FOR REFERENCE - treatment of adrenal metastases

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Claudine
Posts: 267
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

FOR REFERENCE - treatment of adrenal metastases

Postby Claudine » Wed Feb 05, 2020 2:34 pm

When I first posted on this forum, I asked if anyone was in my husband's situation: no primary tumor but two isolated mets, one in the 4th lumbar vertebrae, the other in the left adrenal gland. Now that I've been here a while, I know that this is a pretty unusual situation! Yet isolated mets from CRC to the adrenal gland do occur - just not as often as, say, liver or lung mets: "Metastasis to the adrenal gland is a relatively frequent autopsy finding in cancer patients. Adrenal metastasis from colorectal cancer (CRC) is not rare; however, it usually occurs in patients with multiple synchronous metastases in the terminal stage of cancer. Solitary and clinically curable adrenal metastasis from CRC is extremely unusual."

When we met with the urologist who's going to perform my husband's adrenalectomy next week, he told us that 20 years ago, nobody would have considered treatment beside systemic chemo. Then 10 years ago, it would have been a major, let's-cut-you-all-open surgery. Now it is routinely done laparoscopically - an overnight at the hospital and you go home, able to resume activities fully within the week! Several studies have now shown the benefits (in terms of survival) of directly tackling the tumor, either using radiation (SBRT) or via surgery. At first we thought my husband would be treated via radiation, but his guts make a loop very close to the tumor site and there was concern of "friendly fire". That's fine with us, we'd rather they take the damn thing out! Expecially since it's on the left side, which is easier to access.

Here are links to publications I found:

Cancer, Adrenal Metastasis
https://www.ncbi.nlm.nih.gov/books/NBK441879/

Surgery:
The role of laparoscopic resection of metastases to adrenal glands
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5566667/
Laparoscopic Adrenalectomy for Isolated Adrenal Metastasis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016821/
Adrenalectomy may increase survival of patients with adrenal metastases
https://bmcsurg.biomedcentral.com/artic ... 015-0088-z
Endoscopic Retroperitoneal Adrenalectomy for Adrenal Metastases
https://www.hindawi.com/journals/ije/2014/806194/
Long-term survival after adrenal metastasectomy from colorectal cancer: a report of two cases
https://surgicalcasereports.springerope ... 019-0611-z

SBRT
SBRT to adrenal metastases provides high local control with minimal toxicity
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5707423/
Stereotactic body radiation therapy for adrenal gland metastases: Outcomes and toxicity
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200881/
SBRT: A viable option for treating adrenal gland metastases
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4661344/
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A
No primary (involuted?)
Lytic tumor L4 vertebrae, EBRT radiation 04/18, SBRT 02/19
Resection small intestine 05/18 (no cancer found - Crohn's)
Failed adjuvant Xelox
Folfiri + Avastin since 03/19
6.7 cm left adrenal mass 03/19, 3.67 cm 12/19, successful resection 02/20
CEA since 03/19: high 58, low 3.2, now 10.2
Scan 03/19: Multiple small lung nodules up to 5mm
Scan 12/19: 2 calcified granulomas, one 1mm stable nodule

kandj
Posts: 275
Joined: Sun Sep 27, 2015 11:29 am

Re: FOR REFERENCE - treatment of adrenal metastases

Postby kandj » Wed Feb 05, 2020 3:10 pm

I'm glad your DH is getting his adrenalectomy! My DH has one on his right side that they are going to do an ablation on (it is fairly small, about 1.5cm I think). I have read good things about ablation on them. DH had SBRT on 4 liver mets in Nov2017 and has had good results so far. His radiation oncologist said that it would have been different 10 yrs before. They were too scared of killing the whole liver. He has had no major issues, so that has been great! Good luck to your DH
wife to DH, dx 8/15 stage IV @36, numerous unresectable liver Mets
resection and HAI placed 12/15
Liver resection 5/19/2016 15-20 mets removed (surgeon lost count, but it hopeful he got it all!)
Recurrence 7/2017 4 Liver mets and one possible lung met
Radiation on liver Mets 12/17
Lung met 10/18
VATS on lung met 11/18 started xeloda
Chemo break 6/19-11/19
New spot seen in lungs and adrenal gland 11/2019

