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Feasibility of adrenalectomy with radical nephrectomy
ADULT UROLOGY
FEASIBILITY OF ADRENALECTOMY WITH RADICAL NEPHRECTOMY A. H. KARDAR, M. ARAFA, H. AL SUHAIBANI, B. A. PETTERSSON, E. LINDSTEDT, K. A. HANASH, AND SARWAT HUSSAIN
ABSTRACT Objectives. To evaluate the justification of routine removal of ipsilateral adrenal gland as part of radical nephrectomy for renal cell carcinoma (RCC). Methods. The medical records, pathologic specimens, and computed tomographic (CT) scans of 77 patients who underwent radical nephrectomy and ipsilateral adrenalectomy for RCC were reviewed. Comparison was made between radiologic analysis and pathologic findings regarding involvement of the adrenal gland. Results. The size of the renal tumor varied between 3.5 and 19 cm (mean 8.5). The upper pole was involved in 45%, the lower pole in 28%, and the midpole in 18% of the patients, and in 9% the whole kidney was involved by the tumor. Histologic findings showed that 72 (94%) of the 77 adrenal glands were normal and 70 of these were normal on CT as well. Two adrenal glands involved by metastases showed heterogeneous contrast entrancement on CT. The benign lesions of three adrenal glands were also picked up as abnormal on CT. In 2 patients adrenal glands could not be visualized on CT because of a paucity of retroperitoneal fat. Conclusions. Adrenalectomy with nephrectomy may not be performed in patients with RCC in whom CT demonstrates normal adrenal glands. In patients with adrenal abnormality on CT, magnetic resonance imaging can separate metastases from incidental benign adrenal adenoma, further reducing the number of patients requiring removal of the adrenal gland. UROLOGY 52: 35–37, 1998. © 1998, Elsevier Science Inc. All rights reserved.
T
he removal of the ipsilateral adrenal gland and the regional lymph nodes is a routine part of radical nephrectomy for the treatment of renal cell carcinoma (RCC).1 However, adrenalectomy increases the operative time and is associated with a small but definite additional morbidity.2,3 Therefore, it seems reasonable to preoperatively determine whether or not at radical nephrectomy an adrenal gland needs to be removed. With the advent of modern high-resolution imaging techniques, not only is RCC being diagnosed early, but more accurate disease staging is also occurring. In particular, imaging methods and interventional techniques are successfully used to reli-
From the Departments of Urology, Pathology, and Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia Dr. Pettersson is currently at Countess of Chester Hospital, Health Park, Liverpool Road, Chester CH 12 1UL, United Kingdom. Reprint requests: A. H. Kardar, M.D., Department of Urology, MBC # 83, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia Submitted: November 24, 1997, accepted: January 9, 1998 © 1998, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
ably confirm or exclude metastatic involvement of the adrenal gland. Consequently, investigators have suggested that adrenalectomy may only need to be performed in selected patients rather than routinely.4 In this report, we retrospectively review the pathologic results of 77 consecutive radical nephrectomies with adrenalectomies to evaluate the justification of routine adrenalectomy in the surgical treatment of RCC. MATERIAL AND METHODS During a 10-year period between 1985 and 1995, 77 patients underwent radical nephrectomy and ipsilateral adrenalectomy for RCC at the King Faisal Specialist Hospital and Research Centre. For the purpose of the following description, adrenal gland will mean ipsilateral adrenal gland. There were 48 men and 29 women. Their ages ranged between 29 and 86 years (mean 51). The medical records, pathologic specimens, and computed tomographic (CT) scans of these patients were reviewed for the following parameters: pathologic analysis of renal tumors and adrenal glands and the appearance of adrenal glands on the CT scans. The pathologic review included tumor size, cell type and stage, kidney part involved, and the presence or absence of metastasis in the 0090-4295/98/$19.00 PII S0090-4295(98)00117-4 35
TABLE I.
