Cangussu et al.46 Braz. J. Video-Sur., January / March 2013Case ReportBrazilian Journalof VideoendoscopicSurgery

Accepted after revision: february, 10, 2012.Braz. J. V ideo-Sur , 2013, v. 6, n. 1: 046-051

46

Laparoscopic Adrenalectomy with ConcurrentRetroperitoneal and Pelvic L ymphadenectomy for the

Treatment of Met astatic Melanoma: A Case Report

Adrenalectomia V ideolap aroscópica Concomit ante a LinfadenectomiaRetroperitoneal e Pélvica p ara Tratamento de Metást ase de

Melanoma: Relato de Caso

HERON CRUSOÉ CANGUSSU 1,2,4,5,7; JADSON MURILO SIL VA REIS 1,2,4,5,7; PAULO VICT OR SOARES 8;GALENO JOSÉ EGÍDIO DE MAGALHÃES NET O 2,4,5,7; EDVALDO FAHEL 2,3,5,6,7

1. Specialist in Oncologic Surgery; 2. Certified as a specialist in Laparoscopic Surgery by the BrazilianSociety of Videosurgery/Endoscopic Surgery (SOBRACIL); 3. Full Professor of General Surgery, Bahian

School of Medicine and Public Health; 4. Assistant Professor of General Surgery, Bahian School of Medicineand Public Health; 5. Preceptor of the Residency in General Surgery at São Rafael Hospital; 6. Fellow ofAmerican College of Surgeons; 7. Member of the Brazilian College of Surgeons; 8. Resident in General

Surgery at São Rafael Hospital.

ABSTRACTIntroduction : Melanoma with adrenal metastases constitutes advanced disease with a poor prognosis and limitedtherapeutic options. The use of laparoscopy in the treatment of cancer patients, be it for curative or palliative goals, isfeasible and has low morbidity. Several studies support adrenalectomy as a therapeutic option with improvement, insome cases, of life expectancy. Case report: We describe a laparoscopic approach for treatment of metastatic melanomausing left adrenalectomy and retroperitoneal and pelvic lymphadenectomy performed without changing the patient’sposition. This major surgical procedure was performed without complications and with no residual disease (R0 surgery).The patient was discharged on the second postoperative day. The patient is being followed as an outpatient withoutsigns of recurrence. Discussion: Performing major laparoscopic procedures is now a reality, maintaining the benefits ofminimally invasive surgery. In this case, we avoid the Sims position, opting instead to perform the transperitonealadrenalectomy with the patient supine and the surgical table tilted in order to be able to also perform the retroperitonealand pelvic lymphadenectomy. Although surgical time of the procedure was long, the analysis of separate times was quitesatisfactory, and the patient was still discharged hospital quickly/early. We believe that in the face of metastatic melanoma,the laparoscopic procedure is beneficial, improving disease control and quality of life.

Key words: Laparoscopic adrenalectomy. Retroperitoneal lymphadenectomy. Melanoma. Pelvic lymphadenectomy.

INTRODUCTION

A dvanced melanoma is a disease with highmortality and with limited systemic therapeutic

options for disease control or for palliative treatmentof symptoms. Patients with advanced disease needpalliative care with less morbidity to improve thequality of life, and even, in some cases, disease-freesurvival. Today, laparoscopy constitutes a feasibleand effective access route for oncological proceduresfor cancer of small to major curative or palliativeand aimed mainly extremely important tool in the

surgical staging of various pathologies. Metastaticdisease in the adrenal gland secondary to melanomais a disease with limited prognosis. The literatureoffers us few studies that define the best approachto take in this clinical situation.1 Laparoscopicadrenalectomy was reported in a few studies as atreatment option with improved life-expectancy.2,5,6

In this article we report a case where a laparoscopicapproach was used to perform left adrenalectomyand retroperitoneal and pelvic lymphadenectomy inthe same surgical time for the treatment of metastaticmelanoma.

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CASE REPORT

A 49 year old male, with idiopathic vitiligo anda familial history of melanoma, presented withlymphadenomegaly in the right inguinal lymph nodechain, associated with asthenia and evening fevers,without skin lesions suggestive of malignancy.Laboratory studies were remarkable for a LDH of1074. He initially underwent right inguinal lymph nodebiopsy for clinical suspicion of a lymphoma. The resultof the pathology analysis was consistent withmetastatic melanoma, which was confirmed withimmunohistochemistry and an independent review ofthe tissue slides. For preliminary staging purposesMRIs of the head and the entire abdomen as well asa CT of the chest were obtained. These studiesrevealed extensive right-sided inguinal and pelviclymphadenopathy extending to the right common iliaccompatible with lymph node metastasis, and a 3.0 cmnodule in the left adrenal suggestive of an adenoma.There were no pathologic findings in the head andchest imaging studies.

