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Partial Adrenalectomy for Renal Cell Carcinoma With Bilateral Adrenal Metastases
0022-5347/95/1534-1196$03.00/0
Vol. 153,1196-1198,April 1995 Printed in U.S.A.
THE JOURNAL OF UROLOGY Copyright 8 1995 by AMERICANUROLOGICAL ~
U n O N INC. ,
Case Reports PARTIAL ADRENALECTOMY FOR RENAL CELL CARCINOMA WITH BILATERAL ADRENAL METASTASES N. SCOTT SCHOMER* AND JAMES L. MOHLER From the Division of Urology and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
ABSTRACT
Resection of the adrenal glands precludes participation in many immunotherapy protocols for metastatic renal cell carcinoma. We performed radical nephrectomy with adrenalectomy and contralateral partial adrenalectomy, including adrenal vein ligation for a 4 cm. hilar metastasis without perioperative complications or local recurrence after 30 months. Adrenal function, measured by cosyntropin stimulation tests 6 weeks and 10 months postoperatively, was normal. Partial adrenalectomy with preservation of adrenal function is possible. KEYWORDS:carcinoma, renal cell; adrenal gland neoplasms; kidney neoplasms, adrenalectomy
Adrenal metastases from renal cell carcinoma occur synchronously in approximately 2% of the cases of metastatic disease.’-7 Many physicians have reported the success of aggressive surgical approaches to solitary ipsilateral as well as contralateral adrenal metastases from renal cell carcinoma.215 In such cases the approach incorporates either sparing of the ipsilateral adrenal gland when normal on computerized tomography (CT) and the renal primary is in the lower pole or sacrifice of postoperative adrenal function by standard ipsilateral radical nephrectomy and contralateral adrenale~tomy.”’~“he absence of normal adrenal function precludes participation in many experimental protocols for treatment of metastatic renal cell carcinoma in which many informed patients may be interested. Primary renal cell carcinoma that presents with bilateral adrenal metastases is a management challenge not previously reported in the literature to our knowledge. Luciani et al reported a case of bilateral but metachronous adrenal metastases from renal cell carcinoma following radical nephrectomy.’6 Our management of synchronous bilateral adrenal metastases from renal cell carcinoma is described. We
performed standard radical nephrectomy , including ipsilatera1 adrenalectomy and contralateral partial adrenalectomy, for an adrenal metastasis. We sought to preserve adrenal function to allow our patient desired participation in immunotherapy protocols at the National Cancer Institute. CASE REPORT
A 42-year-old asymptomatic urologist had a right lower pole solid renal mass and bilateral adrenal masses by ultrasonic self-examination performed during an in office sales demonstration. Abdominal CT confirmed the finding of a 7 x 6 X 6 cm. right renal mass, a 6 X 5 X 5 cm. right adrenal mass and a 4 X 3 X 3 cm. left adrenal mass (figs. 1 and 2). Chest x-ray revealed a widened mediastinum. Chest CT showed extensive periaortic adenopathy from the retrocrural space to the aortic arch. Arteriography demonstrated hypervascularity of the 3 lesions. Both adrenal lesions were centrally located but the contralateral lesion appeared vascularized only by an adrenal artery from the aorta, whereas normal adrenal gland at each pole was supplied by other Accepted for ublication Au st 12, 1994. * Current adgess: Urology &up of New Mexico, St. Joseph West arteries. Preoperative diagnosis was right renal cell carciMesa Center, 4801 McMahon N. W., #225, Albuquerque, New Mexico noma with bilateral adrenal and mediastinal periaortic lymph node metastases (stage T4N3M1). 87114.
FIG. 1. A, CT shows 4 X 3 X 3 cm. solid left adrenal mass (arrows)and superior aspect of right adrenal mass. B, CT reveals 6 right solid adrenal mass (arrows). 1196
X
5
X
5 cm.