Subtypes of renal cell carcinoma in 77 cases
Type
Number
Oncocytoma Chromophobe cell carcinoma Papillary neoplasm Adenocarcinoma not otherwise specified (clear/granular)
1 15 8 53
Total
77
Percentage 1.3 19.5 10.4 68.8 100
adrenal gland. The CT images were reviewed by a senior radiologist unaware of the pathologic results. Review included the assessment of the adrenal morphology and characterization of abnormality if present; comparison was also made between radiologic analysis and pathologic findings.
RESULTS The size of renal tumor varied between 3.5 and 19 cm (mean 8.5). The tumor involved the upper pole of the kidney in 35 (45%), lower pole in 21 (28%), and midpole in 14 (18%) of the patients and in 7 (9%) the entire kidney was involved. The RCC was of chromophobe cell type in 15 (19.5%), papillary neoplasm in 8 (10.4%), oncocytoma in 1 (1.3%), and adenocarcinoma not otherwise specified (clear/granular) in 53 (68.8%) patients (Table I). There was evidence of capsular invasion in 32 (41%), perirenal fat involvement was observed in 20 (26%), and renal vein invasion was present in 13 (17%) patients. Regional lymph node metastases were encountered in 11 (14%) patients. On histopathologic examination, 72 (94%) of the 77 adrenal glands were normal and 5 (6%) were abnormal. These 5 were also abnormal on CT. On CT, another 2 (2.6%) glands could not be visualized because of the paucity of the retroperitoneal fat. Hence, 70 adrenal glands were normal both on CT and on pathologic examination. Of the five that were abnormal both on CT and pathologic examination, one contained calcification on CT and showed caseating granuloma on pathologic examination; one plump adrenal gland and one containing a low-density nonenhancing 1-cm nodule were due to adrenal hyperplasia and nonfunctioning adrenal adenoma, respectively. Of the remaining two adrenal glands, a left adrenal gland was involved in the direct extension of a 10-cm upper pole renal cancer and in the other, a right lower pole, small (3-cm) tumor was accompanied by a 3-cm adrenal metastasis that showed heterogeneous contrast enhancement on CT. Six months after nephrectomy, follow-up did not demonstrate metastasis in the contralateral adrenal gland in any patient. 36
COMMENT RCC is associated with a poor prognosis. About one third of all patients have metastases at the time of diagnosis.5 As many as 50% to 90%6,7 of autopsy specimens show evidence of metastases. The prognosis for the patients with distant metastases is dismal, with virtually no survivors after 5 years.8 Because of its profuse vascularity, the adrenal gland is the fourth most common site for metastatic disease.9 In patients with RCC, adrenal metastases were encountered in 6% to 23% of autopsy evaluations.5,10,11 Robson,12 in 1963, reported that ipsilateral adrenalectomy during radical nephrectomy resulted in improved patient survival compared with simple nephrectomy. Since then, the removal of the adrenal gland has become a routine part of radical nephrectomy procedures.13 Later, however, other workers could not confirm the benefits of radical over simple nephrectomy.14,15 Routine removal of adrenal gland during radical nephrectomy has been practiced for two possible reasons: close proximity of the adrenal gland to the kidney and the inability of the imaging techniques to determine malignant involvement of the adrenal gland.16 In the past two decades, with the employment of modern imaging methods, small RCCs are being detected.4 Early detection of cancer has led to the development of conservative, kidney-sparing procedures.17,18 With the application of CT and magnetic resonance imaging (MRI), it is now possible to accurately evaluate adrenal gland morphology in up to 97% of patients.19 CT image analysis of an adrenal abnormality can help to differentiate between incidental benign or malignant metastatic disease.20 When