• Juan J. Sancho 1

• Frédéric Triponez 2

• Xavier Montet 3

• Antonio Sitges-Serra 1

(1) Endocrine Unit. Hospital del Mar. Universitat Autònoma de Barcelona. Barcelona. Spain.

(2) Chirurgie thoracique et endocrinienne. Hôpitaux Universitaires de Genève. Genève. Switzerland.(3) Department of Radiology. Hôpitaux Universitaires de Genève. Genève. Switzerland.

Surgical Managementof Adrenal Metastases

• Introduction• Prevalence• Origin• Clinical manifestations

• Imaging techniques

• Percutaneous biopsy

• Surgical Treatment• Indications• Prognosis• Approach

• Non Surgical options

Surgical Managementof Adrenal Metastases

• Introduction• Prevalence• Origin• Clinical manifestations

• Imaging techniques

• Percutaneous biopsy

• Surgical Treatment• Indications• Prognosis• Approach

• Non Surgical options

Surgical Managementof Adrenal Metastases

The dimensions of the Problem

Where do they come from ?

When we have to be alert ?

10% to 27% of patients dying from cancer

•PrevalenceIntroduction

The dimensions of the Problem

Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer 1950;3(1):74-85.

•PrevalenceIntroduction

The dimensions of the Problem

Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer 1950;3(1):74-85.

•PrevalenceIntroduction

The dimensions of the Problem

Adenoma41%

Metastases19%

Adrenocortical carcinoma

10%

Myelolipoma9%

Pheochromocytoma8%

Other13%

Distribution of diagnosed adrenal masses

•Prevalence

Why?

– Multiple arterial supply

– Intricate lymphatic network

– Rich sinusoidal blood flow

Introduction

The dimensions of the Problem

Introduction• Prevalence• Origin

Where do they come from ?

LUNG29%

BREAST26%

SKIN14%

KIDNEY10%

LIVER7%

GI TRACT6%

SOFT TISSUES3%

OTHER5%

Where do they come from ?

Lam KY, Lo CY. Metastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital. Clin Endocrinol (Oxf). 2002;56:95-101.

Introduction• Prevalence• Origin

Introduction

Where do they come from ?

• Prevalence• Origin

Onuigbo WI. Lymphangiogenesis may explain adrenal selectivity in lung cancer metastases. Med Hypotheses 2010;75:185-6.

Introduction

When must we be alert?

• Prevalence• Origin• Clinical manifestations

95 % clinically silent

Introduction

When must we be alert?

• Prevalence• Origin• Clinical manifestations

95 % clinically silent

Pain- Hemorrage ?

- Melanoma ?

Adrenal insufficiency- Occasionally Addisonian crisis

- Must be bilateral

- May be masked in advanced malignancies

Bretcha-Boix P et al. Surgical treatment of lung cancer with adrenal metastasis. Lung Cancer 2000;27:101-5.

Incidentaloma

in a non*

CancerPatient

AM in a

CancerPatient

Imagein a

CancerPatient

Introduction• Prevalence• Origin• Clinical manifestations

1. Is it a metastasis?

2. Is it the only one?

1. Is it the only one?

1. Is it hypersecreting?

2. Is it malignant?

3. Is it a metastasis?

Incidentaloma

in a non*

CancerPatient

Introduction• Prevalence• Origin• Clinical manifestations

1. Is it hypersecreting?

2. Is it malignant?

3. Is it a metastasis?

Lee JE et al. Unknown primary cancer presenting as an adrenal mass: frequency and implications for diagnostic evaluation of adrenal incidentalomas. Surgery 1998;124:1115-22.

1715 referrals for suspected unknown

primary cancer

76

NO cancer1693Cancer

95 (5.8%)

AM

• 4 (0.2%) AM only

• 4/4 >6 cm

• 3/4 bilateral

• 4/4 symptoms

Incidentaloma

in a non*

CancerPatient

AM in a

CancerPatient

Imagein a

CancerPatient

Introduction• Prevalence• Origin• Clinical manifestations

1. Is it a metastasis?

2. Is it the only one?

1. Is it the only one?

1. Is it hypersecreting?

2. Is it malignant?

3. Is it a metastasis?

Management Plan

Incidentaloma

in a non*

CancerPatient

AM in a

CancerPatient

Imagein a

CancerPatient

Introduction• Prevalence• Origin• Clinical manifestations