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Ann Thorac Surg 1996;62:1614-1616
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Does Resection of Adrenal Metastases From Non–Small Cell Lung Cancer Improve Survival?

Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York

Accepted for publication June 26, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Metastatic non–small cell lung cancer (NSCLC) carries a dismal prognosis, which is minimally affected by chemotherapy. Solitary brain metastases from NSCLC have been resected with 5-year survivals of 10% to 30%. The objective of this study was to determine if resection of isolated adrenal metastases improves survival.

Methods. Isolated adrenal metastases were found in 14 patients with NSCLC. Eight patients had resection after cis-platinum–based chemotherapy, and 6 received chemotherapy alone.

Results. Median survival in the surgical group was significantly greater than that in the chemotherapy group (31 versus 8.5 months; p = 0.03). All patients in the chemotherapy group were dead by 22 months. Three-year actuarial survival in the surgical group was 38%. No difference in locoregional stage, size of adrenal metastases, patient age, or performance status was present between the two groups.

Conclusions. Long-term disease-free survival is possible after resection of isolated adrenal metastases from NSCLC. Resection of isolated adrenal metastases should be considered if the primary NSCLC is resectable.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Metastases from non–small cell lung cancer (NSCLC) are generally multiple, disseminated, and associated with a poor outcome. In a minority of patients, only a solitary site of metastasis can be identified. In a review of more than 2,500 patients with metastatic disease from NSCLC, 7% presented with a solitary metastases [1]. The treatment of this subset of patients with limited metastatic spread from NSCLC remains controversial. Recent reports of resection of brain metastases [2–4] and other solitary sites [5] suggest that some patients may benefit from aggressive surgical resection in selected cases.

The adrenal gland is a common site of metastases from NSCLC. It is estimated that up to 4% of patients with an otherwise operable NSCLC will have a unilateral adrenal mass; up to 40% of these may be malignant and present as a solitary site of metastasis [6]. A number of case studies of resection of adrenal metastases have been reported [7–10]. The objective of this study was to compare the outcome of patients with a solitary adrenal metastasis from a primary NSCLC who were treated by chemotherapy alone versus chemotherapy followed by resection.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
We performed a retrospective review of patients with the diagnosis of NSCLC and a solitary adrenal metastasis who presented to Memorial Sloan Kettering Cancer Center from 1987 to 1993. Eligibility criteria included a resectable primary NSCLC, a solitary adrenal metastasis, good performance status (Eastern Cooperative Oncology Group class 0 or 1), no history of other malignancies, and an otherwise negative metastatic survey. Patients were selected for chemotherapy alone or chemotherapy followed by surgical resection of both the lung cancer and the adrenal metastasis. The chemotherapy included mitomycin, vinblastine, and cis-platinum. Treatment decisions were made according to patient and attending physician preference.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Fourteen patients treated for an isolated adrenal metastasis were identified. All adrenal metastases in the current series were detected during the workup of the primary lung cancer. The adrenal metastases were verified by histologic review of percutaneous needle biopsy or open biopsy specimens. There was no difference in age, sex, performance status, tumor histology, or size of adrenal metastasis between the two groups (Table 1). There was no significant difference in the locoregional stage of the primary NSCLC between the two groups (Table 2).

The median survival in the group treated with chemotherapy alone was 8.5 months, compared with 31 months in the group with chemotherapy followed by surgical resection (p = 0.03) (Fig 1). All patients treated with chemotherapy alone were dead by 21 months. In the surgical group, 3 patients are alive at 3, 21, and 61 months.

View larger version (12K): [in this window] [in a new window]   Fig 1. . Kaplan-Meier survival curve demonstrating a 3-year actuarial survival in the chemotherapy followed by operation group of 38%. Median survival was 31 months in the chemotherapy/operation group compared with 8.5 months in the chemotherapy-alone group (p = 0.03).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

In the presence of a well-controlled or completely resectable primary lung cancer and a negative extensive metastatic workup, surgical removal of a synchronous or metachronous, solitary brain metastasis yields 5-year survival rates ranging from 10% to 30% (Table 3). In a randomized trial, Patchell and associates [3] compared surgical resection plus radiotherapy to radiotherapy alone for single brain metastasis from many primary sites, the majority being from lung. The surgical resection group lived longer, had fewer recurrences of cancer in the brain, and had a better quality of life compared with the radiotherapy-alone group. We recently reported the outcome of 185 patients undergoing resection of brain metastases from NSCLC at Memorial Sloan Kettering Cancer Center [2]. The overall survival rates were as follows: 1 year, 55%; 2 years, 27%; 3 years, 18%; 5 years, 13%; and 10 years, 7%. Complete resection of the primary lung cancer was the major determinant of survival in patients undergoing resection of brain metastases.