this differentiation is not possible on CT, MRI can be used. MRI, using newer sequences of chemical shift imaging, can differentiate between benign adrenal adenomas and metastases, with a reported sensitivity and specificity of 94% and 100%, respectively.21 When imaging results cannot confirm benignity, CT-guided biopsy can safely be carried out. Currently, only a small number of patients may be subjected to CT-guided biopsy for the workup of an adrenal mass.22 An ipsilateral adrenal mass as the only site of metastasis from an RCC occurs in 2.8% of patients,23 and 2% to 9% of all abdominal CT scans show incidental benign adrenal masses.21 In another 2% to 3% of patients, the adrenal glands may not be adequately imaged. Therefore, in the clinical settings of RCC, even if all abnormal or nonvisualized adrenal glands on CT were removed, these would add up to less than 15%. In reality, this figure will probably be much smaller. With the additional help of specialized MRI, eventually the number of adrenal glands requiring extirpation will probably be only UROLOGY 52 (1), 1998
those containing metastases or that were indeterminate or nonvisualized on imaging. Retrospective analysis of the pathologic and CT results in our patients shows that, based on clear visualization of the adrenal gland on CT, adrenalectomy could have been avoided in 70 patients. Of the remaining 7, one gland contained flakey calcification and the other a 1-cm mass without contrast enhancement on postcontrast CT study, both suggesting a benign mass. CT scanning on modern scanners could have prevented adrenalectomy with radical nephrectomy in most of our patients. CONCLUSIONS In a patient with an RCC, the visualization of normal adrenal morphology and an accurate characterization of adrenal abnormality can facilitate preoperative planning and obviate the need for adrenalectomy in every patient. Troublesome bleeding can be avoided and operative time shortened if radical nephrectomy is performed without adrenalectomy.2,24 When the adrenal fossa cannot be well imaged because of technical or patient factors, the gland must be considered abnormal and its removal planned. Careful imaging scrutiny of both glands is warranted in all cases because the contralateral adrenal as the only site of metastasis occurs in 0.7% of patients with RCC.22 Clearly, adrenal mass in patients with disseminated disease is of no clinical importance. Therefore, adrenalectomy with nephrectomy may not be performed in patients with RCC in whom CT demonstrates normal adrenal glands. In patients with adrenal abnormality on CT, MRI can separate metastases from incidental benign adrenal adenoma, further reducing the number of patients requiring removal of the adrenal gland. REFERENCES 1. Dekernion JB, and Belledegron A: Renal tumors, in Walsh PC, Retib AB, Stamey TA, et al (Eds): Campbell’s Urology, 6th ed. Philadelphia, WB Saunders, 1993, vol 2, pp 1053– 1093. 2. Sagalowsky AI, Kadesky KT, Ewalt DM, et al: Factors influencing adrenal metastases in renal cell carcinoma. J Urol 151: 1181–1184, 1994. 3. Kletschev BA, Qian J, Bostwick DG, et al: Prospective analysis of the incidence of ipsilateral adrenal metastases in localized renal cell carcinoma. J Urol 155: 1844 –1846, 1996.
UROLOGY 52 (1), 1998
4. Shalev M, Cipolla B, Guille F, et al: Is ipsilateral adrenalectomy a necessary component of radical nephrectomy? J Urol 153: 1415–1417, 1995. 5. Middleton RG: Surgery for metastatic renal cell carcinoma. J Urol 97: 973–977, 1967. 6. Hajdu SI, and Thomas AG: Renal cell carcinoma at autopsy. J Urol 97: 978 –982, 1967. 7. Soloway HM: Renal tumors: a review of one hundred and thirty cases. J Urol 40: 477– 490, 1938. 8. Dekernion JB: Renal tumors, in Walsh PC, Gittes RF, Perlmutter AD (Eds): Campbell’s Urology, 5th ed. Philadelphia, WB Saunders, 1986, pp 1294 –1338. 