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Laparoscopic adrenalectomy for isolated adrenal metastasis from cervical squamous cell carcinoma and endometrial adenocarcinoma
Gynecologic Oncology 122 (2011) 684–685
Contents lists available at ScienceDirect
Gynecologic Oncology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / y g y n o
Case Report
Laparoscopic adrenalectomy for isolated adrenal metastasis from cervical squamous cell carcinoma and endometrial adenocarcinoma☆ Jacqueline J. Choi a, Simon Buttrick a, Konstantin Zakashansky b, Farr Nezhat b, Edward H. Chin a,⁎ a b
Division of General Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, NY, USA Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai School of Medicine, New York, NY, USA
a r t i c l e
i n f o
Article history: Received 1 April 2011 Accepted 23 May 2011 Available online 12 June 2011 Keywords: Laparoscopic adrenalectomy Adrenal metastasis Cervical squamous cell carcinoma Endometrial adenocarcinoma
Introduction Metastatic spread of gynecologic neoplasms to the adrenal gland is a rare condition. There is no consensus on the role of adrenalectomy for metastatic gynecologic neoplasms, given its extremely low incidence. We present two patients who underwent laparoscopic adrenalectomy for an isolated adrenal metastasis, one originating from squamous cell carcinoma of the cervix, and the other from endometrial adenocarcinoma.
Case reports Case 1 A 53-year-old female of Japanese descent presented to The Mount Sinai Hospital with a large fungating cervical mass. A cervical biopsy demonstrated moderately differentiated squamous cell carcinoma. A positron emission tomography (PET) scan showed increased metabolic activity within this mass, with a standard uptake value (SUV) of 13.5, in addition to hypermetabolic right external iliac lymph nodes (SUV 5.7). Computed tomography (CT) scan demonstrated a 6 mm mass in the left adrenal gland without increased activity on PET scan.
☆ There are no financial acknowledgments. ⁎ Corresponding author at: One Gustave L. Levy Place, Box 1259, New York, NY 10029, USA. Fax: + 1 212 410 0111. E-mail address: [email protected] (E.H. Chin). 0090-8258/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2011.05.030
Diagnosed with stage 1B2 cervical carcinoma, the patient underwent a laparoscopic paraaortic lymph node dissection. 15 out of 16 of the lymph nodes were negative for tumor, and a single right obturator lymph node was positive for poorly differentiated squamous cell carcinoma. She was discharged 48 h after surgery, and subsequently received 6 cycles of cisplatinum and gemcitabine, with external beam radiation therapy. She had an excellent response, with no visible cervical mass on follow-up exam. Subsequent PET/CT scan showed enlargement of the left adrenal nodule to 2.6 cm with increased uptake (SUV 7). A mass was identified at the medial portion of the left adrenal gland without local invasion of surrounding structures, or other sites of metastasis and a laparoscopic adrenalectomy was performed. Pathological examination showed poorly differentiated squamous cell carcinoma with lymphovascular invasion, consistent with metastatic cervical cancer [Fig. 1]. She completed 6 cycles of paclitaxel and cisplatinum therapy. Six months post-operatively, after completion of chemotherapy, the patient underwent PET/CT demonstrating no evidence of metastatic disease. The patient remains disease free to date.
Case 2 A 62-year-old Caucasian female presented with postmenopausal bleeding. An endometrial biopsy showed well-to-moderately differentiated adenocarcinoma with mucinous and squamous differentiation. The patient underwent a laparoscopic-assisted hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and paraaortic lymphadenectomy. Pathologic evaluation showed moderate-to-poorly differentiated adenocarcinoma of the uterus. The left ovary and 1 of 47
J.J. Choi et al. / Gynecologic Oncology 122 (2011) 684–685
Fig. 1. Adrenal metastasis showing poorly differentiated carcinoma with squamoid features.
