Treatment Options for Adrenal Metastases
Surgical resection is the cornerstone of potentially curative treatment for isolated adrenal metastases, with open adrenalectomy being preferred over laparoscopic approaches to reduce the risk of local recurrence and peritoneal dissemination. 1
Diagnostic Evaluation
Before initiating treatment for adrenal metastases, a comprehensive diagnostic workup is essential:
CT/MRI of the abdomen with specific adrenal protocol to evaluate:
- Lesion size (tumors >6 cm have higher likelihood of malignancy)
- Heterogeneity
- Lipid content
- Contrast wash-out patterns
- Margin characteristics 1
Rule out functioning adrenal tumors with:
- Plasma aldosterone and renin activity
- Serum ACTH, cortisol, and DHEA-s
- Fractionated plasma-free metanephrines 1
Additional imaging:
Treatment Algorithm Based on Disease Presentation
1. Isolated Adrenal Metastasis
For Non-Small Cell Lung Cancer (NSCLC):
Synchronous presentation (primary tumor and adrenal metastasis diagnosed simultaneously):
Metachronous presentation (adrenal metastasis after previous primary tumor resection):
- Adrenalectomy is recommended
- 5-year survival similar to synchronous presentation (approximately 25%) 1
For Other Primary Cancers:
- Complete surgical resection (R0) offers the best chance for long-term survival 1, 2
- Open adrenalectomy is generally preferred over laparoscopic approach for malignant lesions 1, 2
- Adjuvant chemotherapy should follow surgical resection 1, 2
2. Multiple Metastatic Sites
When adrenal metastasis is part of widespread metastatic disease:
- Systemic therapy options based on primary tumor type:
- Chemotherapy regimens may include: capecitabine, dacarbazine, doxorubicin, 5-FU, streptozocin, and temozolomide 1
- For adrenal carcinoma: EDP-M (etoposide, doxorubicin, cisplatin plus mitotane) for patients with good performance status and high tumor burden 1
- For less fit patients or those with lower tumor burden: mitotane monotherapy 1
3. Palliative Options for Symptomatic Disease
- Radiotherapy: Effective for painful metastases, particularly bone lesions 1
- Ablative techniques:
- Radiofrequency ablation
- Microwave ablation
- Cryotherapy
- Arterial chemoembolization 1
- Stereotactic Body Radiation Therapy (SBRT): Emerging option for patients who are not surgical candidates 3
Prognostic Factors
Several factors influence outcomes after treatment of adrenal metastases:
- Nodal status: Absence of nodal involvement in the primary tumor is associated with better outcomes 1
- Disease-free interval: Longer interval between primary tumor treatment and adrenal metastasis detection generally indicates better prognosis
- Complete resection: R0 resection is the strongest predictor of long-term survival 1
- Primary tumor type: Outcomes vary based on the biology of the primary malignancy
Follow-up Recommendations
After treatment of adrenal metastases:
- Regular imaging every 3-6 months initially
- CT/MRI of abdomen and chest
- Tumor markers relevant to primary cancer
- Gradual increase in intervals after 2 years of disease-free survival 1
- Long-term follow-up (at least 10 years) is recommended for patients with disease-free survival 1
Complications and Considerations
- Surgical complication rates for adrenal metastasectomy are significant (reported at 37.9% in recent studies) 4
- Common complications include ileus, gastroparesis, wound problems, pneumonia, and cardiac arrhythmias 4
- Perioperative management of hormonal, glycemic, electrolytic, and blood pressure anomalies is essential 1
The treatment approach for adrenal metastases has evolved significantly, with an increasing trend toward surgical management for isolated metastases. However, the high complication rates underscore the importance of careful patient selection and consideration of alternative approaches like SBRT when surgery is not feasible.