Jpn J Clin Oncol 2000;30(9)414416

2000 Foundation for Promotion of Cancer Research

Adrenalectomy for Solitary Adrenal Metastasis from Colorectal
Carcinoma
Atom Katayama, Ken-ichi Mafune and Masatoshi Makuuchi
Department of Surgery, The University of Tokyo Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Received April 3, 2000; accepted July 13, 2000
For reprints and all correspondence: Atom Katayama, Second Department of
Surgery, Faculty of Medicine, The University of Tokyo, 731 Hongo,
Bunkyo-ku, Tokyo 113-8655, Japan. E-mail: katayama-2su@h.u-tokyo.ac.jp
A 60-year-old man underwent anterior resection for advanced rectal carcinoma. Seven years
and 2 months later, right lower pneumonectomy was performed for a metastatic lung tumor.
Two years and 2 months thereafter, left adrenalectomy was performed for solitary adrenal
metastasis. The patient remained disease-free for 10 months postoperatively, until multiple
lung metastases appeared. The patient is alive and well, under mild chemotherapy with oral
doxifluridine, 3 years and 5 months after left adrenalectomy. We conclude that patients with
solitary adrenal metastasis may benefit from surgical resection and that resection could be con-
sidered as a therapy for solitary adrenal metastasis from colorectal carcinoma.
Key words: solitary adrenal metastasis colorectal carcinoma lung metastasis adrenalectomy
long-term survival
INTRODUCTION
Adrenal metastasis is reported to be frequently found at
autopsy and is usually accompanied by progressive systemic
disease. Patients with adrenal metastases from various primary
tumors have been regarded as a part of diffuse systemic spread
and have been regarded as having no indication for surgical
resection.
Solitary adrenal metastasis from colorectal carcinoma is
relatively rare. As far as we have elicited, 17 previously
reported cases have undergone resection (19). We report here
a case of solitary left adrenal metastasis resected 9 years after
resection for advanced rectal carcinoma and a review of the
relevant literature.
CASE REPORT
A 60-year-old man underwent anterior resection for rectal
carcinoma on May 15, 1987; the lesion was a type 2 tumor, 4.0
3.5 cm in size, located in the rectosigmoid colon. Micro-
scopic examination showed moderately differentiated adeno-
carcinoma infiltrating to the subserosal layer, with moderate
lymphatic permeation but no vascular permeation and metas-
tases to three of 35 dissected lymph nodes.
Seven years after the primary operation, chest X-ray exami-
nation detected a coin lesion in his right lung and computed
tomography (CT) showed a tumor 5 cm in diameter in the right
lower lobe of the lung. The serum carcinoembryonic antigen
(CEA) level was increased to 8.4 ng/ml, the normal value
being <5.0 ng/ml. Right lower pneumonectomy was performed
on August 3, 1994; the tumor size was 5.5 4 3 cm and
microscopic examination showed moderately differentiated
adenocarcinoma, with moderate lymphatic and vascular
permeations, compatible with a metastasis from the rectal
carcinoma and metastases to three of 14 dissected lymph
nodes. The patient was started on adjuvant chemotherapy of
orally administered UFT, three capsules/day, each capsule
containing 100 mg of tegafur and 224 mg of uracil. His serum
CEA level decreased to 2.9 ng/ml 6 months postoperatively.
However, the serum CEA level again increased to 18.2 ng/ml
1 year after the right lower pneumonectomy. A total colon-
oscopy showed no sign of local recurrence. An abdominal CT
scan detected a left adrenal mass 3 cm in diameter. The chemo-
therapy was changed to oral 5-doxifluridine (5-DFUR,
Furtulon), 1200 mg/day, five days a week. Six months later, a
CT scan showed that the left adrenal mass had grown to 6 cm in
size, without evident signs of metastases to other organs (Fig. 1).
The serum CEA level was elevated to 24.0 ng/ml. Since chest
and abdominal CT scans showed no sign of other metastatic
diseases, resection was considered. Left adrenalectomy through
a thoracoabdominal approach was performed on October 9,
1996.
Macroscopically the tumor was well encapsulated, 6.1 4.7
3.2 cm in size, and its cross-section showed that nearly all the
left adrenal gland had been replaced by a yellowish tumor
(Fig. 2). Microscopic examination showed adenocarcinoma,
compatible with recurrence of the rectosigmoid carcinoma.
Jpn J Clin Oncol 2000;30(9) 415
Adjuvant chemotherapy was performed with an intravenous
bolus of mitomycin C, 10 mg, on the 14th postoperative day
and oral 5-DFUR, 1200 mg/day 5 days a week, thereafter. The
patients serum CEA level decreased to 4.6 ng/ml 1 month
postoperatively.
The patient remained disease-free for 10 months postopera-
tively, until a chest CT scan in August 1997 detected small
coin lesions in his lung. His serum CEA level began to rise
again, the value being 49.0 ng/ml by February 8, 2000. The
patient is still alive and well, 12 years and 10 months after the
primary operation or 3 years and 5 months after the left adrena-
lectomy.
DISCUSSION
Adrenal metastasis from colorectal carcinoma is usually a part
of the systemic spread and leads to a poor prognosis.
Lo et al. (9) reported 52 resected cases of adrenal metastases
from various origins and showed that patients with potentially
curative resection had a better survival rate than those who had
a palliative resection. They concluded that surgical resection
for adrenal metastasis may result in survival benefit in selected
patients.
Other than the report by Lo et al., there have been 10 cases
that have undergone resection (18). Table 1 describes the 10
previously reported resected cases of solitary adrenal metas-
tasis from colorectal carcinoma and the present case. The
following analyses were made for the 11 cases, whose clinico-
pathological data have been described in detail in the literature.
