Laparoscopic Versus Open Adrenalectomy for Adrenocortical Carcinoma: Surgical and Oncologic Outcome in 152 Patients

Abstract

Background

The role of laparoscopic adrenalectomy in the treatment of patients with adrenocortical carcinoma (ACC) is controversial.

Objective

Our aim was to compare oncologic outcome in patients with ACC who underwent either open adrenalectomy (OA) or laparoscopic adrenalectomy (LA) for localised disease.

Design, setting, and participants

We conducted a retrospective analysis of 152 patients with stage I–III ACC with a tumour ≤10 cm registered with the German ACC Registry.

Intervention

Patients were stratified into two groups according to the surgical procedure (LA or OA). For comparison, we used both a matched pairs approach by selecting for each patient from the LA group (n = 35) one corresponding patient from the OA group (n = 117) and multivariate analysis in all 152 patients.

Measurements

Disease-specific survival was chosen as the predefined primary end point. Secondary end points were recurrence-free survival, frequency of tumour capsule violation and postoperative peritoneal carcinomatosis, and incidence and reasons for conversion from LA to OA.

Results and limitations

LA and OA did not differ with regard to the primary end point using either the matched pairs approach (hazard ratio [HR] for death: 0.79; 95% confidence interval [CI], 0.36–1.72; p = 0.55) or multivariate analysis (HR for death: 0.98; 95% CI, 0.51–1.92; p = 0.92). Similarly, adjusted recurrence-free survival was not different between LA and OA (HR: 0.91; 95% CI, 0.56–1.47; p = 0.69). Frequency of tumour capsule violation and peritoneal carcinomatosis were comparable between groups. In 12 of 35 patients of the LA group, surgery was converted to open surgery with no impact on the clinical outcome.

Conclusions

For localised ACC with a diameter of ≤10 cm, LA by an experienced surgeon is not inferior to OA with regard to oncologic outcome.

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.