Japanese Journal of Clinical Oncology 30:414-416 (2000)
© 2000 Foundation for Promotion of Cancer Research
Adrenalectomy for Solitary Adrenal Metastasis from Colorectal Carcinoma
+Department of Surgery, The University of Tokyo Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONSREFERENCES |
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A 60-year-old man underwent anterior resection for advanced rectal carcinoma. Seven years and 2 months later, right lower pneumonectomy was performed for a metastatic lung tumor. Two years and 2 months thereafter, left adrenalectomy was performed for solitary adrenal metastasis. The patient remained disease-free for 10 months postoperatively, until multiple lung metastases appeared. The patient is alive and well, under mild chemotherapy with oral doxifluridine, 3 years and 5 months after left adrenalectomy. We conclude that patients with solitary adrenal metastasis may benefit from surgical resection and that resection could be considered as a therapy for solitary adrenal metastasis from colorectal carcinoma.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONSREFERENCES |
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Adrenal metastasis is reported to be frequently found at autopsy and is usually accompanied by progressive systemic disease. Patients with adrenal metastases from various primary tumors have been regarded as a part of diffuse systemic spread and have been regarded as having no indication for surgical resection.
Solitary adrenal metastasis from colorectal carcinoma is relatively rare. As far as we have elicited, 17 previously reported cases have undergone resection (1–9). We report here a case of solitary left adrenal metastasis resected 9 years after resection for advanced rectal carcinoma and a review of the relevant literature.
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CASE REPORT |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONSREFERENCES |
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A 60-year-old man underwent anterior resection for rectal carcinoma on May 15, 1987; the lesion was a type 2 tumor, 4.0 x 3.5 cm in size, located in the rectosigmoid colon. Microscopic examination showed moderately differentiated adenocarcinoma infiltrating to the subserosal layer, with moderate lymphatic permeation but no vascular permeation and metastases to three of 35 dissected lymph nodes.
Seven years after the primary operation, chest X-ray examination detected a coin lesion in his right lung and computed tomography (CT) showed a tumor 5 cm in diameter in the right lower lobe of the lung. The serum carcinoembryonic antigen (CEA) level was increased to 8.4 ng/ml, the normal value being <5.0 ng/ml. Right lower pneumonectomy was performed on August 3, 1994; the tumor size was 5.5 x 4 x 3 cm and microscopic examination showed moderately differentiated adenocarcinoma, with moderate lymphatic and vascular permeations, compatible with a metastasis from the rectal carcinoma and metastases to three of 14 dissected lymph nodes. The patient was started on adjuvant chemotherapy of orally administered UFT, three capsules/day, each capsule containing 100 mg of tegafur and 224 mg of uracil. His serum CEA level decreased to 2.9 ng/ml 6 months postoperatively.
However, the serum CEA level again increased to 18.2 ng/ml 1 year after the right lower pneumonectomy. A total colonoscopy showed no sign of local recurrence. An abdominal CT scan detected a left adrenal mass 3 cm in diameter. The chemotherapy was changed to oral 5'-doxifluridine (5'-DFUR, Furtulon), 1200 mg/day, five days a week. Six months later, a CT scan showed that the left adrenal mass had grown to 6 cm in size, without evident signs of metastases to other organs (Fig. 1). The serum CEA level was elevated to 24.0 ng/ml. Since chest and abdominal CT scans showed no sign of other metastatic diseases, resection was considered. Left adrenalectomy through a thoracoabdominal approach was performed on October 9, 1996.
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Macroscopically the tumor was well encapsulated, 6.1 x 4.7 x 3.2 cm in size, and its cross-section showed that nearly all the left adrenal gland had been replaced by a yellowish tumor (Fig. 2). Microscopic examination showed adenocarcinoma, compatible with recurrence of the rectosigmoid carcinoma.
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Adjuvant chemotherapy was performed with an intravenous bolus of mitomycin C, 10 mg, on the 14th postoperative day and oral 5'-DFUR, 1200 mg/day 5 days a week, thereafter. The patient’s serum CEA level decreased to 4.6 ng/ml 1 month postoperatively.
The patient remained disease-free for 10 months postoperatively, until a chest CT scan in August 1997 detected small coin lesions in his lung. His serum CEA level began to rise again, the value being 49.0 ng/ml by February 8, 2000. The patient is still alive and well, 12 years and 10 months after the primary operation or 3 years and 5 months after the left adrenalectomy.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONSREFERENCES |
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Adrenal metastasis from colorectal carcinoma is usually a part of the systemic spread and leads to a poor prognosis.
Lo et al. (9) reported 52 resected cases of adrenal metastases from various origins and showed that patients with potentially curative resection had a better survival rate than those who had a palliative resection. They concluded that surgical resection for adrenal metastasis may result in survival benefit in selected patients.
Other than the report by Lo et al., there have been 10 cases that have undergone resection (1–8). Table 1 describes the 10 previously reported resected cases of solitary adrenal metastasis from colorectal carcinoma and the present case. The following analyses were made for the 11 cases, whose clinicopathological data have been described in detail in the literature.