1197
PARTIAL ADRENALECTOMY
Headache returned and additional brain metastases were treated 14 months postoperatively with y-knife radiation at the University of Pittsburgh, and complete steroid replacement was begun. The patient received autolymphocyte therapy a t the Cellular Biocare Center, Boston, Massachusetts beginning 19 months postoperatively. Treatment was continued at Emory University, Atlanta, Georgia and disease was stable for 9 months. He remained without evidence of local recurrence upon multiple imaging studies and continued to practice urology until 2 weeks before death from renal cell carcinoma 30 months after the initial resection. DISCUSSION
Adrenal metastases result from antegrade hematogenous spread, or retrograde venous or lymphatic spread." These metastatic deposits confer a higher stage of tumor and portend a worse prognosis due to the uniformly poor response FIG.2. CT demonstrates heterogenous solid 7 X 6 X 6 em. right rate of this tumor to systemic chemotherapy. However, long mid renal mass (arrows). survivals from metastatic carcinoma have been described following resection of isolated pulmonary metastasis7." as well as solitary adrenal or liver metastases.3~~ ImmunotherBecause the patient was an otherwise healthy man, he apy shows romise for the treatment of metastatic renal cell wished to remain eligible for experimental protocols for treat- car~inoma!~~'~ However, adequate adrenal function is rement of metastatic renal cell carcinoma. Most protocols re- quired for most immunotherapy protocols to withstand the quired surgical debulking of tumor burden before immunother- physiological stress of the treatment regimen. In addition, apy. Maximal debulking, including bilateral adrenalectomy, surgical reduction of tumor burden may enhance response would have condemned him to steroid dependence, which would rates.23 Thus, for renal cell carcinoma with bilateral adrenal have excluded him from most available protocols. However, he metastases, an innovative approach is necessary to offer the wanted all accessible regional disease excised. Thus,after con- patient experimental treatment. Our case is significant for 3 reasons. 1)To our knowledge, siderable discussion, the patient chose to undergo right radical nephrectomy and partial leR adrenalectomy during the same subtotal adrenalectomy for bilateral adrenal metastates from operation through separate flank incisions. The incisional ap- renal cell carcinoma has not been reported, although it proach was selected by the patient to minimize postoperative should be feasible based upon treatment approaches for intrinsic adrenal disease. In situ evaluation or excision of bimorbidity. '~ Right radical nephrectomy was performed in a standard lateral pheochromocytoma has been r e p ~ r t e d . ~ * ,Autofashion without complications. Left partial adrenalectomy transplantation after subtotal adrenalectomy has produced was performed extrapleurally through a supra-11th rib inci- normal adrenal function in cases of Cushing's d i s e a ~ e . ~ ~2)- ' ~ sion. Gerota's fascia was entered and the adrenal gland con- Function of a solitary adrenal gland remained normal by taining a well circumscribed hilar mass was identified. The stimulation tests performed 6 weeks and 10 months postopadrenal vein and middle adrenal artery were ligated and eratively. f i r ligation of the adrenal vein, we expected divided, and the mass was excised. Approximately 60% of the venous congestion of the adrenal gland with subsequent left adrenal gland remained, with the superior pole supplied thrombosis. However, collateral venous drainage, perhaps by a branch of the left inferior phrenic artery and the lower via the leR phrenic vein, must have preserved adrenal viapole fragment supplied by a branch of the leR renal artery. bility. Simultaneous adrenal fragment autotransplantation The fragments were apposed and wrapped gently with peri- may provide a better chance of preservation of adrenal funcrenal fat before closure of Gerota's fascia and the flankinci- tion. A better choice of procedure might be possible if the existence and distribution of venous collaterals could be elusion. Histological examination of the resected specimens re- cidated preoperatively. 