Claudine
Posts: 267
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Claudine » Wed Feb 05, 2020 3:55 pm

Thanks Kandj! I'll add ablation to the list of treatment procedures :D

https://www.ajronline.org/doi/full/10.2214/AJR.12.10328
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A
No primary (involuted?)
Lytic tumor L4 vertebrae, EBRT radiation 04/18, SBRT 02/19
Resection small intestine 05/18 (no cancer found - Crohn's)
Failed adjuvant Xelox
Folfiri + Avastin since 03/19
6.7 cm left adrenal mass 03/19, 3.67 cm 12/19, successful resection 02/20
CEA since 03/19: high 58, low 3.2, now 10.2
Scan 03/19: Multiple small lung nodules up to 5mm
Scan 12/19: 2 calcified granulomas, one 1mm stable nodule

Claudine
Posts: 267
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Claudine » Tue Feb 11, 2020 5:29 pm

DH had laparoscopic adrenalectomy this morning. The surgery (3.5 hours) went well; the surgeon first had to "move things around" - the pancreas for example, and there was also quite a bit of scar tissue from DH's previous small intestine resection, as well as from chemotherapy. Once he got in position he found that the gland and associated met were in a thick wad of fat; I know that my husband has gained weight (and has been very upset about it) from lack of exercise this past year, but in this case it was a blessing, as everything could be taken out very neatly - the fat made for a nice buffer, the surgeon couldn't even see the tumor. DH should be able to come home as soon as tomorrow and resume normal activities within a few days.
Phew! A good thing done. Now let's hope for low CEA levels during the next control on March 12th... It would be nice for him to be able to stay off chemo for a while.
Last edited by Claudine on Tue Feb 11, 2020 6:19 pm, edited 1 time in total.
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A
No primary (involuted?)
Lytic tumor L4 vertebrae, EBRT radiation 04/18, SBRT 02/19
Resection small intestine 05/18 (no cancer found - Crohn's)
Failed adjuvant Xelox
Folfiri + Avastin since 03/19
6.7 cm left adrenal mass 03/19, 3.67 cm 12/19, successful resection 02/20
CEA since 03/19: high 58, low 3.2, now 10.2
Scan 03/19: Multiple small lung nodules up to 5mm
Scan 12/19: 2 calcified granulomas, one 1mm stable nodule

Claudine
Posts: 267
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Claudine » Tue Feb 11, 2020 6:18 pm

Sorry duplicated post was trying to delete!
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A
No primary (involuted?)
Lytic tumor L4 vertebrae, EBRT radiation 04/18, SBRT 02/19
Resection small intestine 05/18 (no cancer found - Crohn's)
Failed adjuvant Xelox
Folfiri + Avastin since 03/19
6.7 cm left adrenal mass 03/19, 3.67 cm 12/19, successful resection 02/20
CEA since 03/19: high 58, low 3.2, now 10.2
Scan 03/19: Multiple small lung nodules up to 5mm
Scan 12/19: 2 calcified granulomas, one 1mm stable nodule

Malidosa
Posts: 35
Joined: Sun Dec 29, 2019 11:15 pm

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Malidosa » Thu Feb 13, 2020 6:29 pm

