Adrenal metastasis in renal cell carcinoma: A recommendation for adjustment of the TNM staging system

Objectives. To study the incidence of adrenal metastasis in patients with renal cell carcinoma ( RCC) of all stages, its correlation with clinicopathological variables and its impact on survival. Furthermore, the need for adrenalectomy as part of the routine radical nephrectomy was assessed. Material and methods. The medical records of 321 patients with RCC of all stages who were operated on with the aim of performing adrenalectomy combined with radical nephrectomy between 1982 and 2000 were reviewed. The accuracy of the available preoperative radiological examinations was evaluated and any adrenal involvement was compared with other clinical and histopathological findings. Results. Ipsilateral adrenal tumour involvement was detected in 17/ 321 patients ( 5.3%). In four of these patients, the adrenal gland was the only preoperatively found metastatic site. Factors predicting the presence of ipsilateral adrenal metastases were male gender, tumour size, vein invasion, renal capsule and perirenal fat invasion. Tumour location within the kidney and tumour side had no predictive value for the presence of adrenal metastasis. The presence of ipsilateral adrenal involvement was a significant adverse prognostic variable, indicating a short survival time ( p < 0.001). Conclusions. Ipsilateral adrenal metastasis is a highly adverse prognostic factor. In the TNM staging system, adrenal gland involvement should be staged as M1a. Ipsilateral adrenalectomy in conjunction with radical nephrectomy should be performed if an adrenal lesion cannot be cleared of suspicion after preoperative radiological imaging, as in locally advanced tumours. The adrenal gland can be left in situ if the ipsilateral adrenal gland is assessed as normal at the preoperative investigation and perioperatively by the surgeon.