Ann Thorac Surg 1998;65:833-835
© 1998 The Society of Thoracic Surgeons
Case Reports
Transthoracic, Transdiaphragmatic Excision of Simultaneous Lung and Adrenal Lesions
Raja M. Flores, MD,
Daniel J. Goldstein, MD,
Randall S. Sung, MD,
Kenneth M. Steinglass, MD,
Samuel Weinstein, MD,
John A. Chabot, MD
Division of General Surgery, College of Physicians & Surgeons, Columbia University, New York, New York, USA
Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians & Surgeons, Columbia University, New York, New York, USA
Accepted for publication October 7, 1997.
Dr Flores, Department of Thoracic Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115.
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Abstract
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Simultaneous adrenal and pulmonary lesions frequently present a therapeutic challenge to the thoracic surgeon. We describe 2 cases in which a transthoracic, transdiaphragmatic approach was used to establish tissue diagnosis and complete removal of gross tumor. In 1 case an intraoperative decision to perform a pneumonectomy was dictated by the tissue diagnosis of the adrenal mass, which was obtained with relative ease via this method. In both cases the morbidity of traditional approaches for adrenal operation was avoided.
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Introduction
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The surgical approaches to the adrenal gland are dictated by the lesion’s size, its physiologic properties, and the preferences of the individual surgeon. Traditionally described methods include flank, anterior, posterior, and thoracoabdominal approaches. Successful staged and simultaneous resections of lung and adrenal lesions have been previously described [1] in which separate thoracic and abdominal incisions were used to accomplish the metastasectomies. Recently, a thoracoscopic, transdiaphragmatic needle biopsy of an adrenal mass was described [2]. We report 2 cases in which lung resection and transthoracic, transdiaphragmatic adrenalectomy were performed, obviating the need for a separate abdominal or flank incision. In 1 case a significant intraoperative decision to perform a pneumonectomy was based on the findings obtained by this method.
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Case Reports
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Patient 1
A 58-year-old woman underwent total abdominal hysterectomy for uterine leiomyosarcoma. Six years later, she underwent right upper lobe wedge and chest wall resections for recurrent leiomyosarcoma. She remained asymptomatic until 5 years later when, on routine screening, she was found to harbor a recurrence in the right upper lobe and new deposits in the right lower and left upper lobes, as well as a left adrenal mass (Fig 1).
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Abdominal computed tomographic scan after administration of oral and intravenous contrast reveals a left adrenal mass (arrow). No other evidence of intraperitoneal metastases was noted.
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In an effort to resect all recurrences, we performed a left thoracotomy first with the intent of performing a right thoracotomy at a later date to resect the remaining tumor. Under epidural and general anesthesia with a double-lumen endotracheal tube, the patient was positioned in the right lateral decubitus position. A left posterolateral thoracotomy was performed through the eighth interspace. Wedge resection of the left upper lobe lesion was performed. Intraoperative frozen section confirmed recurrent leiomyosarcoma. To avoid a second incision in the abdomen, the decision was made to proceed with adrenalectomy via a transdiaphragmatic approach.
An 8-cm curvilinear incision was made along the posterolateral aspect of the left hemidiaphragm. A 5.0 x 4.0-cm adrenal mass could be seen abutting the diaphragmatic undersurface. Feeding vessels were serially clamped and the mass was resected en bloc and delivered through the thoracotomy incision. The diaphragmatic defect was reapproximated using continuous nonabsorbable suture. A chest tube was placed in the left pleural cavity and the thoracotomy incision was closed in a standard manner. She had an uneventful postoperative recovery and was discharged home on the fifth postoperative day.
Pathologic examination revealed leiomyosarcoma. She was readmitted 4 months later, at which time she underwent a right thoracotomy and right upper and lower lobe wedge resections. She recovered without sequelae and is currently free of recurrence at 4-month follow-up. Follow-up chest roentgenograms revealed no evidence of diaphragmatic herniation.
Patient 2
A 67-year-old man presented with stage IIIA squamous cell carcinoma of the right lung. He was treated with two cycles of cis-platinum and vinorelbine tartrate and external-beam irradiation with partial response. A computed tomographic scan after chemoirradiation showed tumor limited to the right hemithorax with no evidence of mediastinal invasion or adenopathy. A work-up for metastatic disease revealed a 2-cm right adrenal mass on computed tomographic scan (Fig 2). A computed tomography-guided core biopsy was nondiagnostic.
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Abdominal computed tomographic scan, taken with the patient in the prone position, demonstrating a right adrenal mass (arrow). No other intraperitoneal evidence of disease noted.