Ok so I'm having a little bit of a freak out. I had an MRI and PET scan done to look closer at my adrenal nodule. The size came back as 3.2cmx2.3cm. Based on the medical terminology I'm reading in the report it sounds like this could be an a met from my colon cancer (which maybe someone can explain this to me as I was staged at stage 1 with no lymph node involvement) or its adrenal cancer...... This is literally blowing my mind that I could have 2 entirely different cancers diagnosed within a month of each other??? The MRI report is showing that all my other organs are unremarkable. But this just seems insane. I know I'm having the classic freak out that I should be without fully understanding... but of course google has me fearing the worst.... per usual.....
Dx - Cecum mass - age 35
Stage 1 (T2, N0, M0) - CEA level - 0.5
26 nodes negative
Right Colectomy 1/16/20
Currently investigating a 3.2 cm adrenal mass

Claudine
Posts: 267
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Claudine » Thu Feb 13, 2020 11:45 pm

What did the PET scan show in terms of uptake? Are you scheduled for a biopsy? Most adrenal nodules are not malignant. Keep us posted, I really hope it’s not!
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A
No primary (involuted?)
Lytic tumor L4 vertebrae, EBRT radiation 04/18, SBRT 02/19
Resection small intestine 05/18 (no cancer found - Crohn's)
Failed adjuvant Xelox
Folfiri + Avastin since 03/19
6.7 cm left adrenal mass 03/19, 3.67 cm 12/19, successful resection 02/20
CEA since 03/19: high 58, low 3.2, now 10.2
Scan 03/19: Multiple small lung nodules up to 5mm
Scan 12/19: 2 calcified granulomas, one 1mm stable nodule

Claudine
Posts: 267
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Claudine » Thu Feb 13, 2020 11:48 pm

Also, did you get the results from your Lynch syndrome test?
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A
No primary (involuted?)
Lytic tumor L4 vertebrae, EBRT radiation 04/18, SBRT 02/19
Resection small intestine 05/18 (no cancer found - Crohn's)
Failed adjuvant Xelox
Folfiri + Avastin since 03/19
6.7 cm left adrenal mass 03/19, 3.67 cm 12/19, successful resection 02/20
CEA since 03/19: high 58, low 3.2, now 10.2
Scan 03/19: Multiple small lung nodules up to 5mm
Scan 12/19: 2 calcified granulomas, one 1mm stable nodule

Malidosa
Posts: 35
Joined: Sun Dec 29, 2019 11:15 pm

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Malidosa » Fri Feb 14, 2020 10:45 am

It said the SUV was 9 and had no signal dropout. The impression was written as consideration of metastases or adrenal corticol carcinoma. My test for lynch hasn't come back yet I meet with my doctor next Tuesday, but my brothers came back with MAP so my genetic counselor believes that's most likely what I will have too.
All of my other organs came back as unremarkable.

I just don't know how to not freak out at this point. I've suspected well before this all started that I might have Pheochromocytoma if you are familiar with that because I used to experience a lot of panic attack feelings. And when I had my colon surgery my blood pressure spiked which the anasthesiologist suggested is a sign of a pheo. Again something that is one in a million so getting people to consider it is a struggle in itself. I know with the adrenal glands it can be really hard to determine what it really is on scans and can lead to false positive or false negative. But my oncologist told me they most likely wont want to do a biopsy because with the adrenal gland depending on exactly what it is it could leak the hormones that it produces.

And as i'm sure you know there isn't alot of online communities regarding adrenal conditions..... so feeling scared.
Dx - Cecum mass - age 35
Stage 1 (T2, N0, M0) - CEA level - 0.5
26 nodes negative
Right Colectomy 1/16/20
Currently investigating a 3.2 cm adrenal mass

Claudine
Posts: 267
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Claudine » Fri Feb 14, 2020 11:15 am

I had to google MAP, I had never heard of it. I found an article that says this:

MUTYH polyposis (also referred to as MUTYH-associated polyposis, or MAP) is characterized by a greatly increased lifetime risk of colorectal cancer (CRC). Although typically associated with ten to a few hundred colonic adenomatous polyps, CRC develops in some individuals in the absence of polyposis. Serrated adenomas, hyperplastic/sessile serrated polyps, and mixed (hyperplastic and adenomatous) polyps can also occur. Duodenal adenomas are common, with an increased risk of duodenal cancer. The risk for malignancies of the ovary and bladder is also increased, and there is some evidence of an increased risk for breast and endometrial cancer. Additional reported features include thyroid nodules, benign adrenal lesions, jawbone cysts, and congenital hypertrophy of the retinal pigment epithelium.