3)The goal of any surgical or medical vealed grade 3 clear cell renal cell carcinoma with bilateral procedure should be to improve the quality of life and duraadrenal metastases and negative surgical margins. Conva- tion of survival. The unpredictable natural history of renal lescence was uneventful. On postoperative day 1 a 2-hour cell carcinoma prohibits assessment of the effect upon surcosyntropin-stimulated cortisol level was 14.4 pg./dl. Since vival in this case. However, tumor burden was decreased and 95% of patients stimulated postoperatively to 19.6 pg./d.17 or adrenal function was preserved. Steroid replacement and its greater, he was discharged on postoperative day 3 on 5 mg. side effects were avoided until secondary adrenal failure resulted from brain metastases. Normal adrenal function prednisone each morning and 2.5 mg. each evening. The patient tapered the steroids postoperatively without allowed the patient to participate in experimental immunoincident and 40 days postoperatively a cosyntropin stimula- therapy. The patient suffered no apparent harm since tumor tion test performed at the National Institutes of Health did not recur locally. As immunotherapy continues to evolve for the treatment of yielded a 2-hour stimulated cortisol level of 22.1, consistent with normal adrenal function. The tumor progressed after 1 metastatic renal cell carcinoma, the preservation of adrenal cycle of interleukin-4 and the patient had a partial response function becomes more important. Our case demonstrates to 5 cycles of interleukin-2 that was discontinued when ad- that subtotal adrenalectomy for renal cell metastases can be renal insufficiency developed 10 months after the initial op- performed safely in select patients who may be candidates for eration. Cosyntropin stimulation tests were normal, which immunotherapy. Partial adrenalectomy may also be approsuggested adrenal insufficiency due to lack of pituitary-pro- priate in patients with metachronous adrenal metastasis duced adrenocorticotropic hormone. Visual changes and following contralateral radical nephrectomy or in patients headaches developed while awaiting test results, and cranial undergoing partial nephrectomy for renal cell carcinoma in a CT revealed a pituitary metastasis for which he underwent solitary kidney who have a n isolated ipsilateral adrenal metransphenoidal resection. tastasis.
PARTIAL ADRENALECTOMY
1198 REFERENCES
1. O'Brien, W. M. and Lynch, J. H.: Adrenal metastases by renal cell carcinoma: incidence at nephrectomy. Urology, 29 605, 1987. 2. Robey, E. L. and Schellhammer, P. F.: The adrenal gland and renal cell carcinoma: is ipsilateral adrenalectomy a necessary component of radical nephrectomy? J. Urol., 1 3 5 453, 1986. 3. Previte, S. R., Willscher, M. K and Burke, C. R.: Renal cell carcinoma with solitary adrenal metastasis: experience with 2 cases. J . Urol., 128: 132, 1982. 4. Foucar, E. and Dehner, L. P.: Renal cell carcinoma occurring with contralateral adrenal metastasis: a clinical and pathological trap. Arch. Surg., 114: 959, 1979. 5. Neal, P. M., Leach, G. E., Kaswick, J. A. and Lieber, M. M.: Renal cell carcinoma: recognition and treatment of synchronous solitary contralateral adrenal metastasis. J. Urol., 1 2 8 135, 1982. 6. Campbell, C. M., Middleton, R. G. and Rigby, 0. F.: Adrenal metastasis in renal cell carcinoma. Urology, 21: 403, 1983. 7. Tolia, B. M. and Whitmore, W. F., Jr.: Solitary metastasis from renal cell carcinoma. J. Urol., 114: 836, 1975. 8. O'Dea, M. J., Zincke, H., Utz, D. C. and Bernatz, P. E.: The treatment of renal cell carcinoma with solitary metastasis. J. Urol., 120: 540, 1978. 