Dergiler / Türk Üroloji Dergisi/Turkish Journal of Urology / 2004 / Cilt: 30 - Sayı: 4
Aynı taraf adrenalektomi radikal nefrektominin bir parçası olmalı mı?
- Sayfa
- 422–425
- DOI
- —
Özet
Böbrek kitlesi nedeniyle yapılan radikal nefrektomilerde ipsilateral sürrenalektominin yeri tartışmalıdır. Biz bu çalışmada kendi serimizi inceleyerek radikal nefrektomilerde ipsilateral sürrenalektominin bilgisayarlı tomografi bulguları ışığında gerekliliğini araştırdık. 1996-2004 yılları arasında Böbrek Hücreli Kanser (BHK) nedeniyle radikal nefrektomiyle beraber ipsilateral sürrenalektomi yapılan 50 hasta retrospektif olarak değerlendirildi. Operasyonlarda Gerota fasyası ile beraber böbrek, üreterin 1/3 proksimali ve sürrenal çıkartıldı. Bölgesel lenf nodları eksize edildi. Operasyon materyali patolojik olarak değerlendirilip TNM (AJCC 1997) sınıflamasına göre evrelendirildi. 20’si kadın 30’u erkek toplam 50 olgu vardı. Tümörlerin 19’i sağ, 31’i sol böbrekte lokalize idi. Tümörlerin 24 adedi üst, 7 adedi orta, 17 adedi alt zonda lokalize, 2 adeti ise tüm böbreği infiltre etmişti. 25 tümör stage I, 13 tümör stage II, 6 tümör stage III, 6 tümör stage IV idi. Tümör çapı ortalama 6,58 (2-23) cm idi. 2 olguda sürrenal invazyona rastlandı. Her iki olguda da bilgisayarlı tomografide (BT) sürrenal tutulum yönünde bulgu saptandı. Bir olguda ise BT sonucu patolojiyle uyumlu değildi. 50 hastadan oluşan serimizi göz önüne aldığımızda böbrek tümörlü hastalara ameliyat öncesi yapılan BT incelemesinde sürrenalde herhangi bir lezyon yoksa radikal nefrektomi ile beraber ipsilateral sürrenalektomi yapılmayabileceği sonucuna ulaştık.
Abstract
Introduction: Malignant involvement of ipsilateral adrenal gland is noted in 1.2-10% of radical nefrectomy specimens. Despite the low incidence of adrenal involvement, in 1969 Robson et al, recommended radical with ipsilateral adrenalectomy as the treatment of choice for renal cell carcinoma and for early vascular control. Although nefrectomy with ipsilateral adrenalectomy is a safe and simple procedure, we have to keep in mind the 20% adrenal deficiency rate in metastatic renal cell carcinoma. In this study we assess the need of ipsilateral adrenalectomy in renal cell carcinoma (RCC) with the help of computerized tomography. Materials and Methods: We investigate 50 patients with RCC who were treated with radical nefrectomy with ipsilateral adrenalectomy from 1996 to 2004 retrospectively. Mean ages of patients were 59.32 (40-80). 20 of them were female and 30 were male. In all cases kidney, proximal 1/3 ureter, and adrenal were taken out with Gerota’s fascia. Spermatic and ovarian veins were legated. Regional lymph node was excised. The pathologist reviewed all materials and TNM classification was used. Siemens-Somatom CT scan was the radiological method. 2-3 minutes after the administration of non-ionic contrast material, CT images were taken. In all cases, the tumor location, size, lymph node involvement and adrenal abnormalities were recorded from CT. to determine the accuracy of preoperative CT in identifying adrenal involvement with renal cancer, the histopathology records of the radical nefrectomy specimens were compared with preoperative CT. Results: When retrospective analysis of renal cancer was made, 19 cases have right, 31 have left renal cancer. 24 cases have upper, 7 have mid, 17 have lower zone tumor and 2 patients have tumor in all zones. 25 tumor were stage I, 13 tumor stage II, 6 tumor stage III, 6 tumor stage IV. Mean tumor size was 6.58 (2-23 cm). 2 patients have adrenal involvement (invasion). In the first 63 years old male patient, preoperative CT demonstrate tumor on the upper pole and tumor size was 6 cm and adrenal abnormalities were nodule formation and surface irregularity and 2.5 cm hilar LAP were found. Histopathological results after radical nefrectomy demonstrated adrenal metastasis and lymph node involvement. In the second 54 years old male patient, preoperative CT scan demonstrate 7.5 cm upper pole tumor infiltrating to pancreas, spleen and adrenal gland. Histopathological findings demonstrate adrenal involvement. One patient has an 8 cm upper pole tumor with adrenal abnormality on preoperative CT and patient has no adrenal involvement on histopathological investigation. Conclusion: In our study, we only found 2 adrenal metastasis in 24 upper poles RCC and the intrarenal tumor size was between 6.5 and 7.5 cm. 4% adrenal metastasis rate in upper pole tumor is statistically significant but it was very low. Of the 2 patients with adrenal metastasis in our study, intrarenal tumor size in CT was 6.75 cm. Preoperative CT demonstrated 100% specificity, 98% sensitivity, 68% positive predictive value, 100% negative predictive value and 98% positive value for adrenal involvement by RCC. Because of that preoperative investigation of adrenal gland involvement by RCC with CT is useful to determine whether ipsilateral adrenalectomy during radical nefrectomy is required or not. CT is a reliable method for adrenal metastasis.