Given the extent of the disease and in orderto plan adjuvant/ therapy, a PET-CT study wasobtained which showed evidence of tumor activity witha SVU of 16.7 in the right inguinal and pelvic region, asubcutaneous nodule in the lower third of the rightthigh, and a left juxtarenal para-aortic lymph node(Figure 1). The clinical predicament of metastaticmelanoma of unknown primary was discussed in amultidisciplinary oncology case conference. Given thedifferent findings of the PET-CT and the abdominalMRI, surgery was recommended to complete thestaging by establishing whether the adrenal nodule wasor was not a metastasis, and to reduce the tumorburden in case the patient was a candidate forchemotherapy.

The surgical approach chosen was leftadrenalectomy associated with right retroperitonealand pelvic lymphadenectomy through a laparoscopicapproach with radical right inguinal lymphadenectomyand resection of the subcutaneous nodule in the rightthigh with ample margins. The procedure began witha laparoscopic approach with the patient in dorsaldecubitus and reverse Trendelenburg, the surgeonpositioned between the patient’s legs, and the monitorat the head of the surgical table. A 12 mm trocar forthe optic was inserted 2 cm above the umbilicus andthree 5 mm trocars were placed in the right flank, leftflank and left upper quadrant (Figure 2).

After initial inspection, lesions in theperitoneum and left hemidiaphragm suggestive ofmetastasis were submitted to pathology; frozen sectionexamination was negative for malignancy. Thepresence of retroperitoneal lymphadenopathyextending to the right pelvic chain was noted. Noother suspicious lesions were observed. The operatingtable was titled 45 degrees to the right in preparationfor the approach to left adrenal. The splenic flexureof the colon was freed using ultrasonic coagulatingscissors and the spleen and tail of the pancreas were

Figure 1 - Identification of metastatic lesions by PET-CT: lesionshown in the left adrenal topography, with large uptake (top rightwithout contrast; top left with contrast); right iliac lymph nodes(bottom right, with uptake, and lower left, without contrast).

Figure 2 - Adaptation of the placement of trocars so that the threeprocedures can be performed with the same approach.

Cangussu et al.48 Braz. J. Video-Sur., January / March 2013

dissected and pulled medially. This was followed bydissection of the left adrenal gland which had a tumorof approximately 3.0 cm in diameter with a nodularappearance (Figure 3).

The adrenal vessels were ligated with anUltracision harmonic scalpel and the adrenalectomywas completed. The specimen was removed in thefinger of a glove and sent to the pathology service.After reversing the lateral table tilt and with the patientin Trendelenburg, another 5 mm trocar was introducedin the epigastrium and another 12 mm trocar belowthe umbilicus to which the optic was transferred. Theround ligament of the liver was transected, and thetransverse colon and greater omentum as well asproximal segment of the small intestine were reflectedcephally. The root of the mesentery was retractedfor median exposure of the retroperitoneum.

Figure 6 – Dissected aorta (yellow arrow), with the lateralizedgonadal vessels (green arrow), and identification of the left ureter(red arrow).

Figure 5 – Dissected aorta (yellow arrow), with identification ofthe inferior mesenteric artery (red arrow).

Figure 4 – Medial retroperitoneal access with visualization of thevena cava (blue arrow) and the left renal vein (yellow arrow). Theduodenal arch was folded upward (green arrow).

Figure 3 – View of the left adrenal (green arrow), inferior pole ofthe spleen (yellow arrow) and tail of the pancreas (blue arrow).

The retroperitoneal dissection began withmedial access, close to the cecum and extending untilrelease of duodenal arch and identification of the leftrenal vein (Figure 4). The paracaval space wasdissected with preservation of the right ureter andgonadal vessels. All paracaval lymph node tissue wasdissected to the left of the aorta, from the left renalvein to the left common iliac artery, preserving theinferior mesenteric artery (Figures 5 and 6).

The left ureter and gonadal vessels weredisplaced laterally. The para-aortic and aortic-intercaval lymph nodes were dissected withpreservation of the nerve plexus, leaving the vena cavaand aorta completely exposed; this completed theretroperitoneal lymphadenectomy (Figure 7). Weopted to not ligate the lumbar vessels following nervepreservation principles adopted by our service. The

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surgical specimen was removed from the cavity usinga 10 mm Endopouch®.

The monitor was then moved to the patient’sright side, close to right foot, for better visualization ofthe pelvic lymph nodes. The dissection was initiatedin the medial portion of the psoas muscle, close to thececum, displacing the right ureter medially. Dissectionprogressed to deep inguinal ring, where Cloquet’sganglion was identified.