lymph nodes were also positive for metastasis. The tumor was positive for estrogen and progesterone receptors, and stage T3aN1. Adjuvant chemotherapy with 6 cycles of cisplatinum, which has well documented results for recurrent endometrial cancer, was undertaken. Surveillance PET/CT scan performed 10 months after surgery detected an isolated 6 cm hypermetabolic mass in the left adrenal gland (SUV 18) with no signs of local invasion. A CT-guided needle biopsy of the left adrenal mass was performed, which was positive for metastatic adenocarcinoma, with positive staining for CA-125, CK7, CK20 and Vimentin, consistent with an endometrial primary. The patient underwent a laparoscopic left adrenalectomy. Pathologic examination confirmed metastatic adenocarcinoma. Several months later, she developed a new liver lesion on CT scan, with a complete response to doxorubicin. She is currently 35 months post-adrenalectomy, and remains well with no radiographic evidence of disease. Both adrenalectomies were performed by general surgeons with laparoscopic expertise. Discussion Metastatic spread of cervical carcinoma to the adrenal gland is exceedingly rare. To our knowledge, we present only the second case
685
of adrenal metastasis from cervical squamous cell carcinoma, with Baron et al. reporting a case of metachronous adrenal metastases in 2008 treated by unilateral open adrenalectomy. The contralateral adrenal gland metastasized 6 months later, and was also treated by open adrenalectomy, followed by chemotherapy. The patient expired 6 months later [1]. Solitary adrenal metastasis from endometrial adenocarcinoma is similarly rare. The most recently reported case was treated with laparoscopic adrenalectomy, followed by 3 cycles of paclitaxel and carboplatin. 5 years and 7 months after surgery, patient is still alive with no evidence of disease [2]. Surgical intervention is indicated only if the adrenal gland is the isolated site of metastasis. Aggressive surgical intervention appears to yield improved 5 and 10 year survival rates in metastatic disease to non-adrenal sites so it is reasonable to assume that the same would apply to adrenal metastasis [3]. While laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most primary adrenal tumors, its use in the setting of metastatic disease remains a topic of debate. Local recurrence and peritoneal metastases raised concerns for inadequate resection margins and a potential for peritoneal tumor dissemination. In a recent series of 63 open adrenalectomies and 31 laparoscopic adrenalectomies performed for isolated metastasis, Strong et al. found both procedures to be equivalent for margin status, local recurrence, disease-free interval, and overall survival. Operative time, blood loss, length of hospital stay, and complication rate were significantly reduced in the laparoscopic adrenalectomy group [4]. Surgical resection may be appropriate in cases of isolated metastatic disease. Conflict of interest statement There are no financial disclosures or conflicts of interest for any of the authors.
References [1] Baron M, Hamou L, Laberge S, et al. Metastatic spread of gynaecological neoplasms to the adrenal gland: case reports with a review of the literature. Eur J Gynaecol Oncol 2008;29(5):523–6. [2] Izaki H, Takahashi M, Shiirevnyamba A, et al. Long-term recurrence-free survivor after laparoscopic removal of solitary adrenal metastasis from endometrial adenocarcinoma. J Med Invest 2010;57(1–2):174–7. [3] Anraku M, Yokoi K, Nakagawa K, et al. Pulmonary metastasis from uterine malignancies: results of surgical resection in 133 patients. J Thorac Cardiovasc Surg 2004;127(4):1107–12. [4] Strong VE, D'Angelica M, Tang L, et al. Laparoscopic adrenalectomy for isolated adrenal metastasis. Ann Surg Oncol 2007;14(12):3392–400.
Contents lists available at ScienceDirect
Gynecologic Oncology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / y g y n o
Case Report
Laparoscopic adrenalectomy for isolated adrenal metastasis from cervical squamous cell carcinoma and endometrial adenocarcinoma☆ Jacqueline J. Choi a, Simon Buttrick a, Konstantin Zakashansky b, Farr Nezhat b, Edward H. Chin a,⁎ a b
Division of General Surgery, Department of Surgery, Mount Sinai School of Medicine, New York, NY, USA Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai School of Medicine, New York, NY, USA
a r t i c l e
i n f o
Article history: Received 1 April 2011 Accepted 23 May 2011 Available online 12 June 2011 Keywords: Laparoscopic adrenalectomy Adrenal metastasis Cervical squamous cell carcinoma Endometrial adenocarcinoma
Introduction Metastatic spread of gynecologic neoplasms to the adrenal gland is a rare condition. There is no consensus on the role of adrenalectomy for metastatic gynecologic neoplasms, given its extremely low incidence. We present two patients who underwent laparoscopic adrenalectomy for an isolated adrenal metastasis, one originating from squamous cell carcinoma of the cervix, and the other from endometrial adenocarcinoma.
Case reports Case 1 A 53-year-old female of Japanese descent presented to The Mount Sinai Hospital with a large fungating cervical mass. A cervical biopsy demonstrated moderately differentiated squamous cell carcinoma. A positron emission tomography (PET) scan showed increased metabolic activity within this mass, with a standard uptake value (SUV) of 13.5, in addition to hypermetabolic right external iliac lymph nodes (SUV 5.7). Computed tomography (CT) scan demonstrated a 6 mm mass in the left adrenal gland without increased activity on PET scan.
