AdrenalsLaparoscopic Versus Open Adrenalectomy for Adrenocortical Carcinoma: Surgical and Oncologic Outcome in 152 Patients
Introduction
Minimally invasive retroperitoneoscopic or laparoscopic adrenalectomy (LA) has become the accepted gold standard for the treatment of benign adrenal tumours because it leads to fewer complications, a shorter hospital stay, and reduced 30-d morbidity rates [1], [2], [3], [4], [5]. Although initially this technique was restricted to small tumours, today experienced surgeons can safely remove benign tumours up to 12 cm [4]. Although in such larger tumours operative time, blood loss, and hospital stay may be increased, the general benefits of LA are maintained [6].
In contrast, for adrenocortical carcinoma (ACC), the role of LA is controversial. Surgery is of utmost importance in the treatment of ACC because a margin-free complete resection (R0 resection) provides the only means to achieve long-term cure. Although evidence of invasive disease before surgery requires an open approach, localised tumours (stage I/II) with a diameter <10 cm may also be accessible by LA. However, although some surgeons claim that LA for localised ACC may be performed with equal oncologic outcome [7], others believe this approach is contraindicated [4]. Initial reports on LA for ACC described tumour fragmentation and port-site and local recurrences [8], [9]. In addition, Gonzalez et al. [10] reported on a high risk of peritoneal carcinomatosis after LA for ACC, and this concern was reiterated in a recent report from France [11]. In contrast, a growing number of reports on laparoscopic surgery for ACC suggest a comparable or even superior oncologic outcome compared with open surgery [12], [13]. In most cases the tumour diameter was <8.5 cm [7], but recently laparoscopic surgery for malignant tumours with a size up to 15 cm has been reported [14]. Because ACC frequently recurs after surgery with curative intent [15], [16], evaluation of the best surgical strategy requires long-term follow-up in a sufficient number of patients.
Due to the rarity of the disease, the number of ACC cases in these series has been small, the follow-up time was limited, and suitable controls, who underwent open adrenalectomy (OA) for ACC, were frequently lacking [7].
To overcome these limitations, we provide data here from the German ACC Registry on the role of the surgical approach for the oncologic outcome in patients with ACC.
Section snippets
German Adrenocortical Carcinoma Registry
At the time of the analysis (April 2010), the German ACC Registry (www.nebennierenkarzinom.de) contained 608 patients. All data were collected by trained medical personnel as described previously [17], [18], [19]. Follow-up data were obtained approximately every 3 mo. The German ACC Registry was approved by the ethics committee at the University of Würzburg, and patients gave written informed consent. The diagnosis had been confirmed by histopathology [16]. Stage designation was based on the
Surgical outcome
Table 1 lists patient characteristics. In 35 of 152 patients (23%), LA was performed. In 33 patients, a laparoscopic transperitoneal approach was used (94%); two patients had undergone retroperitoneoscopic adrenalectomy. In the OA group, 85 patients (73%) had transperitoneal, 31 patients (26%) had retroperitoneal, and 1 patient (1%) had thoracoabdominal surgery. In 12 cases the surgeons converted from LA to open surgery due to bleeding (n = 4), adhesions (n = 4), bowel perforation (n = 1), or other
Discussion
The major finding of our analysis is a similar outcome after minimally invasive and open surgery for localised ACC with a diameter ≤10 cm. This result was consistently derived both by a matched pairs approach and by multivariate analysis. It relates both to oncologic outcome parameters like disease-specific survival and recurrence-free survival as well as to surgical complications like tumour capsule violation and occurrence of peritoneal carcinomatosis. Compared with previous investigations,
Conclusions
Our study suggests that LA is not inferior to OA in localised ACC with a diameter ≤10 cm with regard to oncologic outcome. Therefore, LA performed by an experienced adrenal surgeon is justified for potentially malignant adrenal incidentalomas and for selected cases of stage I and II ACC.
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These authors contributed equally.