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In two cases the metastasis was synchronous and in nine it was metachronous. Ten cases had a metastatic tumor in the unilateral adrenal gland and one to the bilateral (at a different period).
Four cases, including ours, had developed asynchronous solitary lung metastasis, each of which was resected, before the adrenal metastasis. The mean duration between the primary operation and the lung metastasis was 51 months (range 23–86 months, SD 26 months). As for cases with asynchronous adrenal metastases, the interval between the primary resection and adrenalectomy tends to be longer in cases that had prior asynchronous lung metastases (mean 73.5 months, range 33–106 months, SD 33.4 months) than in cases without prior lung metastases (mean 21.4 months, range 14–37 months, SD 9.6 months). This might suggest a route of hematogenous metastasis from the primary lesion via the lung to the adrenal gland. These data also suggest the importance of long-term follow-up of colorectal carcinoma patients after resection; the physician should be alert to the increased risk of adrenal metastasis, especially after the resection of lung metastasis.
In all cases the metastatic adrenal tumors were confirmed by CT scan. At the time of adrenal metastasis, the patients’ serum CEA levels were elevated in 10 of the 11 cases (91%). In nine of the ten cases (90%) the serum CEA levels decreased considerably after adrenalectomy. In one case, the serum CEA level still remained elevated after left adrenalectomy and the CT scan showed a tumor in the contralateral side. The serum CEA level and CT scan are valid predictors of recurrence.
The follow-up period of the 11 patients after the resection of adrenal metastasis ranged from 4 months to 9 years. Three patients died of recurrence 4–33 months (mean 22.7 months, SD 16.2 months) after resection of adrenal metastasis. Three cases showed recurrence 8–13 months after adrenalectomy, but were still alive at the time of the report. Five of the 11 patients were alive without signs of recurrence 8 months–9 years after adrenalectomy (with a mean follow-up period of 33.5 months). These data suggested that resection of solitary adrenal metastasis from colorectal carcinoma may improve selected cases’ chances of survival. We conclude that resection could be considered as a therapy for solitary adrenal metastasis from colorectal carcinoma.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONSREFERENCES |
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Surgical resection may result in survival benefit in selected patients with solitary adrenal metastasis from colorectal carcinoma. Resection could be considered as a therapy for solitary adrenal metastasis from colorectal carcinoma. A hematogenous route of metastasis from colorectal carcinoma via the lung to the adrenal gland is suggested.
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FOOTNOTES |
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+ For reprints and all correspondence: Atom Katayama, Second Department of Surgery, Faculty of Medicine, The University of Tokyo, 7–3–1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail: katayama-2su@h.u-tokyo.ac.jp
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REFERENCES |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONCONCLUSIONSREFERENCES |
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1 Fujii H, Iino H, Miyasaka Y, Honda Y, Okuda J, Iimuro Y, et al. Adrenal metastasis from carcinoma of the colon. Report of a resected case with a long survival. Nippon Daicho Komonbyo Gakkai Zasshi 1994;47:582–8 (in Japanese).
2 Fujita K, Kameyama S, Kawamura M. Surgically removed adrenal metastasis from cancer of the rectum. Report of a case. Dis Colon Rectum 1988;31:141–3.[Medline]
3 Kamasako A, Kawamoto S, Tanaka R, Shibasaki S, Murakami A. A successfully resected case of colonic cancer with synchronous adrenal metastasis. Nippon Shokaki Geka Gakkai Zasshi 1995;28:2308–11 (in Japanese).
4 Matsui A, Nakata M, Sakabe H, Usui T, Takahashi T, Minamisato K. A case of solitary adrenal metastasis from rectal carcinoma. Nippon Shokaki Geka Gakkai Zasshi 1985;18:506 (in Japanese).
5 Mizutani S, Maruta M, Miyajima Y, Kuromizu J, Utumi T, Tohyama K, et al. A case of adrenectomy for the metastasis of the right adrenal gland after curative operation of rectal cancer. Nippon Daicho Komonbyo Gakkai Zasshi 1995;48:330–5 (in Japanese).
6 Ozawa M, Ochiai K, Fujita M, Moriya H, Ohyama H, Shindo G, et al. A resected case of solitary adrenal metastasis from carcinoma of the colon. Nippon Shokaki Geka Gakkai Zasshi 1996;29:1825–9 (in Japanese).
7 Sakagawa T, Kihara S, Kinoshita S, Kobayashi N, Kuzuhara Y. Resected case of adrenal metastasis of a rectal cancer. Nippon Geka Gakkai Zasshi 1995;56:1436–40 (in Japanese).
8 Watatani M, Ooshima M, Wada T, Terashita H, Matsuda T, Shindo K, et al. Adrenal metastasis from carcinoma of the colon and rectum: a report of three cases. Surg Today 1993;23:444–8.[Medline]
9 Lo CY, van Heerden JA, Soreide JA, Grant CS, Thompson GB, Lloyd RV, et al. Adrenalectomy for metastatic disease to the adrenal glands. Br J Surg 1996;83:528–31.[Medline]
Received April 3, 2000; accepted July 13, 2000.
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