9. Seidenwurm, D. J., Elmer, E. B., Kaplan, L. M., Williams, E. K, Moms, D. G. and HofFmann, A. R.: Metastases to the adrenal glands and the development of Addison's disease. Cancer, 54: 552, 1984. 10. Masuda, F., Ohnishi, T., Higashi, Y., Ikemoto, I. and Machida, T.: Renal cell carcinoma with contralateral adrenal metastasis. Jap. J. Urol., 74: 2138, 1983. 11. Katsuoka,Y., Murakami, Y., Kawashima, T. and Shiramizu,M.: Contralateral adrenal metastasis in renal cell carcinoma. Jap. J. Urol., 7 5 1646, 1984. 12. Kondoh, N., Fujioka, H., Matsuda, M. and Takaha, M.: A case of renal cell carcinoma with contralateral adrenal metastasis. Acta Urol. Jap., 32 575,1986. 13. Hasegawa, J., Kanamori, S., Okumura, S., Yoshida, K., Abe, H. and Akimoto, M.: Renal cell carcinoma with solitary contralateral adrenal metastasis. Urology, 3 2 52, 1988. 14. Deodhar, S. D., Mehendale, V. G. and Bhave, G. G.: Renal cell carcinoma with unusual metastases. J. Postgrad. Med., 24:55, 1978. 15. Lemmers, M., Ward, K, Hatch, T. and Stenzel, P.: Renal adenocarcinoma with solitary metastasis to the contralateral adrenal gland report of 2 cases and review of the literature. J. Urol., 141: 1177, 1989. 16. Luciani, L., Scappini, P., F'usiol, T. and Rscioli, F.: Aspiration cytdogy of simultaneous bilateral adrenal metastases from
renal cell carcinoma. A case report and review of the literature. J. Urol., 134.315, 1985. 17. Mohler, J. L., Michael, K. A., Freedman, A. M., Griffen, W. 0.. Jr. and McRoberts, J. W.: The evaluation of postoperative function of the adrenal gland. Surg., Gynec. & Obst., 161: 445, 1985. 18. Erye, R. C., Balogh, K. and Bosco, P. J.: Renal cell carcinoma with solitary adrenal metastasis. Contemp. Surg., 41: 22, 1992. 19. Barney, J. D. and Churchill, E. J.: Adenocarcinoma of the kidney with metastasis to the lung: cured by nephrectomy and lobectomy. J. Urol., 42:269, 1939. 20. Wirth, M. P.: Immunotherapy for metastatic renal cell carcinoma. Urol. Clin. N. Amer., 2 0 283, 1993. 21. Sawczuk, I. H.: Autolymphocyte therapy in the treatment of metastatic renal cell carcinoma. Urol. Clin. N. Amer., 2 0 297, 1993. 22. Marshall, M. E., Mendelsohn, L., Butler, K., Riley, L., Cantrell, J., Wiseman, C., Taylor, T. and Macdonald, J. S.: Treatment of metastatic renal cell carcinoma with coumarin (1,a-benzopyrone) and cimetadine: a pilot study. J. Clin. Oncol., 5 862, 1987. 23. Robertson, C. N., Linehan, W. M., Pass, H. I., Gomella, L. G., Haas, G. P., Berman, A., Merino, M. and Rosenberg, S. A,: Preparative cytoreductive surgery in patients with metastatic renal cell carcinoma treated with adoptive immunotherapy with interleukin-2 or interleukin-2 plus lymphokine activated killer cells. J . Urol., 14& 614, 1990. 24. Birnbaum, J., Giuliano, A. and Van Herle, A. J.: Partial adrenalectomy for pheochromocytoma with maintenance of adrenocortical function. J. Clin. Endocr. Metab., 69 1078, 1989. 25. Van Heerden, J. A., Sizemore, G. W., Carney, J. A, Brennan, M. D. and Sheps, S.G.: Bilateral subtotal adrenal resection for bilateral pheochromocytomas in multiple endocrine neoplasia, type Ila: a case report. Surgery, 98: 363,1985. 26. Hardy, J. D.: Surgical management of Cushing's syndrome with emphasis on adrenal autotransplantation. Ann. Surg., 188: 290, 1978. 27. Ott, R., Calandra, D., Prinz, R. A., Brooks, M. H., Lawrence, A. M. and Paloyan, E.: Successful adrenal autotransplantation in Cushing's disease. Surgery, 96:1054, 1984. 28. Xu, Y. M., Chen, Z.-D., Qiao, Y. and Jin, N.-T.: The value of adrenal autotransplantation with attached blood vessels for the treatment of Cushing's disease: a preliminary report. J. Urol., 147: 1209, 1992. 29. Demeter, J. G., De Jong, S. A., Brooks, M. H., Lawrence, A. M. and Paloyan, E.: Long-term results of adrenal autotransplantation in Cushing's disease. Surgery, 108: 1117, 1990.
