Moudouni S M, En-nia I, Manunta A, Guillé F, Lobel B
Department of Urology and Pathology, Hospital Pontchaillou, CHU Rennes, Morocco.
Int Urol Nephrol. 2003;35(2):141-7. doi: 10.1023/b:urol.0000020299.36091.33.
We determine the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluate the role of adrenalectomy as part of radical nephrectomy.
From 1993 to 1999, 210 patients with renal cell carcinoma (RCC), (139 men and 71 women, mean age 60.8 years, range 12-96) underwent radical nephrectomy with associated adrenalectomy. Patients were divided into two subgroups of 106 with localized (stage T1-2 tumor, groupl) and 104 with advanced (stage T3-4N01M01, group2) renal cell carcinoma. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared to postoperative histopathological results to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis.
Of the 210 patients, 15 (7.1%) had adrenal involvement. Tumor stage correlated with probability of adrenal spread, with T3-4 and T1-2 accounting for 13.4% and 0.9% of cases, respectively (p < 0.001). Upper pole intrarenal RCC most likely to spread was local extension to the adrenal gland, representing 53.3% of adrenal involvement. In contrast, multifocal, lower pole and mid region RCC tumors metastasized hematogenously, representing 21.4%, 7%, and 14% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 7.8 cm, range 4 to 21) and adrenal involvement was not statistically significant. Preoperative CT demonstrated 97.7% specificity, 98.4% negative predictive value, 87% sensitivity and 80% positive value for adrenal involvement by RCC.
Ipsilateral adrenalectomy should only be performed if a lesion is seen preoperatively on CT scan or if gross disease is seen at the time of nephrectomy. The prognosis is poor for RCC with ipsilateral involvement even with complete removal. Because of this poor prognosis we believe that adrenal involvement should constitute a separate stage category.
我们确定肾上腺受累在局限性和进展性肾细胞癌中的发生率及特征，并评估肾上腺切除术作为根治性肾切除术一部分的作用。
1993年至1999年，210例肾细胞癌患者（139例男性和71例女性，平均年龄60.8岁，范围12 - 96岁）接受了根治性肾切除术及相关肾上腺切除术。患者被分为两个亚组，106例局限性肾细胞癌（T1 - 2期肿瘤，第1组）和104例进展性肾细胞癌（T3 - 4N01M01期，第2组）。对术前腹部计算机断层扫描（CT）进行回顾性分析。随后将影像学检查结果与术后组织病理学结果进行比较，以评估肿瘤特征和影像学检查在确定肾上腺转移方面的预测价值。
210例患者中，15例（7.1%）有肾上腺受累。肿瘤分期与肾上腺转移概率相关，T3 - 4期和T1 - 2期分别占病例的13.4%和0.9%（p < 0.001）。肾上极肾内肾细胞癌最易发生的转移是局部侵犯肾上腺，占肾上腺受累的53.3%。相比之下，多灶性、下极和中部区域的肾细胞癌肿瘤通过血行转移，分别占肾上腺转移的21.4%、7%和14%。肾内肿瘤大小（平均7.8 cm，范围4至21 cm）与肾上腺受累之间的关系无统计学意义。术前CT对肾细胞癌肾上腺受累的特异性为97.7%，阴性预测值为98.4%，敏感性为87%，阳性预测值为80%。
仅当术前CT扫描发现病变或肾切除时发现肉眼可见病变时，才应进行同侧肾上腺切除术。即使完全切除，同侧受累的肾细胞癌预后也较差。鉴于这种不良预后，我们认为肾上腺受累应构成一个单独的分期类别。
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