☆ There are no financial acknowledgments. ⁎ Corresponding author at: One Gustave L. Levy Place, Box 1259, New York, NY 10029, USA. Fax: + 1 212 410 0111. E-mail address: [email protected] (E.H. Chin). 0090-8258/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2011.05.030
Diagnosed with stage 1B2 cervical carcinoma, the patient underwent a laparoscopic paraaortic lymph node dissection. 15 out of 16 of the lymph nodes were negative for tumor, and a single right obturator lymph node was positive for poorly differentiated squamous cell carcinoma. She was discharged 48 h after surgery, and subsequently received 6 cycles of cisplatinum and gemcitabine, with external beam radiation therapy. She had an excellent response, with no visible cervical mass on follow-up exam. Subsequent PET/CT scan showed enlargement of the left adrenal nodule to 2.6 cm with increased uptake (SUV 7). A mass was identified at the medial portion of the left adrenal gland without local invasion of surrounding structures, or other sites of metastasis and a laparoscopic adrenalectomy was performed. Pathological examination showed poorly differentiated squamous cell carcinoma with lymphovascular invasion, consistent with metastatic cervical cancer [Fig. 1]. She completed 6 cycles of paclitaxel and cisplatinum therapy. Six months post-operatively, after completion of chemotherapy, the patient underwent PET/CT demonstrating no evidence of metastatic disease. The patient remains disease free to date.
Case 2 A 62-year-old Caucasian female presented with postmenopausal bleeding. An endometrial biopsy showed well-to-moderately differentiated adenocarcinoma with mucinous and squamous differentiation. The patient underwent a laparoscopic-assisted hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic and paraaortic lymphadenectomy. Pathologic evaluation showed moderate-to-poorly differentiated adenocarcinoma of the uterus. The left ovary and 1 of 47
J.J. Choi et al. / Gynecologic Oncology 122 (2011) 684–685
Fig. 1. Adrenal metastasis showing poorly differentiated carcinoma with squamoid features.
lymph nodes were also positive for metastasis. The tumor was positive for estrogen and progesterone receptors, and stage T3aN1. Adjuvant chemotherapy with 6 cycles of cisplatinum, which has well documented results for recurrent endometrial cancer, was undertaken. Surveillance PET/CT scan performed 10 months after surgery detected an isolated 6 cm hypermetabolic mass in the left adrenal gland (SUV 18) with no signs of local invasion. A CT-guided needle biopsy of the left adrenal mass was performed, which was positive for metastatic adenocarcinoma, with positive staining for CA-125, CK7, CK20 and Vimentin, consistent with an endometrial primary. The patient underwent a laparoscopic left adrenalectomy. Pathologic examination confirmed metastatic adenocarcinoma. Several months later, she developed a new liver lesion on CT scan, with a complete response to doxorubicin. She is currently 35 months post-adrenalectomy, and remains well with no radiographic evidence of disease. Both adrenalectomies were performed by general surgeons with laparoscopic expertise. Discussion Metastatic spread of cervical carcinoma to the adrenal gland is exceedingly rare. To our knowledge, we present only the second case
685
of adrenal metastasis from cervical squamous cell carcinoma, with Baron et al. reporting a case of metachronous adrenal metastases in 2008 treated by unilateral open adrenalectomy. The contralateral adrenal gland metastasized 6 months later, and was also treated by open adrenalectomy, followed by chemotherapy. The patient expired 6 months later [1]. Solitary adrenal metastasis from endometrial adenocarcinoma is similarly rare. The most recently reported case was treated with laparoscopic adrenalectomy, followed by 3 cycles of paclitaxel and carboplatin. 5 years and 7 months after surgery, patient is still alive with no evidence of disease [2]. Surgical intervention is indicated only if the adrenal gland is the isolated site of metastasis. Aggressive surgical intervention appears to yield improved 5 and 10 year survival rates in metastatic disease to non-adrenal sites so it is reasonable to assume that the same would apply to adrenal metastasis [3]. While laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most primary adrenal tumors, its use in the setting of metastatic disease remains a topic of debate. Local recurrence and peritoneal metastases raised concerns for inadequate resection margins and a potential for peritoneal tumor dissemination. In a recent series of 63 open adrenalectomies and 31 laparoscopic adrenalectomies performed for isolated metastasis, Strong et al. found both procedures to be equivalent for margin status, local recurrence, disease-free interval, and overall survival. Operative time, blood loss, length of hospital stay, and complication rate were significantly reduced in the laparoscopic adrenalectomy group [4]. Surgical resection may be appropriate in cases of isolated metastatic disease. Conflict of interest statement There are no financial disclosures or conflicts of interest for any of the authors.
References [1] Baron M, Hamou L, Laberge S, et al. Metastatic spread of gynaecological neoplasms to the adrenal gland: case reports with a review of the literature. Eur J Gynaecol Oncol 2008;29(5):523–6. [2] Izaki H, Takahashi M, Shiirevnyamba A, et al. Long-term recurrence-free survivor after laparoscopic removal of solitary adrenal metastasis from endometrial adenocarcinoma. J Med Invest 2010;57(1–2):174–7. [3] Anraku M, Yokoi K, Nakagawa K, et al. Pulmonary metastasis from uterine malignancies: results of surgical resection in 133 patients. J Thorac Cardiovasc Surg 2004;127(4):1107–12. [4] Strong VE, D'Angelica M, Tang L, et al. Laparoscopic adrenalectomy for isolated adrenal metastasis. Ann Surg Oncol 2007;14(12):3392–400.