Vol. 153,1196-1198,April 1995 Printed in U.S.A.
THE JOURNAL OF UROLOGY Copyright 8 1995 by AMERICANUROLOGICAL ~
U n O N INC. ,
Case Reports PARTIAL ADRENALECTOMY FOR RENAL CELL CARCINOMA WITH BILATERAL ADRENAL METASTASES N. SCOTT SCHOMER* AND JAMES L. MOHLER From the Division of Urology and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
ABSTRACT
Resection of the adrenal glands precludes participation in many immunotherapy protocols for metastatic renal cell carcinoma. We performed radical nephrectomy with adrenalectomy and contralateral partial adrenalectomy, including adrenal vein ligation for a 4 cm. hilar metastasis without perioperative complications or local recurrence after 30 months. Adrenal function, measured by cosyntropin stimulation tests 6 weeks and 10 months postoperatively, was normal. Partial adrenalectomy with preservation of adrenal function is possible. KEYWORDS:carcinoma, renal cell; adrenal gland neoplasms; kidney neoplasms, adrenalectomy
Adrenal metastases from renal cell carcinoma occur synchronously in approximately 2% of the cases of metastatic disease.’-7 Many physicians have reported the success of aggressive surgical approaches to solitary ipsilateral as well as contralateral adrenal metastases from renal cell carcinoma.215 In such cases the approach incorporates either sparing of the ipsilateral adrenal gland when normal on computerized tomography (CT) and the renal primary is in the lower pole or sacrifice of postoperative adrenal function by standard ipsilateral radical nephrectomy and contralateral adrenale~tomy.”’~“he absence of normal adrenal function precludes participation in many experimental protocols for treatment of metastatic renal cell carcinoma in which many informed patients may be interested. Primary renal cell carcinoma that presents with bilateral adrenal metastases is a management challenge not previously reported in the literature to our knowledge. Luciani et al reported a case of bilateral but metachronous adrenal metastases from renal cell carcinoma following radical nephrectomy.’6 Our management of synchronous bilateral adrenal metastases from renal cell carcinoma is described. We
performed standard radical nephrectomy , including ipsilatera1 adrenalectomy and contralateral partial adrenalectomy, for an adrenal metastasis. We sought to preserve adrenal function to allow our patient desired participation in immunotherapy protocols at the National Cancer Institute. CASE REPORT
A 42-year-old asymptomatic urologist had a right lower pole solid renal mass and bilateral adrenal masses by ultrasonic self-examination performed during an in office sales demonstration. Abdominal CT confirmed the finding of a 7 x 6 X 6 cm. right renal mass, a 6 X 5 X 5 cm. right adrenal mass and a 4 X 3 X 3 cm. left adrenal mass (figs. 1 and 2). Chest x-ray revealed a widened mediastinum. Chest CT showed extensive periaortic adenopathy from the retrocrural space to the aortic arch. Arteriography demonstrated hypervascularity of the 3 lesions. Both adrenal lesions were centrally located but the contralateral lesion appeared vascularized only by an adrenal artery from the aorta, whereas normal adrenal gland at each pole was supplied by other Accepted for ublication Au st 12, 1994. * Current adgess: Urology &up of New Mexico, St. Joseph West arteries. Preoperative diagnosis was right renal cell carciMesa Center, 4801 McMahon N. W., #225, Albuquerque, New Mexico noma with bilateral adrenal and mediastinal periaortic lymph node metastases (stage T4N3M1). 87114.
FIG. 1. A, CT shows 4 X 3 X 3 cm. solid left adrenal mass (arrows)and superior aspect of right adrenal mass. B, CT reveals 6 right solid adrenal mass (arrows). 1196
X
5
X
5 cm.