Medially, lymphadenectomy was performedwith exposure of the common and external iliac arteryand vein. The obturator fossa was accessed, exposingthe obturator nerve. Pelvic lymphadenectomy wasperformed with preservation of the superior vesicalartery. The surgical specimens were extracted insidea 10 mm Endopouch®.

The cavity was inspected and the portsclosed. With the abdominal time concluded,Trendelenburg was reversed and the patientrepositioned with legs closed. Antisepsis wasperformed and surgical fields were prepared overthe groin and right thigh. A nodular tumor in lowerthird of the right thigh was excised with resection ofadjacent tissue to the pre-fascial plane. After closure,the right inguinal lymphadenectomy was started. Aitalics “S” shaped incision was made encompassingthe previous scar (Figure 8).

A skin graft was fashioned and dissectiondown to the vastus medialis and sartorius musclelaterally, and the angle of Scarpa’s triangle, inferiorly,was performed. Radical inguinal lymphadenectomywith saphenous vein ligation and complete exposure

of the femoral vessels was performed (Figure 9). A19 Fr closed drain was placed and the skin flaps wereclosed.

Figure 9 – Right inguinal region dissected with exposure of su-perficial femoral vessels: femoral artery (yellow arrow) andfemoral vein (blue arrow).

Figure 8 – Italics “S” shaped incision in the right inguinal region.

Figure 7 – Final result of the retroperitoneal dissection withexposure of the vena cava (green arrow), duodenal arch (redarrow), left renal vein (blue arrow), aorta (yellow arrow) andsuperior mesenteric artery (orange arrow).

Cangussu et al.50 Braz. J. Video-Sur., January / March 2013

The total surgical time of 300 minutes wasdistributed as follows: 40 minutes for the leftadrenalectomy; 120 minutes for the retroperitoneallymphadenectomy; 20 minutes for changing theposition of the monitor; 50 minutes for the right pelviclymphadenectomy; 30 minutes for preparing theinguinal field; 40 minutes for the resection of thesubcutaneous tumor and the inguinallymphadenectomy. The only intraoperativecomplication was minor bleeding from the externaliliac vein, which was controlled with a single LT 300metallic clip. Total blood loss from surgery wasestimated at 100 ml after accounting for laparoscopicvacuum residue. At the end of surgery, there wereno signs of residual disease.

The patient stayed overnight in the intensivecare unit for 12 hours for better monitoring and wastransferred to a regular room the next day with goodacceptance of diet in 24 hours. He was dischargedon the second postoperative day with an inguinaldrain. He was seen as an outpatient on the fourthpost-operative day; he had no pain complaints, nolymphedema, and no gastrointestinal or genitourinarycomplaints. He returned again a week later with anuneventful course and continued asymptomatic.Pathological examination confirmed metastaticmelanoma in the left adrenal and in the nodular tu-mor in the right thigh, but all 31 resected lymph nodeswere inflammatory and negative for malignancy.Currently, the patient is being followed as anoutpatient and receiving chemotherapy, withoutevidence of disease.

DISCUSSION

Metastases to the adrenal are rare, butmelanoma is among the principal neoplasias associatedwith such lesions. Several studies have shown thatthe prognosis of patients with adrenal metastasescaused by melanoma is poorer than with otherneoplasias.4,6 There is no consensus in the literatureregarding the surgical treatment of adrenal metastasesfrom melanoma, nor whether there is any differencein outcomes between laparotomic or laparoscopicapproaches.

One study with 154 cases of adrenalmetastasis from melanoma conducted by

MITTENDORF and cols. found an average survivalof 6.4 months, which correlated directly with elevatedLDH and synchronicity of the lesion. Patients in thisstudy who underwent surgery had longer disease-freesurvival rates. Another study, by SANCHO and cols.,found that adrenalectomy was only indicated in patientswith controlled local disease who had no othermetastases, imaging studies compatible with adrenalmetastases, and a performance status that permittedaggressive treatment.

Laparoscopic adrenalectomy is nowconsidered a well established and safe approach— both by transperitoneal or retroperitoneal routes— with the patient in various positions for anterior,lateral and posterior access. Retroperitoneallymphadenectomy is most commonly performedusing an anterior transperitoneal approach primarilyin gynecological and urological cancers, althoughthese may also be performed using extraperitonealaccess.

In our service we have performedtransperitoneal adrenalectomy with 45 degreesrecumbency and fixation of the hip and upper limbsas the position preferred to the Sims position. Inthis case, we also did not use the Sims position,opting for conducting the transperitonealadrenalectomy with the patient supine and thesurgical table tilted laterally in order to favor themajor procedure which was the retroperitoneal andpelvic lymphadenectomy, while minimizing the to-tal surgical time, since there were three proceduresusing the same approach.

