Resection of Solitary Adrenal Metastases from NSCLC Improves Survival
Resection of Solitary Adrenal Metastases from NSCLC Improves Survival
Abstract & CommentarySynopsis: The presence of adrenal metastases should not make a patient with a resectable primary lesion ineligible for an attempt at curative surgery. In this small series of 14 patients, three of eight patients who underwent simultaneous lung and adrenal resection were long-term survivors.
Source: Luketich JD, Burt ME. Ann Thorac Surg 1996;62:1614-1616.
More than 170,000 americans will develop lung cancer this year, and because this tumor is rarely localized at presentation, we will be challenged regularly with the management of metastatic disease. Although chemotherapy has improved markedly with the approval of the taxanes, gemcitabine, and topoisomerase inhibitors, the major curative modality remains the surgeon and his/her knife. Thus, it seems logical to try and use surgery whenever it is reasonable. However, how reasonable is it to perform surgery on patients with metastatic non-small cell lung cancer (NSCLC)? The literature would suggest that it is definitely reasonable in certain circumstances. For example, a randomized trial has shown that surgical resection of intracranial metastases improves survival.1 Luketich et al have analyzed the Memorial Sloan Kettering Cancer Center experience of surgical resection of solitary, nonadrenal and adrenal extracranial metastases. Only small numbers of patients were treated (14 in both cases), but it appeared that surgery led to a significant chance of five-year survival (in carefully selected patients). Fully 80% of patients with nonadrenal metastases survived five years.2 In their study of 14 patients with solitary adrenal metastases, Luketich et al resected the adrenal mass and primary lung tumor in eight patients after two cycles of cisplatin-based chemotherapy while six patients received chemotherapy alone (usually three cycles). The median survival was 8.5 months for patients receiving chemotherapy alone and 31 months if they had surgery. Three of eight patients who underwent surgery remain alive, although only one has reached the five-year mark, whereas all patients treated with chemotherapy alone died in less than two years. The authors suggest that surgery be considered for carefully staged patients with good performance status who have a resectable primary NSCLC and a solitary adrenal metastasis.COMMENT
Adrenal metastases are fairly common in patients with NSCLC, common enough at our institution to require all chest CTs performed for lung cancer to include a few cuts below the diaphragm so the adrenal glands can be evaluated. In approximately 4% of patients, one adrenal gland is the sole site of metastatic disease. At our tumor board, we would conclude that this patient had metastatic disease, no surgery would be scheduled, and the patient would be referred for chemotherapy, or,, increasingly in this age of managed care, not referred to an oncologist at all and merely sent home. Hospice may be the right choice for many of our patients with stage IV NSCLC but certainly not for all. There is no disease viewed with more cynicism by our primary care doctors than lung cancer, with the possible exception of pancreatic cancer. Although the reputation is largely deserved, we have to be careful not to paint everyone with the same brush. If we do we will miss the occasional patients who might experience great benefit from individualized therapy. We are overly aggressive with combination chemotherapy for Stage IV NSCLC, but we do feel that there are patients who are likely to benefit and have tried to convince our referring pulmonologists and primary care gatekeepers of this fact. Perhaps we should also be trying to expand the role of our most effective weapon against NSCLC, surgery. Neither this study, nor the other 16 published cases reviewed by the authors, was randomized and, therefore, each is subject to a variety of criticisms. Patients were selected and it is likely that the patients with the smallest tumor burden and those in the best overall shape were selected for surgery. Nevertheless, some patients have survived five years without disease recurrence following surgery. It would be a great challenge for a medical oncologist to find a similar patient treated with chemotherapy. Surgery is often performed for isolated metastases in patients with sarcoma, colorectal, and renal cell cancer. Given the terrible prognosis of this disease and the small number of patients who present with solitary adrenal metastases, we think it is reasonable to give the patient the benefit of the doubt and perform the surgery.References
1. Patchell RA, et al. N Engl J Med 1990;322:494-500.2. Luketich JD, et al. Ann Thorac Surg 1995;60:1609-1611.
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