1197
PARTIAL ADRENALECTOMY
Headache returned and additional brain metastases were treated 14 months postoperatively with y-knife radiation at the University of Pittsburgh, and complete steroid replacement was begun. The patient received autolymphocyte therapy a t the Cellular Biocare Center, Boston, Massachusetts beginning 19 months postoperatively. Treatment was continued at Emory University, Atlanta, Georgia and disease was stable for 9 months. He remained without evidence of local recurrence upon multiple imaging studies and continued to practice urology until 2 weeks before death from renal cell carcinoma 30 months after the initial resection. DISCUSSION
Adrenal metastases result from antegrade hematogenous spread, or retrograde venous or lymphatic spread." These metastatic deposits confer a higher stage of tumor and portend a worse prognosis due to the uniformly poor response FIG.2. CT demonstrates heterogenous solid 7 X 6 X 6 em. right rate of this tumor to systemic chemotherapy. However, long mid renal mass (arrows). survivals from metastatic carcinoma have been described following resection of isolated pulmonary metastasis7." as well as solitary adrenal or liver metastases.3~~ ImmunotherBecause the patient was an otherwise healthy man, he apy shows romise for the treatment of metastatic renal cell wished to remain eligible for experimental protocols for treat- car~inoma!~~'~ However, adequate adrenal function is rement of metastatic renal cell carcinoma. Most protocols re- quired for most immunotherapy protocols to withstand the quired surgical debulking of tumor burden before immunother- physiological stress of the treatment regimen. In addition, apy. Maximal debulking, including bilateral adrenalectomy, surgical reduction of tumor burden may enhance response would have condemned him to steroid dependence, which would rates.23 Thus, for renal cell carcinoma with bilateral adrenal have excluded him from most available protocols. However, he metastases, an innovative approach is necessary to offer the wanted all accessible regional disease excised. Thus,after con- patient experimental treatment. Our case is significant for 3 reasons. 1)To our knowledge, siderable discussion, the patient chose to undergo right radical nephrectomy and partial leR adrenalectomy during the same subtotal adrenalectomy for bilateral adrenal metastates from operation through separate flank incisions. The incisional ap- renal cell carcinoma has not been reported, although it proach was selected by the patient to minimize postoperative should be feasible based upon treatment approaches for intrinsic adrenal disease. In situ evaluation or excision of bimorbidity. '~ Right radical nephrectomy was performed in a standard lateral pheochromocytoma has been r e p ~ r t e d . ~ * ,Autofashion without complications. Left partial adrenalectomy transplantation after subtotal adrenalectomy has produced was performed extrapleurally through a supra-11th rib inci- normal adrenal function in cases of Cushing's d i s e a ~ e . ~ ~2)- ' ~ sion. Gerota's fascia was entered and the adrenal gland con- Function of a solitary adrenal gland remained normal by taining a well circumscribed hilar mass was identified. The stimulation tests performed 6 weeks and 10 months postopadrenal vein and middle adrenal artery were ligated and eratively. f i r ligation of the adrenal vein, we expected divided, and the mass was excised. Approximately 60% of the venous congestion of the adrenal gland with subsequent left adrenal gland remained, with the superior pole supplied thrombosis. However, collateral venous drainage, perhaps by a branch of the left inferior phrenic artery and the lower via the leR phrenic vein, must have preserved adrenal viapole fragment supplied by a branch of the leR renal artery. bility. Simultaneous adrenal fragment autotransplantation The fragments were apposed and wrapped gently with peri- may provide a better chance of preservation of adrenal funcrenal fat before closure of Gerota's fascia and the flankinci- tion. A better choice of procedure might be possible if the existence and distribution of venous collaterals could be elusion. Histological examination of the resected specimens re- cidated preoperatively. 