptoms to detect earlier metastatic localizations 1-3.
References
1. Sarela AI, Murphy I, Coit DG, et al.: Metastasis to the Adrenal
Gland: The emerging role of laparoscopic surgery. Annals of Surgical
Oncology 2003, 10:1191-196.
2. Lam KY, Lo CY: Metastatic tumours of the adrenal glands: A
30-year experience in a teaching hospital. Clinical Endocrinology,
2002; 56, 95-101.
Riassunto
3. Uberoi J, Munver R: Surgical management of metastases to the
adrenal gland: Open, laparoscopic, and ablative approaches. Current
Urology Reports, 2009; 10:67-72.
Le metastasi sono le più comuni forme di massa surrenalica dopo gli adenomi, e possono derivare dalla diffusione di svariate neoplasie; la Letteratura dimostra
4. weng lj, akhurst t: Colon cancer metastasis to the adrenal gland
demonstrated with FDG PET/CT. Clin Nucl Med, 2004; 29: 444.
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