When DH's adrenal met was confirmed via PET scan, his SUV was 17.8 so quite a bit higher than your value of 9 (but in absolute values I'm not sure what this means).
If they don't biopsy, what is the next step they're planning to take to determine the nature of the adrenal mass?

Not knowing is so hard, I really feel for you - of course it would be better to have a benign mass, but if it isn't, it would be good to know its nature ASAP so the appropriate treatment can start.
Wishing you strength through this ordeal XXXXXXXXXX
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A
No primary (involuted?)
Lytic tumor L4 vertebrae, EBRT radiation 04/18, SBRT 02/19
Resection small intestine 05/18 (no cancer found - Crohn's)
Failed adjuvant Xelox
Folfiri + Avastin since 03/19
6.7 cm left adrenal mass 03/19, 3.67 cm 12/19, successful resection 02/20
CEA since 03/19: high 58, low 3.2, now 10.2
Scan 03/19: Multiple small lung nodules up to 5mm
Scan 12/19: 2 calcified granulomas, one 1mm stable nodule

Malidosa
Posts: 35
Joined: Sun Dec 29, 2019 11:15 pm

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Malidosa » Fri Feb 14, 2020 11:34 am

At this point I'm waiting to meet with my oncologist next Tuesday. I just jumped ahead of the game and read the reports on my own so naturally freaked myself out, fearing the worst. He is the overly cautious type (which is good) but I know he is gonna through around words that are hard to hear no matter what. ( I think in some ways I'm still having moments where I feel out of body like, is this really happening to me?)

He mentioned that he will be sending me to an endocrinologist no matter what the scans showed. So I'm prepared for that. And honestly no matter what it is I want it out... its something that's not supposed to be there no matter what. And yeah my genetic counselor told me benign adrenal nodules are common with people with MAP. (but again I haven't been told I have MAP just an assumption because my brother does).

Its so ridiculous how the mind works.... you know there is nothing you can do at the moment... you know you need to look at your facts and not others.... but its like something inside constantly has to remind you of the struggle and the fear. UGH....trying to focus on whats good instead of whats bad.....
Dx - Cecum mass - age 35
Stage 1 (T2, N0, M0) - CEA level - 0.5
26 nodes negative
Right Colectomy 1/16/20
Currently investigating a 3.2 cm adrenal mass

Malidosa
Posts: 35
Joined: Sun Dec 29, 2019 11:15 pm

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Malidosa » Fri Feb 14, 2020 11:50 am

Claudine, any information you are willing to share at this point would be appreciated.

I see your husband went to a urologist for his? I'm being told I need to see an endocrinologist is there a reason that he was sent to a different specialilty? I know your husband's was shrunk before surgery was there an ideal size they were trying to achieve? Did you have a hard time finding a surgeon? I know that this is one of those things that you really want someone who knows what they are doing.
Dx - Cecum mass - age 35
Stage 1 (T2, N0, M0) - CEA level - 0.5
26 nodes negative
Right Colectomy 1/16/20
Currently investigating a 3.2 cm adrenal mass

Claudine
Posts: 267
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Claudine » Fri Feb 14, 2020 12:18 pm

Well, I'm not sure why a urologist and not an endocrinologist but the surgeon who operated on my husband is the specialist for the whole state (granted we're in Montana which isn't that populated but still!). That's pretty much all he does - travels around to excise adrenal glands! Add to this that a close friend of mine praised him highly (he operated on her son) and we knew we were in good hands (plus he really is a super nice guy, he's local, and the hospital just received a brand-new robot to perform the surgery with).