3)The goal of any surgical or medical vealed grade 3 clear cell renal cell carcinoma with bilateral procedure should be to improve the quality of life and duraadrenal metastases and negative surgical margins. Conva- tion of survival. The unpredictable natural history of renal lescence was uneventful. On postoperative day 1 a 2-hour cell carcinoma prohibits assessment of the effect upon surcosyntropin-stimulated cortisol level was 14.4 pg./dl. Since vival in this case. However, tumor burden was decreased and 95% of patients stimulated postoperatively to 19.6 pg./d.17 or adrenal function was preserved. Steroid replacement and its greater, he was discharged on postoperative day 3 on 5 mg. side effects were avoided until secondary adrenal failure resulted from brain metastases. Normal adrenal function prednisone each morning and 2.5 mg. each evening. The patient tapered the steroids postoperatively without allowed the patient to participate in experimental immunoincident and 40 days postoperatively a cosyntropin stimula- therapy. The patient suffered no apparent harm since tumor tion test performed at the National Institutes of Health did not recur locally. As immunotherapy continues to evolve for the treatment of yielded a 2-hour stimulated cortisol level of 22.1, consistent with normal adrenal function. The tumor progressed after 1 metastatic renal cell carcinoma, the preservation of adrenal cycle of interleukin-4 and the patient had a partial response function becomes more important. Our case demonstrates to 5 cycles of interleukin-2 that was discontinued when ad- that subtotal adrenalectomy for renal cell metastases can be renal insufficiency developed 10 months after the initial op- performed safely in select patients who may be candidates for eration. Cosyntropin stimulation tests were normal, which immunotherapy. Partial adrenalectomy may also be approsuggested adrenal insufficiency due to lack of pituitary-pro- priate in patients with metachronous adrenal metastasis duced adrenocorticotropic hormone. Visual changes and following contralateral radical nephrectomy or in patients headaches developed while awaiting test results, and cranial undergoing partial nephrectomy for renal cell carcinoma in a CT revealed a pituitary metastasis for which he underwent solitary kidney who have a n isolated ipsilateral adrenal metransphenoidal resection. tastasis.
PARTIAL ADRENALECTOMY
1198 REFERENCES
1. O'Brien, W. M. and Lynch, J. H.: Adrenal metastases by renal cell carcinoma: incidence at nephrectomy. Urology, 29 605, 1987. 2. Robey, E. L. and Schellhammer, P. F.: The adrenal gland and renal cell carcinoma: is ipsilateral adrenalectomy a necessary component of radical nephrectomy? J. Urol., 1 3 5 453, 1986. 3. Previte, S. R., Willscher, M. K and Burke, C. R.: Renal cell carcinoma with solitary adrenal metastasis: experience with 2 cases. J . Urol., 128: 132, 1982. 4. Foucar, E. and Dehner, L. P.: Renal cell carcinoma occurring with contralateral adrenal metastasis: a clinical and pathological trap. Arch. Surg., 114: 959, 1979. 5. Neal, P. M., Leach, G. E., Kaswick, J. A. and Lieber, M. M.: Renal cell carcinoma: recognition and treatment of synchronous solitary contralateral adrenal metastasis. J. Urol., 1 2 8 135, 1982. 6. Campbell, C. M., Middleton, R. G. and Rigby, 0. F.: Adrenal metastasis in renal cell carcinoma. Urology, 21: 403, 1983. 7. Tolia, B. M. and Whitmore, W. F., Jr.: Solitary metastasis from renal cell carcinoma. J. Urol., 114: 836, 1975. 8. O'Dea, M. J., Zincke, H., Utz, D. C. and Bernatz, P. E.: The treatment of renal cell carcinoma with solitary metastasis. J. Urol., 120: 540, 1978. 