The adrenal gland is another frequent site of metastases from NSCLC. Autopsy data show that adrenal metastases occur in about one-third of all patients dying of NSCLC. Routine abdominal computed tomographic scans during staging of NSCLC reveal adrenal metastases in 5% to 10% of patients [6, 11, 12]. The incidence may be higher because computed tomographic scanning has a low sensitivity for the detection of metastases in normal-sized glands [13–15]. It has generally been thought that adrenal metastases preclude any further surgical intervention and a universally poor outcome can be expected. However, case studies totaling 16 patients have been reported where surgical resection of an isolated adrenal metastasis was performed [7–10]. A summary of these case reports demonstrates that selected patients with an isolated adrenal metastasis can undergo resection with a reasonable long-term survival (Fig 2).

View larger version (9K): [in this window] [in a new window]   Fig 2. . Summary of reported cases (n = 16) of patients with non–small cell lung cancer and a solitary adrenal metastasis who underwent surgical resection of both lesions.

The current study suggests that a surgical approach should be considered in patients with a solitary adrenal metastasis from NSCLC. Based on our experience and a review of reported cases, 5-year survival rates of 25% to 40% may be seen in selected series. Prerequisites for this consideration are complete control of the primary lung cancer, an extensive metastatic survey revealing only a solitary site of metastasis, and good performance status.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Doctor Luketich's current address is Section of Thoracic Surgery, University of Pittsburgh Medical Center, 300 Kaufmann Bldg, 3471 Fifth Ave, Pittsburgh, PA 15213-3221.

Address reprint requests to Dr Burt, Thoracic Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10021.

This article has been selected for the open discussion forum on the STS Web site:

http://www.sts.org/annals

The discussion leaders for this article are Dr John Benfield, Sacramento, CA; Dr Harvey Pass, Bethesda, MD; and Dr Thomas Shields, Chicago, IL.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Albain KS, Crowley JJ, LeBlanc M, Livingston RB. Survival determinants in extensive-stage non–small-cell lung cancer: the Southwest Oncology Group experience. J Clin Oncol 1991;9:1618–26.[Abstract]
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3. Patchell RA, Tibbs PA, Walsh JW, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990;322:494–500.[Abstract]
4. Read RC, Boop WC, Yoder G, Schaefer R. Management of non–small cell lung carcinoma with solitary brain metastases. J Thorac Cardiovasc Surg 1989;98:884–91.[Abstract]
5. Luketich JD, Martini N, Ginsberg RJ, Rigberg D, Burt ME. Successful treatment of solitary extracranial metastases from non–small cell lung cancer. Ann Thorac Surg 1995;60:1609–11.
6. Burt ME, Heelan R, Coit D, McCormack PM, Ginsberg RJ. Prospective evaluation of unilateral adrenal metastases in patients with operable non–small cell lung cancer: impact of magnetic resonance imaging. J Thorac Cardiovasc Surg 1995;107:584–9.
7. Twomey P, Montgomery C, Clark O. Successful treatment of adrenal metastases from large-cell carcinoma of the lung. JAMA 1982;248:581–3.[Abstract]
8. Raviv G, Klein E, Yellin A, Schneebaum S, Ben-Ari G. Surgical treatment of solitary adrenal metastases from lung carcinoma. J Surg Oncol 1990;43:123–4.[Medline]
9. Reyes L, Parvez Z, Nemoto T, Regal AM, Takita H. Adrenalectomy for adrenal metastases from lung carcinoma. J Surg Oncol 1990;44:32–4.[Medline]
10. Higashiyama M, Doi O, Kodama K, Yokouchi H, Imaoka S, Koyama H. Surgical treatment of adrenal metastasis following pulmonary resection for lung cancer: comparison of adrenalectomy with palliative therapy. Int J Surg 1994;79:124–9.
11. Nielsen ME Jr, Heaston DK, Kunnick NR, Korobkin M. Preoperative CT evaluation of adrenal glands in non–small cell bronchogenic carcinoma. AJR 1982;139:317–20.[Abstract/Free Full Text]
12. Sandler MA, Paerlberg JL, Madrazo BL, et al. Computed tomographic evaluation of the adrenal gland in the preoperative assessment of bronchogenic carcinoma. Radiology 1982;145:733–6.[Free Full Text]
13. Allard P, Yankaskas BC, Fletcher RH, et al. Sensitivity and specificity of computed tomography for the detection of adrenal metastatic lesions among 91 autopsied lung cancer patients. Cancer 1990;66:457–62.[Medline]
14. Ettinghausen SE, Burt ME. Prospective evaluation of unilateral adrenal masses in patient with operable non–small cell lung cancer. J Clin Oncol 1991;9:462–6.
15. Oliver TW, Bernardino ME, Miller JI, et al. Isolated adrenal masses in non–small cell bronchogenic carcinoma. Radiology 1984;153:217–8.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James D. Luketich Michael E. Burt Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Luketich, J. D. Articles by Burt, M. E. Search for Related Content PubMed PubMed Citation Articles by Luketich, J. D. Articles by Burt, M. E.