9. Williams RD: Renal, perirenal and ureteral neoplasms, in Gillenwater JY, Grayhack JT, Howards SS, et al (Eds): Adult and Paediatric Urology. St Louis, Mosby-Year Book, 1991, vol 1, pp 571– 614. 10. Bennigton JL, and Kradigan RM: Renal Carcinoma. Philadelphia, WB Saunders, 1967, pp 156 –179. 11. Wright FW: Adrenal metastases from renal cell carcinoma diagnosed by selective renal angiography. Br J Urol 46: 472, 1974. 12. Robson CJ: Radical nephrectomy for renal cell carcinoma. J Urol 89: 37– 42, 1963. 13. Li GR, Soulie M, Plante P, et al: Micro-metastatic adrenal invasion by renal carcinoma in patients undergoing nephrectomy. Br J Urol 78: 826 – 828, 1996. 14. Skinner DG, Galvin RB, Vermillion CD, et al: Diagnosis and management of renal cell carcinoma: a clinical and pathological study of 309 cases. Cancer 28: 1165–1177, 1971. 15. Refla S: Renal cell carcinoma: natural history and results of treatment. Cancer 25: 26 – 40, 1970. 16. Gill IS, McCleannan BL, Kenbel K, et al: Adrenal involvement from renal cell carcinoma: predictive value of computerised tomography. J Urol 152: 1082–1885, 1994. 17. Bazeed MA, Scharfe T, Bechet E, et al: Conservative surgery of renal cell carcinoma. Eur Urol 12: 238 –243, 1986. 18. Morgan WR, and Zincke H: Progression and survival after renal conserving surgery for renal cell carcinoma: experience in 104 patients and extended follow-up. J Urol 144: 852– 858, 1990. 19. Hussain S, and Swerdlow PH: The work up of adrenal disease. Postgrad Radiol 5: 251–270, 1985. 20. Hussain S, Belldegrun A, Seltzer SE, et al: Differentiation of malignant from benign adrenal masses: predictive indices on computed tomography. Am J Roentgenol 144: 61– 65, 1985. 21. Schwartz LH, Panicek DM, Doyle MV, et al: Comparison of two algorithms and their associated changes when evaluating adrenal masses in patients with malignancies. Am J Roentgenol 168: 1575–1578, 1997. 22. Hussain S: Gantry angulation in CT guided percutaneous adrenal biopsy. Am J Roentgenol 166: 537–539, 1996. 23. Saitoh H, Nakayama M, Nakamura K, et al: Distant metastasis of renal adenocarcinoma in nephrectomized cases. J Urol 127: 1092–1095, 1982. 24. O’Brien WM, and Lynch JH: Adrenal metastasis by renal cell carcinoma. Urology 24: 605– 607, 1987.
37
FEASIBILITY OF ADRENALECTOMY WITH RADICAL NEPHRECTOMY A. H. KARDAR, M. ARAFA, H. AL SUHAIBANI, B. A. PETTERSSON, E. LINDSTEDT, K. A. HANASH, AND SARWAT HUSSAIN
ABSTRACT Objectives. To evaluate the justification of routine removal of ipsilateral adrenal gland as part of radical nephrectomy for renal cell carcinoma (RCC). Methods. The medical records, pathologic specimens, and computed tomographic (CT) scans of 77 patients who underwent radical nephrectomy and ipsilateral adrenalectomy for RCC were reviewed. Comparison was made between radiologic analysis and pathologic findings regarding involvement of the adrenal gland. Results. The size of the renal tumor varied between 3.5 and 19 cm (mean 8.5). The upper pole was involved in 45%, the lower pole in 28%, and the midpole in 18% of the patients, and in 9% the whole kidney was involved by the tumor. Histologic findings showed that 72 (94%) of the 77 adrenal glands were normal and 70 of these were normal on CT as well. Two adrenal glands involved by metastases showed heterogeneous contrast entrancement on CT. The benign lesions of three adrenal glands were also picked up as abnormal on CT. In 2 patients adrenal glands could not be visualized on CT because of a paucity of retroperitoneal fat. Conclusions. Adrenalectomy with nephrectomy may not be performed in patients with RCC in whom CT demonstrates normal adrenal glands. In patients with adrenal abnormality on CT, magnetic resonance imaging can separate metastases from incidental benign adrenal adenoma, further reducing the number of patients requiring removal of the adrenal gland. UROLOGY 52: 35–37, 1998. © 1998, Elsevier Science Inc. All rights reserved.