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The operative plan was for right pneumonectomy with transdiaphragmatic right adrenalectomy. A right posterolateral thoracotomy was performed with a fifth rib resection. At exploration, the tumor was noted to extend into the right atrium. Because of this degree of local invasion, we decided to proceed with the pulmonary resection only if the adrenal mass proved not to be a metastasis. The posterolateral diaphragm was incised in a circumferential fashion. The liver was retracted medially, and the right kidney was retracted laterally. Dissection in the retroperitoneal fat allowed exposure of the right adrenal gland. The gland, which was largely replaced by the mass, was mobilized by sharp dissection; the arteries and vein were exposed and clipped. The frozen-section diagnosis was cortical adenoma; hence, the pneumonectomy proceeded as planned. The postoperative course was uneventful. Final pathologic diagnosis confirmed the finding of adrenal cortical adenoma; the pulmonary resection specimen showed microscopic tumor involvement of the bronchial margin and in one of twelve peribronchial lymph nodes. Follow-up chest roentgenograms revealed a normal right hemidiaphragm.
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Comment
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A variety of operative approaches have been described for performing adrenalectomy. In general, the surgical approach is dictated by the size and nature of the adrenal lesion. However, all the traditional approaches are cumbersome and time consuming, and they carry additional morbidity in patients already undergoing a thoracotomy. Our approach allows for simultaneous removal of thoracic and adrenal tumors through a single incision. In situations in which surgical management depends on histologic evaluation of the adrenal gland, an accurate sample of tissue can be obtained with relative ease.
Our first patient underwent repeated surgical procedures in an effort to control her metastatic leiomyosarcoma. For a subset of patients with visceral metastases from sarcomas, surgical resection of the metastatic deposits can result in prolonged disease-free survival and cure [3][4]. There are no current guidelines limiting the number of metastatic nodules to be considered for resection, and these patients usually undergo multiple staged procedures in an effort to minimize the morbidity from the underlying disease. However each additional surgical procedure increases their overall operative morbidity. Our approach in patients with simultaneous lung and adrenal metastasis would reduce the number of separate surgical procedures required to obtain the desired amount of tumor control, therefore, decreasing overall morbidity.
Our second patient underwent a pneumonectomy based on the intraoperative identification of a benign adrenal lesion. Adrenal metastases are noted in approximately 15% of lung cancer patients in some series [5], and benign cortical adenomas of the adrenal glands are a frequent normal finding seen in 3% to 5% of the general population [6]. Percutaneous biopsy of the adrenal gland is advocated when preoperative computed tomographic evaluation reveals adrenal enlargement in patients with non–small cell bronchogenic carcinoma. However, biopsy results are subject to sampling error and differing pathologic opinions; furthermore, specimens are commonly nondiagnostic. The transthoracic, transdiaphragmatic approach is an easy and convenient method of determining with certainty the nature of an adrenal mass in equivocal cases.
The literature suggests that extrathoracic spread of lung cancer implies inoperability, so patients with primary lung lesions solely metastatic to the adrenal gland have not been considered surgical candidates. However, with modern adjuvant therapy, aggressive surgical resection may require reevaluation. There have been several reports of combined excision of primary lung tumors and metastatic adrenal lesions with improved survival [7][8]. The transthoracic, transdiaphragmatic adrenalectomy may offer a less morbid and technically easier approach to aggressive tumor resection in this subset of patients.
Transthoracic, transdiaphragmatic adrenalectomy is a useful tool for the subset of patients in whom resection of simultaneous lung and adrenal lesions is warranted and fine-needle aspiration of the adrenal has failed. The procedure can be done on either side of the diaphragm. The approach is technically simple and expeditious and provides excellent exposure while obviating the need for a separate abdominal incision. The transthoracic, transdiaphragmatic approach appears to be a safe and useful option in the surgeon’s armamentarium in managing simultaneous thoracic and adrenal disease.
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References
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- Reyes L, Parvez Z, Nemoto T, Regal AM, Takita H Adrenalectomy for adrenal metastasis from lung carcinoma. J Surg Oncol 1990;44:32-34.[Medline]
- Mack MJ, Aronoff RJ, Acuff TE, Ryan WH Thoracoscopic transdiaphragmatic approach for adrenal biopsy. Ann Thorac Surg 1993;55:772-773.[Abstract]
- Putnam JB, Roth JA, Wesley MN, et al. Analysis of prognostic factors in patients undergoing resection of pulmonary metastases from soft tissue sarcomas. J Thorac Cardiovasc Surg 1984;87:260-267.[Abstract]
- Creagan ET, Fleming TR, Edmonson JH, et al. Pulmonary resection for metastatic nonosteogenic sarcoma. Cancer 1984;44:1901-1912.
- Cromartie RS, Parker EF, May JE, et al. Carcinoma of the lung: a clinical review. Ann Thorac Surg 1980;30:30-35.[Abstract]
- Allard P, Yankaskas BC, Fletcher RH, et al. Sensitivity and specificity of computed tomography for the detection of adrenal metastatic lesions among 91 autopsied lung cancer patients. Cancer 1990;66:457-462.[Medline]
- Twomey P, Montgomery C, Clark O Successful treatment of adrenal metastasis from large-cell carcinoma of the lung. JAMA 1982;248:581-583.[Abstract]
- Raviv G, Klein E, Yellin A, et al. Surgical treatment of solitary adrenal metastasis from lung carcinoma. J Surg Oncol 1990;43:123-124.[Medline]
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Abstract
Introduction
