Adrenalectomy: defining its role in the surgical treatment of renal cell carcinoma.

OBJECTIVES

With the recent widespread use of modern imaging techniques, the frequency of small low-stage renal cell carcinomas (RCC) has grown considerably, giving rise to more conservative surgical approaches. We evaluated the characteristics of adrenal involvement and the accuracy of computerized tomography (CT) in the diagnosis of RCC, defining the real need for adrenalectomy during surgical treatment.

METHODS

The medical records of 201 patients undergoing radical nephrectomy and ipsilateral adrenalectomy for localized or advanced RCC, from 1996 to 2002, were analyzed, retrospectively. We considered 76 with stage T1-2 disease and 125 with T3-4N0-1M0-1 disease. In all cases a blinded review of the preoperative abdominal CT was performed. Histopathology records of the surgical specimens were examined to determine the accuracy of the CT in identifying adrenal involvement by RCC.

RESULTS

The overall incidence of adrenal metastasis was 4.4%. The mean renal tumor size in patients with adrenal involvement was 7.8 cm. The tumor stage correlated with a probability of adrenal spread (p < 0.05), with T1-2 tumors accounting for 1.3% of cases only. The adrenal gland was diagnosed as abnormal on preoperative CT in 21 patients (10.4%). CT scan demonstrated 88.8% sensitivity, 92.1% specificity, 99.4% negative predictive value and 34.7% positive predictive value for adrenal involvement by RCC.

CONCLUSIONS

Adrenal involvement is not likely in patients with localized early stage RCC and adrenalectomy can be omitted in such cases, particularly when CT is negative. However, in selected patients with large high-risk tumors, radical nephrectomy, including removal of the ipsilateral adrenal gland, should be performed.