T
he removal of the ipsilateral adrenal gland and the regional lymph nodes is a routine part of radical nephrectomy for the treatment of renal cell carcinoma (RCC).1 However, adrenalectomy increases the operative time and is associated with a small but definite additional morbidity.2,3 Therefore, it seems reasonable to preoperatively determine whether or not at radical nephrectomy an adrenal gland needs to be removed. With the advent of modern high-resolution imaging techniques, not only is RCC being diagnosed early, but more accurate disease staging is also occurring. In particular, imaging methods and interventional techniques are successfully used to reli-
From the Departments of Urology, Pathology, and Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia Dr. Pettersson is currently at Countess of Chester Hospital, Health Park, Liverpool Road, Chester CH 12 1UL, United Kingdom. Reprint requests: A. H. Kardar, M.D., Department of Urology, MBC # 83, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia Submitted: November 24, 1997, accepted: January 9, 1998 © 1998, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
ably confirm or exclude metastatic involvement of the adrenal gland. Consequently, investigators have suggested that adrenalectomy may only need to be performed in selected patients rather than routinely.4 In this report, we retrospectively review the pathologic results of 77 consecutive radical nephrectomies with adrenalectomies to evaluate the justification of routine adrenalectomy in the surgical treatment of RCC. MATERIAL AND METHODS During a 10-year period between 1985 and 1995, 77 patients underwent radical nephrectomy and ipsilateral adrenalectomy for RCC at the King Faisal Specialist Hospital and Research Centre. For the purpose of the following description, adrenal gland will mean ipsilateral adrenal gland. There were 48 men and 29 women. Their ages ranged between 29 and 86 years (mean 51). The medical records, pathologic specimens, and computed tomographic (CT) scans of these patients were reviewed for the following parameters: pathologic analysis of renal tumors and adrenal glands and the appearance of adrenal glands on the CT scans. The pathologic review included tumor size, cell type and stage, kidney part involved, and the presence or absence of metastasis in the 0090-4295/98/$19.00 PII S0090-4295(98)00117-4 35
TABLE I.
Subtypes of renal cell carcinoma in 77 cases
Type
Number
Oncocytoma Chromophobe cell carcinoma Papillary neoplasm Adenocarcinoma not otherwise specified (clear/granular)
1 15 8 53
Total
77
Percentage 1.3 19.5 10.4 68.8 100
adrenal gland. The CT images were reviewed by a senior radiologist unaware of the pathologic results. Review included the assessment of the adrenal morphology and characterization of abnormality if present; comparison was also made between radiologic analysis and pathologic findings.
RESULTS The size of renal tumor varied between 3.5 and 19 cm (mean 8.5). The tumor involved the upper pole of the kidney in 35 (45%), lower pole in 21 (28%), and midpole in 14 (18%) of the patients and in 7 (9%) the entire kidney was involved. The RCC was of chromophobe cell type in 15 (19.5%), papillary neoplasm in 8 (10.4%), oncocytoma in 1 (1.3%), and adenocarcinoma not otherwise specified (clear/granular) in 53 (68.8%) patients (Table I). There was evidence of capsular invasion in 32 (41%), perirenal fat involvement was observed in 20 (26%), and renal vein invasion was present in 13 (17%) patients. Regional lymph node metastases were encountered in 11 (14%) patients. On histopathologic examination, 72 (94%) of the 77 adrenal glands were normal and 5 (6%) were abnormal. These 5 were also abnormal on CT. On CT, another 2 (2.6%) glands could not be visualized because of the paucity of the retroperitoneal fat. Hence, 70 adrenal glands were normal both on CT and on pathologic examination. Of the five that were abnormal both on CT and pathologic examination, one contained calcification on CT and showed caseating granuloma on pathologic examination; one plump adrenal gland and one containing a low-density nonenhancing 1-cm nodule were due to adrenal hyperplasia and nonfunctioning adrenal adenoma, respectively. Of the remaining two adrenal glands, a left adrenal gland was involved in the direct extension of a 10-cm upper pole renal cancer and in the other, a right lower pole, small (3-cm) tumor was accompanied by a 3-cm adrenal metastasis that showed heterogeneous contrast enhancement on CT. Six months after nephrectomy, follow-up did not demonstrate metastasis in the contralateral adrenal gland in any patient. 36