9. Seidenwurm, D. J., Elmer, E. B., Kaplan, L. M., Williams, E. K, Moms, D. G. and HofFmann, A. R.: Metastases to the adrenal glands and the development of Addison's disease. Cancer, 54: 552, 1984. 10. Masuda, F., Ohnishi, T., Higashi, Y., Ikemoto, I. and Machida, T.: Renal cell carcinoma with contralateral adrenal metastasis. Jap. J. Urol., 74: 2138, 1983. 11. Katsuoka,Y., Murakami, Y., Kawashima, T. and Shiramizu,M.: Contralateral adrenal metastasis in renal cell carcinoma. Jap. J. Urol., 7 5 1646, 1984. 12. Kondoh, N., Fujioka, H., Matsuda, M. and Takaha, M.: A case of renal cell carcinoma with contralateral adrenal metastasis. Acta Urol. Jap., 32 575,1986. 13. Hasegawa, J., Kanamori, S., Okumura, S., Yoshida, K., Abe, H. and Akimoto, M.: Renal cell carcinoma with solitary contralateral adrenal metastasis. Urology, 3 2 52, 1988. 14. Deodhar, S. D., Mehendale, V. G. and Bhave, G. G.: Renal cell carcinoma with unusual metastases. J. Postgrad. Med., 24:55, 1978. 15. Lemmers, M., Ward, K, Hatch, T. and Stenzel, P.: Renal adenocarcinoma with solitary metastasis to the contralateral adrenal gland report of 2 cases and review of the literature. J. Urol., 141: 1177, 1989. 16. Luciani, L., Scappini, P., F'usiol, T. and Rscioli, F.: Aspiration cytdogy of simultaneous bilateral adrenal metastases from
renal cell carcinoma. A case report and review of the literature. J. Urol., 134.315, 1985. 17. Mohler, J. L., Michael, K. A., Freedman, A. M., Griffen, W. 0.. Jr. and McRoberts, J. W.: The evaluation of postoperative function of the adrenal gland. Surg., Gynec. & Obst., 161: 445, 1985. 18. Erye, R. C., Balogh, K. and Bosco, P. J.: Renal cell carcinoma with solitary adrenal metastasis. Contemp. Surg., 41: 22, 1992. 19. Barney, J. D. and Churchill, E. J.: Adenocarcinoma of the kidney with metastasis to the lung: cured by nephrectomy and lobectomy. J. Urol., 42:269, 1939. 20. Wirth, M. P.: Immunotherapy for metastatic renal cell carcinoma. Urol. Clin. N. Amer., 2 0 283, 1993. 21. Sawczuk, I. H.: Autolymphocyte therapy in the treatment of metastatic renal cell carcinoma. Urol. Clin. N. Amer., 2 0 297, 1993. 22. Marshall, M. E., Mendelsohn, L., Butler, K., Riley, L., Cantrell, J., Wiseman, C., Taylor, T. and Macdonald, J. S.: Treatment of metastatic renal cell carcinoma with coumarin (1,a-benzopyrone) and cimetadine: a pilot study. J. Clin. Oncol., 5 862, 1987. 23. Robertson, C. N., Linehan, W. M., Pass, H. I., Gomella, L. G., Haas, G. P., Berman, A., Merino, M. and Rosenberg, S. A,: Preparative cytoreductive surgery in patients with metastatic renal cell carcinoma treated with adoptive immunotherapy with interleukin-2 or interleukin-2 plus lymphokine activated killer cells. J . Urol., 14& 614, 1990. 24. Birnbaum, J., Giuliano, A. and Van Herle, A. J.: Partial adrenalectomy for pheochromocytoma with maintenance of adrenocortical function. J. Clin. Endocr. Metab., 69 1078, 1989. 25. Van Heerden, J. A., Sizemore, G. W., Carney, J. A, Brennan, M. D. and Sheps, S.G.: Bilateral subtotal adrenal resection for bilateral pheochromocytomas in multiple endocrine neoplasia, type Ila: a case report. Surgery, 98: 363,1985. 26. Hardy, J. D.: Surgical management of Cushing's syndrome with emphasis on adrenal autotransplantation. Ann. Surg., 188: 290, 1978. 27. Ott, R., Calandra, D., Prinz, R. A., Brooks, M. H., Lawrence, A. M. and Paloyan, E.: Successful adrenal autotransplantation in Cushing's disease. Surgery, 96:1054, 1984. 28. Xu, Y. M., Chen, Z.-D., Qiao, Y. and Jin, N.-T.: The value of adrenal autotransplantation with attached blood vessels for the treatment of Cushing's disease: a preliminary report. J. Urol., 147: 1209, 1992. 29. Demeter, J. G., De Jong, S. A., Brooks, M. H., Lawrence, A. M. and Paloyan, E.: Long-term results of adrenal autotransplantation in Cushing's disease. Surgery, 108: 1117, 1990.