The reasoning behind waiting for surgery was of course to reduce the size of the met, but that wasn't the main reason. When DH did adjuvant chemo and it failed, there was no way to know if it was working or not - nothing to measure (his lumbar spine lesion is lytic, so it doesn't shrink, it's just this black spot on a scan where bone tissue should be). His oncologist wanted to use the adrenal met as the proverbial "canary in a coal mine" to assess the efficacy of the new chemo regimen (Folfiri + Avastin). Because of the adrenal met, and the many tiny lung met, it was clear that DH's cancer wasn't under control. Since the adrenal gland shrank (especially at first), it gave the oncologist confidence that other "floating" cancer cells were also affected. Then in early winter it became clear that the shrinkage had almost stopped, and since all other lesions appeared stable, we got the green light for adrenalectomy.
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A
No primary (involuted?)
Lytic tumor L4 vertebrae, EBRT radiation 04/18, SBRT 02/19
Resection small intestine 05/18 (no cancer found - Crohn's)
Failed adjuvant Xelox
Folfiri + Avastin since 03/19
6.7 cm left adrenal mass 03/19, 3.67 cm 12/19, successful resection 02/20
CEA since 03/19: high 58, low 3.2, now 10.2
Scan 03/19: Multiple small lung nodules up to 5mm
Scan 12/19: 2 calcified granulomas, one 1mm stable nodule

jsbsf
Posts: 30
Joined: Sat Aug 24, 2019 6:01 am
Location: San Francisco

Re: FOR REFERENCE - treatment of adrenal metastases

Postby jsbsf » Sun Feb 16, 2020 2:18 am

Hey Claudine,

My husband coincidentally had surgery on the very same day as yours. It was his first real surgery. His was a laparoscopic liver resection. He spent the night in the hospital, was in quite a bit of pain on Wednesday. We went for a hike on Friday and again today, and the pain has almost completely diminished. So he’s recovering quite well. I hope your husband is feeling better after his.
DH 61
2019
8/23 C-scopy, 5+cm mass. CEA:4.1
8/26 CT ~1cm lvr met?
9/6 PET: liver spot
9/16 MSS. MRI: 2 liver mets: 2.7 & 7mm
9/23 Port
9/30 Start FOLFOX
10/4 Lg lvr met ~3.7cm (raised concern), pri tmr stable.
CEA: 10/13,12.5;10/27,4.7;11/10,3.3; 11/24,3.1;12/8,3.3
11/5 both lvr mets ~ 2/3 smaller.
12/17 PET: sm lvr met gone, remaining tmrs @10% of orig sz & actvty
Chemo break: MWA 2/5, Lap resection 2/11

Claudine
Posts: 267
Joined: Tue Mar 12, 2019 2:41 pm
Location: Montana

Re: FOR REFERENCE - treatment of adrenal metastases

Postby Claudine » Sun Feb 16, 2020 7:36 pm

That’s fantastic jsbsf! When it’s possible, laparoscopic surgery is such a better option than being cut open, in terms of recovery. DH is currently spinning in the basement... He did 10k Thursday and 10k Friday (tried going to work Friday morning but that was a bit much). Spinning is great as it is lower impact than other sports.
I hope your husband’s recovery continues at this pace!
Wife of Dx 04/18 (51 yo). MSS, KRAS G12A
No primary (involuted?)
Lytic tumor L4 vertebrae, EBRT radiation 04/18, SBRT 02/19
Resection small intestine 05/18 (no cancer found - Crohn's)
Failed adjuvant Xelox
Folfiri + Avastin since 03/19
6.7 cm left adrenal mass 03/19, 3.67 cm 12/19, successful resection 02/20
CEA since 03/19: high 58, low 3.2, now 10.2
Scan 03/19: Multiple small lung nodules up to 5mm
Scan 12/19: 2 calcified granulomas, one 1mm stable nodule


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