COMMENT RCC is associated with a poor prognosis. About one third of all patients have metastases at the time of diagnosis.5 As many as 50% to 90%6,7 of autopsy specimens show evidence of metastases. The prognosis for the patients with distant metastases is dismal, with virtually no survivors after 5 years.8 Because of its profuse vascularity, the adrenal gland is the fourth most common site for metastatic disease.9 In patients with RCC, adrenal metastases were encountered in 6% to 23% of autopsy evaluations.5,10,11 Robson,12 in 1963, reported that ipsilateral adrenalectomy during radical nephrectomy resulted in improved patient survival compared with simple nephrectomy. Since then, the removal of the adrenal gland has become a routine part of radical nephrectomy procedures.13 Later, however, other workers could not confirm the benefits of radical over simple nephrectomy.14,15 Routine removal of adrenal gland during radical nephrectomy has been practiced for two possible reasons: close proximity of the adrenal gland to the kidney and the inability of the imaging techniques to determine malignant involvement of the adrenal gland.16 In the past two decades, with the employment of modern imaging methods, small RCCs are being detected.4 Early detection of cancer has led to the development of conservative, kidney-sparing procedures.17,18 With the application of CT and magnetic resonance imaging (MRI), it is now possible to accurately evaluate adrenal gland morphology in up to 97% of patients.19 CT image analysis of an adrenal abnormality can help to differentiate between incidental benign or malignant metastatic disease.20 When this differentiation is not possible on CT, MRI can be used. MRI, using newer sequences of chemical shift imaging, can differentiate between benign adrenal adenomas and metastases, with a reported sensitivity and specificity of 94% and 100%, respectively.21 When imaging results cannot confirm benignity, CT-guided biopsy can safely be carried out. Currently, only a small number of patients may be subjected to CT-guided biopsy for the workup of an adrenal mass.22 An ipsilateral adrenal mass as the only site of metastasis from an RCC occurs in 2.8% of patients,23 and 2% to 9% of all abdominal CT scans show incidental benign adrenal masses.21 In another 2% to 3% of patients, the adrenal glands may not be adequately imaged. Therefore, in the clinical settings of RCC, even if all abnormal or nonvisualized adrenal glands on CT were removed, these would add up to less than 15%. In reality, this figure will probably be much smaller. With the additional help of specialized MRI, eventually the number of adrenal glands requiring extirpation will probably be only UROLOGY 52 (1), 1998
those containing metastases or that were indeterminate or nonvisualized on imaging. Retrospective analysis of the pathologic and CT results in our patients shows that, based on clear visualization of the adrenal gland on CT, adrenalectomy could have been avoided in 70 patients. Of the remaining 7, one gland contained flakey calcification and the other a 1-cm mass without contrast enhancement on postcontrast CT study, both suggesting a benign mass. CT scanning on modern scanners could have prevented adrenalectomy with radical nephrectomy in most of our patients. CONCLUSIONS In a patient with an RCC, the visualization of normal adrenal morphology and an accurate characterization of adrenal abnormality can facilitate preoperative planning and obviate the need for adrenalectomy in every patient. Troublesome bleeding can be avoided and operative time shortened if radical nephrectomy is performed without adrenalectomy.2,24 When the adrenal fossa cannot be well imaged because of technical or patient factors, the gland must be considered abnormal and its removal planned. Careful imaging scrutiny of both glands is warranted in all cases because the contralateral adrenal as the only site of metastasis occurs in 0.7% of patients with RCC.22 Clearly, adrenal mass in patients with disseminated disease is of no clinical importance. Therefore, adrenalectomy with nephrectomy may not be performed in patients with RCC in whom CT demonstrates normal adrenal glands. In patients with adrenal abnormality on CT, MRI can separate metastases from incidental benign adrenal adenoma, further reducing the number of patients requiring removal of the adrenal gland. REFERENCES 1. Dekernion JB, and Belledegron A: Renal tumors, in Walsh PC, Retib AB, Stamey TA, et al (Eds): Campbell’s Urology, 6th ed. Philadelphia, WB Saunders, 1993, vol 2, pp 1053– 1093. 2. Sagalowsky AI, Kadesky KT, Ewalt DM, et al: Factors influencing adrenal metastases in renal cell carcinoma. J Urol 151: 1181–1184, 1994. 3. Kletschev BA, Qian J, Bostwick DG, et al: Prospective analysis of the incidence of ipsilateral adrenal metastases in localized renal cell carcinoma. J Urol 155: 1844 –1846, 1996.