Although we encountered considerabledifficulty freeing the colon and pancreas and spleen,surgical time was still considerably reduced, as therewas no need to secure the upper extremities and hipsor reposition the patient in dorsal decubitus with thearms alongside, which we consider the best positionfor the lymphadenectomies.

Regarding the positioning of the trocars, weshifted the flank trocars 2.0 cm cephally, and weshifted the epigastrium trocar to the left upper quadrantto facilitate the adrenalectomy. Although the totalprocedure time was long, analysis of the separate ti-mes for each component was quite satisfactory, whichwe can attribute to better positioning of the trocarsand the patient.

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RESUMOIntrodução: O melanoma avançado com metástase em glândula adrenal representa doença com prognóstico limitadoe com terapêutica discutível. A utilização da laparoscopia no tratamento do paciente oncológico, paliativo ou curativo, éfactível e com baixa morbidade. Alguns estudos defendem a realização da adrenalectomia como possibilidade terapêu-tica com melhora, em alguns casos, da expectativa de vida. Relato de caso: Neste artigo, descrevemos uma aborda-gem laparoscópica para realização de adrenalectomia esquerda associado à linfadenectomia retroperitoneal e pélvicano mesmo tempo cirúrgico e sem modificação no posicionamento do paciente, para tratamento de melanomametastático. Procedimento de grande porte cirúrgico transcorrido sem intercorrências, sem doença residual (CirurgiaR0), com o paciente recebendo alta hospitalar no segundo dia pós-operatório. No momento em acompanhamentoambulatorial regular e sem sinais de recidiva. Discussão: A realização de procedimentos laparoscópicos de grandeporte é hoje uma realidade, com manutenção dos benefícios da cirurgia minimamente invasiva. Neste caso, evitamosa posição de Sims, optando pela realização da adrenalectomia transperitoneal com decúbito horizontal e lateralizaçãoda mesa cirúrgica buscando beneficiar o procedimento de maior porte que seria a linfadenectomia retroperitoneal epélvica. Apesar do tempo cirúrgico do procedimento ter sido longo, a análise dos tempos separados foi bastantesatisfatória, e o paciente manteve alta hospitalar precoce. Acreditamos que diante de tal patologia, melanoma metastático,o procedimento laparoscópico traz benefícios, como também, melhora da qualidade de vida e controle da doença.

Palavras chave: Adrenalectomia laparoscópica. Linfadenectomia retroperitoneal. Melanoma. Linfadenectomia pelvic.

REFERENCES

1. Sancho JJ, Triponez F, Montet X, Sitges-Serra A. Surgicalmanagement of adrenal metastases. Langenbecks Arch Surg.2012 Feb; 397(2):179-94.

2. Crenn G, Delaunay B, Salloum A, Vezzosi D, Bellec L,Thoulouzan M, Bennet A, Rischmann P, Plante P, Caron P,Soulie M, Huyghe E. Carcinological results of laparoscopicadrenalectomy for adrenal metastasis. Prog Urol. 2011 Oct;21(9):607-14.

3. Mittendorf EA, Lim SJ, Schacherer CW, Lucci A, CormierJN, Mansfield PF, Gershenwald JE, Ross MI, Lee JE.Melanoma adrenal metastasis: natural history and surgicalmanagement. Am J Surg. 2008 Mar; 195(3):363-8; discussion368-9.

4. Muth A, Persson F, Jansson S, Johanson V, Ahlman H,Wängberg B. Prognostic factors for survival after surgery foradrenal metastasis. Eur J Surg Oncol. 2010 Jul; 36(7):699-704. Epub 2010 May 7.

Brazilian Journal of Videoendoscopic Surgery - v. 6 - n. 1 - Jan./Mar. 2013 - Subscription: + 55 21 3325-7724 - E-mail: revista@sobracil.org.brISSN 1983-9901: (Press) ISSN 1983-991X: (on-line) - SOBRACIL - Press Graphic & Publishing Ltd. Rio de Janeiro, RJ-Brasil

5. Castillo OA, Vitagliano G, Kerkebe M, Parma P, Pinto I,Diaz M. Laparoscopic adrenalectomy for suspectedmetastasis of adrenal glands: our experience. Urology. 2007Apr; 69(4):637-41.

6. Sebag F, Calzolari F, Harding J, Sierra M, Palazzo FF, HenryJF. Isolated adrenal metastasis: the role of laparoscopicsurgery. World J Surg. 2006 May; 30(5):888-92.

Correspondence address:HERON CRUSOÉ CANGUSSUAv. Princesa Isabel 590, Apt. 902, BarraSalvador, BA, Brazil40140-000Phone.: (71) 3267-2902 / 8197-1610E-mail: heron@oncovideo.com.br