Incidence of adrenal involvement and assessing adrenal function in patients with renal cell carcinoma: is ipsilateral adrenalectomy indispensable during radical nephrectomy?



We read this article with great interest [1]; recent attention has been called to the indication of ipsilateral adrenalectomy during radical nephrectomy for RCC. There have been many retrospective studies which concluded that the benefit of concomitant adrenalectomy is limited, based on the low incidence of involvement on the pathological examination of concomitantly resected ipsilateral adrenal gland. There have also been a few studies showing that RCC rarely recurs on the spared ipsilateral adrenal gland [2]. We congratulate the authors that their study is, to our knowledge, the first report showing a potential adverse effect of ipsilateral adrenalectomy during radical nephrectomy. Their data suggest that ipsilateral adrenalectomy should feasibly be avoided unless there is a clear indication, such as a positive imaging study, for adrenal involvement or large (>T2) tumour located to upper portion of the kidney.

In their retrospective study of 247 patients with RCC, the authors reported a similar incidence of ipsilateral adrenal involvement to those in contemporary series [2,3]. They also showed that ipsilateral adrenalectomy results in an impairment of adrenal function in terms of the response to a rapid ACTH test 2 weeks after surgery compared to that before. In our series, a rapid ACTH test was conducted in five and eight patients undergoing nephrectomy with and without concomitant ipsilateral adrenalectomy, respectively. As a result, the 30-min cortisol response to ACTH injection at 1 week after surgery was significantly lower in patients with adrenalectomy than in those undergoing adrenal-sparing nephrectomy, at a mean  (sd) of 138 (21) vs 202 (34)% from baseline value (P = 0.01, Mann-Whitney U-test). The response of aldosterone was not significantly different between the groups, at 191 (64) vs 214 (71)% from baseline (P = 0.77, Mann-Whitney U-test). Our data support the conclusion of the study, showing that ipsilateral adrenalectomy during radical nephrectomy results in at least a short-term deterioration of adrenal function.

Although the study provides important evidence of adverse aspects of ipsilateral adrenalectomy, some points should be addressed. As adrenal function was evaluated only at 2 weeks after surgery, the duration and clinical impact of weakened adrenal function is still unclear. It should be clarified whether and when the impaired adrenal function recovers in future studies. In addition, it is also yet to be elucidated how impaired adrenal function affects the recurrence rate and disease-specific survival. A lower response to exogenous and endogenous stress may result in an impaired immune response, which may cause adverse events or higher recurrence rates after surgery.