林威廷1 林劭潔1 林毅志2 洪崇傑2 李政昌1 林博文1 成功大學附設醫院大腸直腸科1一般外科部2 大腸直腸癌併腎上腺轉移─ 4個案例報告併文獻回顧 Colorectal cancer with adrenal metastasis– fours case reports and literature review 林威廷1 林劭潔1 林毅志2 洪崇傑2 李政昌1 林博文1 成功大學附設醫院大腸直腸科1一般外科部2

Literature review The most critical factor causing mortality of patients with CRC is metastasis9. Colorectal cancer tends to metastasize to distant organs, including the liver and lung. According to previous different study, adrenal metastasis from CRC is rare2. The incidence of adrenal metastasis from CRC ranges from 1.9% to 17.4%6. However, the incidence may be underestimated because of the adrenal mass being mistaken for a lombo-aortic node8. 4th common metastasis of malignancy: Lung, liver, bone Adrenal metastasis: Lung, breast and kidney

Adrenal metastasis from rectal cancer: Report of a case Adrenal metastasis from rectal cancer: Report of a case. Surg Today (2003) 33: 126-130.

However, isolated adrenal metastasis is rare; adrenal lesions usually occur in the presence of multiple synchronous metastases and are detected in the terminal phase of cancer9. A number of routes of adrenal metastasis from CRC exist, including systemic venous, portal venous, arterial and lymphatic routes. Katayama et al3. suggested that there is a route of hematogenous metastasis from the primary lesion via the lung to the adrenal gland. Adrenalectomy for solitary adrenal metastasis from colorectal carcinoma. Jpn J Clin Oncol 2000, 30:414-6

Image diagnosis The imaging has a very important role in the diagnosis of the adrenal metastasis5. Radiological modalities, such as ultrasonography, CT, ,MRI and positron emission tomography (PET/CT), are commonly used for early detection of adrenal metastasis8. Tumor marker CEA is considered as a good indicator of the presence of adrenal metastasis after surgery5. Pre-op diagnosis is very hard, because adrenal metastasis are general asyptomatic

Therapeutic approach Adrenal metastasis from CRC is usually a part of systemic disease, accompanied poor prognosis. Surgical resection may result in survival benefit in selected patients with solitary adrenal metastasis from CRC3.

Surgery The option for surgery of adrenal metastasis5 The metastasis were isolated The patient has responded to the neoadjuvant chemotherapy Resection of the isolated adrenal metastasis provides better survival especially when it has developed after 6 months of the surgery. It is generally accepted that a solitary adrenal metastasis should be resected to achieve good prognosis, although the incidence of truly resectable such lesion is very low. there are some cases in which curative resection of a solitary adrenal metastasis from colorectal cancer is feasible.(2022) It is generally accepted that a solitary adrenal metastasis should be resected to achieve good prognosis, although the incidence of truly resectable such lesions is very low.(23, 24) Metachronous bilateral isolated adrenal metastasis from rectal adenocarcinoma: a case report. Case Rep Gastrointest Med. 2014; 2014: 516403.

Adrenal metastasis Date/Diagnosis tool/ site Adrenal op date/method Age/ Sex Date Initial diagnosis C/T Adrenal metastasis Date/Diagnosis tool/ site Adrenal op date/method CEA Level Outcome 1 48/F 2007Mar Rectal cancer with liver metastasis FOLFOX +Erbitus → FOLFIRI +Avastin 2010 Dec PET-CT Right 2011 Jan Right adrenalectomy + Partial hepatectomy 6.83 Died (2012-7) 2 74/M 2010 Jun Sigmoid colon cancer with pancreas head lymph-adenopathy FOLFOX 2010 Jul PET-CT (-) 1.63 Died (2012-12) 3 57/F 2009 Oct RS colon cancer FOLFOX→ FOLFIRI + Avastin → Erbitus 2014 Sep CT 2014 Dec Right adrenalectomy + Right lobectomy + Roux-en Y hepatico-jejunostomy 2.2 Died (2016-7) 4 75/M Rectal cancer UFUR → FOLFIRI + Avastin → Erbitux 2012 Sep Left 2013 Apr Left adrenalectomy 3.34 Alive still 5   6 7 FOLFOX Leucovorin + 5 FU + Oxaplatin FOLFIRI Leucovorin + 5 FU + Campto Case 1 : liver/lung/adrenal/splenic 1st LAR + partial hepatectomy & 2nd Hepatectomy Case 2 : Bone/Right adrenal metastasis Case 3 : Liver/Adrenal/Lung 1st AR (2009)-> 2nd S8 partial hepatectomy (2013) Case 4 : Adrenal /Lung 1st TME(2010)

Case 1 Adrenalectomy PET/CT

Case 4 Adrenalectomy CT

Conclusion Adrenal metastasis from CRC is relatively rare. Surgical resection for selected patient is good choice and to achieve good prognosis. To detect adrenal metastasis early, radiological modalities such as US, CT, MRI and PET/CT as well as the measurement of serum CEA, should be done regularly4. Recently, metastasis to the adrenal glands has been more frequently recognized during follow‑up subsequent to surgery for cancer, due to an improvement in high‑resolution imaging modalities

Reference M. Watatani, M. Ooshima, T. Wada. Adrenal metastasis from carcinoma of the colon and rectum: A Report of three cases. Jpn J Surg (1993) 23: 444-48. C. Kosmidis, C. Efthimiadis, G. Anthismidis. Adrenalectomy for solitary adrenal mestasis from colorectal cancer: A case report. Cases Journal 2008, 1:49. Katayama A, Mafune K, Makuuchi M. Adrenalectomy for solitary adrenal metastasis from colorectal carcinoma. Jpn J Clin Oncol 2000, 30:414-6. S. Murakami, M. Terakado, T. Hashimoto. Adrenal metastasis from rectal cancer: Report of a case. Surg Today (2003) 33: 126-130. Jabir H, Tawfiq N, Moukhlissi M. Metachronous bilateral isolated adrenal metastasis from rectal adenocarcinoma: a case report. Case Rep Gastrointest Med. 2014; 2014: 516403. Kim SH, Brennan MF, Russo P, Burt ME, Goit DG: The role of surgery in the treatment of clinically isolated adrenal metastasis. Cancer 1998, 82:389-94.

Reference-2 Capaldi M, Ricci G. Colon cancer adrenal metastasis: case report and review of the literature. G Chir. 2011 Aug-Sep;32(8-9):361-3. Liu YY, Chen ZH, Zhai ET. Case of metachronous bilateral isolated adrenal metastasis from colorectal adenocarcinoma and review of the literature. World J Gastroenterol 2016 April 14; 22(14): 3879-3884 Uemura M, Kim HM, Ikeda M. Long-term outcome of adrenalectomy for metastasis resulting from colorectal cancer with other metastatic sites: A report of 3 cases. Oncology ketters 12: 1649-1653, 2016