Page 26 - Delaware Medical Journal - January 2018
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LETTER TO THE EDITOR
Response to Two Cases of Adrenal Insufficiency Caused by Isolated Bilateral Adrenal Metastasis from Breast Cancer Raul N. Uppot, MD; James F. Lally, MD
To the Editor:
The recent publication in the Delaware Medical Journal (October, 2017) “Two Cases Bilateral Adrenal Metastasis from Breast Cancer” deserves commendation as it is an excellent presentation; noteworthy are the authors’ clinical acumen in the exquisite documentation of the skin hyperpigmentation and their detailed management of two extremely rare cases should serve as a model for those who may unknowingly believe approach to the treatment of patients with suspected metastatic disease to the adrenal glands. The careful exclusion of disseminated disease with computed tomography (CT) and positron emission tomography (PET) scans allowed them to explore treatment options for isolated adrenal metastasis.
Equally unusual in both of their patients
is the disease-free interval before the detection of metachronous metastasis; in patient one, 15 years, and in patient two,
13 years. This is certainly a lesson for those who believe that there is something cancer-free as occasionally physicians will see patients with breast cancer presenting with metastasis long after their initial cases of isolated adrenal metastasis from breast cancer of interest as they seemingly defy the English surgeon Stephen Paget’s (1855-1926) 19th century “seed and soil” theory that has borne the test of time. Paget, after studying the autopsy records of 735 patients with breast cancer, observed that breast cancer when it metastasizes
cancer has a proclivity to spread to the adrenal glands, breast cancer does not.
The reader may be left with the
impression that adrenalectomy (primarily laparoscopic) is the gold standard for isolated metastasis to the adrenal glands. One author of this commentary (Uppot) and his colleagues, as well as a number of other investigators, have demonstrated the value of alternative strategies for managing adrenal metastasis.1,2
We particularly take issue with the statement in Conclusion: “Treatment with adrenalectomy may be considered for patients with isolated adrenal metastasis.” Although surgery is currently an accepted option, it is not the only option for managing isolated adrenal metastasis. A number of papers have described the role of image- guided ablation as a treatment option for metastatic adrenal lesions.1-5 Image-guided ablation offers a minimally invasive alternative to treating adrenal metastasis using radio frequency ablation, cryoablation or microwave ablation with equivalent
local control and low complication rates.
In a study of 46 adrenal metastasis from
two institutions treated with ablation, the estimated local control and overall survival was 75 percent and 65 percent at two years. These results compare favorably with published results from surgery and radiation therapy. The advantage of ablation over bilateral total adrenalectomy is the potential to preserve normal adrenal tissue and, therefore, minimizing the likelihood of post- that may not be possible when the gland is completely replaced.
A larger series that compares treatment
are least invasive and the most likely to lengthen survival is obviously needed. Until such results are published, we believe that patients with adrenal metastasis should also be offered the option of non-surgical treatment.
CONTRIBUTING AUTHOR
■ RAUL N. UPPOT, MD is an Interventional Radiologist at Massachusetts General Hospital and an Assistant Professor of Radiology at Harvard Medical School in Boston, Mass.
■ JAMES F. LALLY, MD is a retired Radiologist and a member of the Medical Society of Delaware Editorial Board.
REFERENCES
1. Uppot RN, Gervais, DA. Image-guided adrenal tumor ablation. Am J Roentgenol. 2013;200:1226-1233.
2. Frenk NE, Daye D, Tuncali K, et al.
Local control and survival after image- guided percutaneous ablation of adrenal metastasis. J Vasc Interv Radiol. Available online 18 September 2017.
3. Carrrafiello G, Lagana D, Recaldini C, et al. Image-guided percutaneous radio frequency ablation of adrenal metastasis: preliminary results at a single institution with a
single device. Cardiovasc Intervent Radiol. 2008;31:762-767.
4. Welch BT, Calistrom MR, Carpenter PC, et al. A single-institution experience in image- guided thermal ablation of adrenal gland metastasis.
J Vasc Intev Radiol. 2014;25:593-598.
5. Hasegawa T, Yamakado K, Nakatsuka A, et al. Unresectable adrenal metastasis: clinical outcomes of radiofrequency ablation. Radiology. 2015;277:584-593.
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Del Med J | January 2018 | Vol. 90 | No. 1