UROLOGY 52 (1), 1998
4. Shalev M, Cipolla B, Guille F, et al: Is ipsilateral adrenalectomy a necessary component of radical nephrectomy? J Urol 153: 1415–1417, 1995. 5. Middleton RG: Surgery for metastatic renal cell carcinoma. J Urol 97: 973–977, 1967. 6. Hajdu SI, and Thomas AG: Renal cell carcinoma at autopsy. J Urol 97: 978 –982, 1967. 7. Soloway HM: Renal tumors: a review of one hundred and thirty cases. J Urol 40: 477– 490, 1938. 8. Dekernion JB: Renal tumors, in Walsh PC, Gittes RF, Perlmutter AD (Eds): Campbell’s Urology, 5th ed. Philadelphia, WB Saunders, 1986, pp 1294 –1338. 9. Williams RD: Renal, perirenal and ureteral neoplasms, in Gillenwater JY, Grayhack JT, Howards SS, et al (Eds): Adult and Paediatric Urology. St Louis, Mosby-Year Book, 1991, vol 1, pp 571– 614. 10. Bennigton JL, and Kradigan RM: Renal Carcinoma. Philadelphia, WB Saunders, 1967, pp 156 –179. 11. Wright FW: Adrenal metastases from renal cell carcinoma diagnosed by selective renal angiography. Br J Urol 46: 472, 1974. 12. Robson CJ: Radical nephrectomy for renal cell carcinoma. J Urol 89: 37– 42, 1963. 13. Li GR, Soulie M, Plante P, et al: Micro-metastatic adrenal invasion by renal carcinoma in patients undergoing nephrectomy. Br J Urol 78: 826 – 828, 1996. 14. Skinner DG, Galvin RB, Vermillion CD, et al: Diagnosis and management of renal cell carcinoma: a clinical and pathological study of 309 cases. Cancer 28: 1165–1177, 1971. 15. Refla S: Renal cell carcinoma: natural history and results of treatment. Cancer 25: 26 – 40, 1970. 16. Gill IS, McCleannan BL, Kenbel K, et al: Adrenal involvement from renal cell carcinoma: predictive value of computerised tomography. J Urol 152: 1082–1885, 1994. 17. Bazeed MA, Scharfe T, Bechet E, et al: Conservative surgery of renal cell carcinoma. Eur Urol 12: 238 –243, 1986. 18. Morgan WR, and Zincke H: Progression and survival after renal conserving surgery for renal cell carcinoma: experience in 104 patients and extended follow-up. J Urol 144: 852– 858, 1990. 19. Hussain S, and Swerdlow PH: The work up of adrenal disease. Postgrad Radiol 5: 251–270, 1985. 20. Hussain S, Belldegrun A, Seltzer SE, et al: Differentiation of malignant from benign adrenal masses: predictive indices on computed tomography. Am J Roentgenol 144: 61– 65, 1985. 21. Schwartz LH, Panicek DM, Doyle MV, et al: Comparison of two algorithms and their associated changes when evaluating adrenal masses in patients with malignancies. Am J Roentgenol 168: 1575–1578, 1997. 22. Hussain S: Gantry angulation in CT guided percutaneous adrenal biopsy. Am J Roentgenol 166: 537–539, 1996. 23. Saitoh H, Nakayama M, Nakamura K, et al: Distant metastasis of renal adenocarcinoma in nephrectomized cases. J Urol 127: 1092–1095, 1982. 24. O’Brien WM, and Lynch JH: Adrenal metastasis by renal cell carcinoma. Urology 24: 605– 607, 1987.
37