In two cases the metastasis was synchronous and in nine it
was metachronous. Ten cases had a metastatic tumor in the
unilateral adrenal gland and one to the bilateral (at a different
period).
Four cases, including ours, had developed asynchronous
solitary lung metastasis, each of which was resected, before the
adrenal metastasis. The mean duration between the primary
operation and the lung metastasis was 51 months (range 2386
months, SD 26 months). As for cases with asynchronous
adrenal metastases, the interval between the primary resection
and adrenalectomy tends to be longer in cases that had prior
asynchronous lung metastases (mean 73.5 months, range 33
106 months, SD 33.4 months) than in cases without prior lung
metastases (mean 21.4 months, range 1437 months, SD 9.6
months). This might suggest a route of hematogenous metas-
tasis from the primary lesion via the lung to the adrenal gland.
These data also suggest the importance of long-term follow-up
of colorectal carcinoma patients after resection; the physician
should be alert to the increased risk of adrenal metastasis, espe-
cially after the resection of lung metastasis.
In all cases the metastatic adrenal tumors were confirmed by
CT scan. At the time of adrenal metastasis, the patients serum
CEA levels were elevated in 10 of the 11 cases (91%). In nine
of the ten cases (90%) the serum CEA levels decreased consid-
erably after adrenalectomy. In one case, the serum CEA level
still remained elevated after left adrenalectomy and the CT
scan showed a tumor in the contralateral side. The serum CEA
level and CT scan are valid predictors of recurrence.
The follow-up period of the 11 patients after the resection of
adrenal metastasis ranged from 4 months to 9 years. Three
patients died of recurrence 433 months (mean 22.7 months,
SD 16.2 months) after resection of adrenal metastasis. Three
cases showed recurrence 813 months after adrenalectomy,
but were still alive at the time of the report. Five of the 11
patients were alive without signs of recurrence 8 months9
years after adrenalectomy (with a mean follow-up period of
33.5 months). These data suggested that resection of solitary
adrenal metastasis from colorectal carcinoma may improve
selected cases chances of survival. We conclude that resection
Figure 1. Computed tomography of the abdomen showing a low-density left
adrenal mass 6 cm in diameter.
Figure 2. Cross-section of the resected left adrenal gland showing a well-
encapsulated yellowish tumor.
416 Adrenalectomy for adrenal metatasis
could be considered as a therapy for solitary adrenal metastasis
from colorectal carcinoma.
CONCLUSIONS
Surgical resection may result in survival benefit in selected
patients with solitary adrenal metastasis from colorectal carci-
noma. Resection could be considered as a therapy for solitary
adrenal metastasis from colorectal carcinoma. A hematoge-
nous route of metastasis from colorectal carcinoma via the
lung to the adrenal gland is suggested.
References
1. Fujii H, Iino H, Miyasaka Y, Honda Y, Okuda J, Iimuro Y, et al. Adrenal
metastasis from carcinoma of the colon. Report of a resected case with a
long survival. Nippon Daicho Komonbyo Gakkai Zasshi 1994;47:5828
(in Japanese).
2. Fujita K, Kameyama S, Kawamura M. Surgically removed adrenal metas-
tasis from cancer of the rectum. Report of a case. Dis Colon Rectum
1988;31:1413.
3. Kamasako A, Kawamoto S, Tanaka R, Shibasaki S, Murakami A. A suc-
cessfully resected case of colonic cancer with synchronous adrenal metas-
tasis. Nippon Shokaki Geka Gakkai Zasshi 1995;28:230811 (in
Japanese).
4. Matsui A, Nakata M, Sakabe H, Usui T, Takahashi T, Minamisato K. A
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Table 1. Eleven cases of solitary adrenal metastasis from colorectal carcinoma
M, male; F, female;?, unknown (not described); Dukes D, by the modified classification; y, years; m, months; Lt, left; Rt, right; Syn, synchronous; by CT, the size
of the tumor estimated by CT.
Ref. Patient data Resection of
colorectal carcinoma:
macroscopic findings
Previous site of
metastasis
Adrenal metastasis After resection of adrenal
gland
No. Age Gender Location Dukes Organ Interval Interval Side Specimen size
(cm)
Recurrence Outcome
Organ Interval
2 1 39 F Rectum C Lung 3y 11m 7y 11m Lt 5.7 4.2 4.0 None Alive at 1y 11m
8 2 66 M Cecum C None 1y 6m Lt 9 8 by CT None Alive at 1y
8 3 52 M Rectum D None Syn Rt 10.5 6 5 Lung (6m) +
liver (later)
6m Died at 2y 9m
8 4 49 M Sigmoid ? Lung 4y 5y Lt 6.0 5.2 3.5
5y 6m Rt 5 3 by CT Multiple
organs
4m Died at 4 m
4 5 71 M Rectum B None 2y Rt 10 6.5 6.5 None Alive at 8m
1 6 57 M Ascending B None 3y 1m Rt 6 4 3 None Alive at 9y
5 7 58 M Rectum B None 1y 2m Rt 4.0 3.5 2.0 Lung,
prostate, etc.
4m Died at 2y 7m
6 8 46 M Descending C None 1y 2m Rt 10 9.1 5.7 None Alive at 1y 2m
3 9 71 F Sigmoid C None Syn Rt 6.5 5.0 3.5 Liver 8m Alive at 11m
7 10 64 M Rectum A Lung 1y 11m 2y 9m Lt 8.5 6.5 5.0 Lung
(bilateral)
1y 1m Alive at 1y 1m
This
case
11 60 M Rectum C Lung 7y 2m 8y 10m Lt 3.2 3.2 2.8 Lung 10m Alive at 3y