title: Routine adrenalectomy in patients with locally advanced renal cell cancer does not offer oncologic benefit and places a significant portion of patients at risk for an asynchronous metastasis in a solitary adrenal gland.
abstract: BACKGROUND
  The indications for the removal of the ipsilateral adrenal gland in patients with renal cell carcinoma (RCC) and the long-term outcomes have not been well studied.
  
  
  OBJECTIVE
  We evaluated the risk of synchronous and asynchronous adrenal involvement in patients with RCC and the effect of adrenalectomy on recurrence and survival in a large, single-institution cohort.
  
  
  METHODS
  From 1970 to 2006, 4018 consecutive patients with RCC treated by surgical extirpation (radical nephrectomy [RN]: 3107; partial nephrectomy [PN]: 911) from Mayo Clinic were studied for adrenal involvement. Risk of asynchronous adrenal metastasis and cancer-specific survival (CSS) were also compared between those who underwent concomitant ipsilateral adrenalectomy (n = 1541) and those who did not (n = 2477) using multivariate Cox models.
  
  
  METHODS
  Surgical removal of the adrenal gland at the time of kidney tumor resection.
  
  
  METHODS
  Primary outcome is cancer specific survival; secondary outcomes are incidence of synchronous and asynchronous adrenal metastases.
  
  
  CONCLUSIONS
  Median postoperative follow-up among those still alive was 8.2 yr (interquartile range [IQR]: 5.3-13.6). Synchronous ipsilateral adrenal involvement was rare (n = 88; 2.2%). Ipsilateral adrenalectomy at the time of nephrectomy did not lower the risk of subsequent adrenal metastasis (hazard ratio [HR]: 0.96; 95% confidence interval [CI], 0.64-1.42) or improve CSS (HR: 1.08; 95% CI, 0.95-1.22). The development of asynchronous adrenal metastasis occurred in 147 patients (3.7%) at a median of 3.7 yr (IQR: 1.2-7.7) after initial surgery. The risk of developing an ipsilateral versus a contralateral asynchronous adrenal metastasis was equivalent at 10 yr in those who did not undergo adrenalectomy at initial surgery. This study is limited by its single-institution, nonrandomized nature.
  
  
  CONCLUSIONS
  Routine ipsilateral adrenalectomy in patients with high-risk features does not appear to offer any oncologic benefit while placing a significant portion of patients at risk for metastasis in a solitary adrenal gland. Therefore, adrenalectomy should only be performed with radiographic or intraoperative evidence of adrenal involvement.
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, MN 55905, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Weight
authors.forename: Simon P
authors.initials: SP
authors.lastname: Kim
authors.forename: Christine M
authors.initials: CM
authors.lastname: Lohse
authors.forename: John C
authors.initials: JC
authors.lastname: Cheville
authors.forename: R Houston
authors.initials: RH
authors.lastname: Thompson
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Boorjian
authors.forename: Bradley C
authors.initials: BC
authors.lastname: Leibovich
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D000315:Adrenalectomy / Q000009:adverse effects* / Q000401:mortality; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D016009:Chi-Square Distribution; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D009361:Neoplasm Invasiveness; D009392:Nephrectomy / Q000009:adverse effects / Q000401:mortality; D016016:Proportional Hazards Models; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult