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BRIEF REPORT |
Division of Urology (C.-H.L., P.-J.H.), Department of Surgery, Cardinal Tien Hospital, 231 Taipei, Taiwan; College of Medicine (C.-H.L., P.-J.H.), Fu Jen Catholic University, 242 Hsin Chuang, Taipei, Taiwan; and Department of Urology (S.-C.C., M.-K.L., J.C.), National Taiwan University Hospital and College of Medicine, National Taiwan University, 100 Taipei, Taiwan
Address all correspondence and requests for reprints to: Shih-Chieh Chueh, M.D., Ph.D., Room 11-09, National Taiwan University Hospital, No. 7 Chung-Shan South Road, Taipei 100, Taiwan. E-mail: scchueh{at}ha.mc.ntu.edu.tw.
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsDiscussionReferences |
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Patients and Methods: Among 210 LAs performed in 6 yr, 39 patients had potentially malignant tumors greater than 5 cm in diameter. Their perioperative and follow-up data were retrospectively analyzed.
Results: All 39 patients had successful LAs without perioperative mortality, conversion to open surgery, or capsular disruption during dissection. The mean tumor size was 6.2 cm (range, 5–12 cm), operative time 207 min (115–315 min), and blood loss 75 ml (minimal–1400 ml). Complications included one intraoperative diaphragmatic perforation, three mild wound infections, and one pneumonia. Preoperatively there were 27 nonfunctioning tumors, seven pheochromocytomas, three cortisol-secreting tumors, and two virilizing tumors. Final pathology revealed eight malignant (four adrenocortical carcinomas and four metastatic carcinomas) and 31 benign tumors (14 cortical adenomas, eight pheochromocytomas, six myelolipomas, and three ganglioneuromas). Median follow-up was 39 months. Four patients (two adrenocortical carcinomas, one metastatic hepatoma, and one lymphoma) died 24, 10, 9, and 3 months after surgery, respectively. A hand-assisted device was used in 10 patients. Only the tumor size was larger and length of postoperative hospital stay longer for those in the hand-assisted group.
Conclusions: LA is a reasonable option for selected large adrenal tumors when complete resection is technically feasible and there is no evidence of local invasion. Hand-assisted LA is a good alternative to open conversion if a difficult dissection is encountered intraoperatively.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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There were 39 patients among our 210 cases who had a tumor greater than 5 cm and fulfilled the inclusion criteria for the analysis.
Surgical technique
All operations were performed with the lateral transperitoneal approach (11, 12), and a hand-assisted device (HAD) was used (placed midline for a left LA and in the subcostal area for a right LA with a 7-cm incision) whenever necessary. Special attention was given to achieving an en-bloc excision of the tumor with wide surgical margins and as much periadrenal tissue as possible. All of the procedures were performed by a single experienced laparoscopic surgeon to ensure that the principles of oncologic surgery were strictly followed.
Statistical analysis
The data are expressed as mean ± SEM and range. Comparisons between groups were made by nonparametric analysis (Wilcoxon’s rank sum tests). P < 0.05 was considered statistically significant.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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Preoperatively, the case numbers and initial diagnoses of various tumors are listed in Table 1
. The patients’ mean age was 45 ± 4.1 (4–75) yr. The tumor measured 6.2 ± 1.2 (5–12) cm. Sixteen left and 23 right LAs were performed. All 39 patients had their tumor excised laparoscopically via en-bloc resection. There was no perioperative mortality and no capsular disruption during dissection. Mean operative time was 207 ± 53 (115–315) min, and mean blood loss was 75 ± 79 (minimal–1400) ml. No patient required a conversion to conventional open surgery, whereas a HAD was used in 10 patients. All of the patients resumed oral intake within 24 h after surgery.
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Pathology results and prognosis
Table 1
details the pathological diagnosis on all tumors. Preoperatively malignancy could not be ruled out in all these patients because of the large size and/or heterogeneous enhancement in imaging studies. The tumor resection margins were negative in all of the patients with adrenal metastasis or primary adrenocortical carcinoma (ACC). The median follow-up time was 39 (3–68) months. Four patients [two with ACC, one with metastatic hepatocellular carcinoma (HCC), and one with malignant lymphoma] died 24, 10, 9, and 3 months after surgery, respectively.
Six of the 39 patients had past histories of extraadrenal malignancies, but no other metastasis had been detected preoperatively. Two patients with RCC had undergone ipsilateral nephrectomy. Pathology revealed a benign adenoma in the one with diaphragmatic perforation and metastatic RCC in the other. One patient with bladder transitional cell carcinoma had an adrenal mass noted during staging work-up, which turned out to be a nonfunctioning benign adenoma. Metastasis was also confirmed in the patients with past history of lymphoma, HCC, and esophageal squamous cell carcinoma.
Table 2 depicts follow-up information on eight patients with pathologically proven malignancies. The patient with metastatic RCC had inoperable mediastinal and pulmonary metastasis 6 months later, and immunotherapy was administered. The patient with metastatic HCC died 9 months after operation due to rupture of a new hepatic recurrence. In the patient with relapsing lymphoma, contralateral adrenal metastasis and multiple lymphadenopathy were found 1 month after surgery. He died due to sepsis after chemotherapy. The patient with metastatic squamous cell carcinoma (SCC) was still alive after 9 months with further chemotherapy. No local recurrence or port seeding was noted in all these four metastatic patients.
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). In patient 5, a metastatic lymph node in the resected en-bloc mass, tumor invasion to capsules, and tumor emboli in a few vessels were reported. Local recurrence was found 5 months later, and she died after 24 months despite chemotherapy. Patient 6 had multiple metastases 3 months after surgery and died 10 months after. Patient 7 had a previous history of endometriosis. Her preoperative images showed a fat-containing tumor favoring myelolipoma, but pathology reports showed a cortical adenoma with a high mitotic figure yet not meeting the malignant criteria for a carcinoma. She had an ovarian tumor rupture 22 months after LA, and metastatic ACC was reported. Hand-assisted LA
Ten patients had hand-assisted LA. Operative time, blood loss, postoperative narcotic requirements, and incidence of wound infection were comparable between the hand-assisted LA group and those who had pure LA (n = 29). Only the mean tumor size was larger (7.33 ± 1.5 vs. 5.84 ± 1.7 cm, P = 0.01), and postoperative hospital stay was longer for those in the hand-assisted group (6.9 ± 2.1 vs. 4.2 ± 1.8 d, P = 0.03).
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Discussion |
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LA for large and/or potentially malignant adrenal tumors was first proposed by Henry et al. (4), who chose 4 cm as a cut-off point and performed 48 such LAs. Their perioperative results were comparable with those for small benign tumors. Hobart et al. (5), Novitsky et al. (7), and Tsuru et al. (10) also reported successful LAs performed in patients with adrenal tumors greater than 5 cm. They concluded that LA is safe and effective for large tumors but cautioned that strict oncological surgical principles must be observed. Moreover, other surgeons who chose 6 cm as the cut-off point (6, 8, 9) had similar conclusions. Data from our series also confirm that LA for selected tumors greater than 5 cm can be performed successfully without obvious morbidities or mortality. One important reason for the 5-cm-size cut-off was to include two of our four primary ACCs that were diagnosed at the sizes of 5–5.5 cm.
Primary ACC is a rare malignancy and has a 5-yr survival, ranging from 16 to 60% (13). Even when patients have localized disease and complete tumor resection, recurrences occur in at least two thirds of cases (13). Cobb et al. (14) reviewed LA for primary ACCs and found 10 of 25 (40%) had local recurrence. Porpiglia et al. (15) reported the outcome of six primary ACCs in 205 LAs with no intraoperative complications and one open conversion. In a mean follow-up of 30 months, only one died of stroke and the other five were disease free. Moinzadeh and Gill (16) recently reported three of the seven patients with primary ACCs receiving LA remained alive in a 26-month follow-up. In contrast, all six ACCs excised laparoscopically in the series by Gonzalez et al. (3) had local recurrences. Another review (2) concluded that any tumor greater than 6 cm has a greater risk of being malignant and should be resected by an open approach.
In our series, only one of four patients with ACCs had local recurrence, corroborating the feasibility of LA for en-bloc local resection. However, these patients still had an ominous prognosis. Cancer-specific survival was 50% and three of four patients had distant metastasis during follow-up. From our data and those just reviewed, it is difficult to conclude whether LA offers the same therapeutic efficacy for ACCs. One reason is that ACCs are so rare that most other contemporary papers contained five to seven cases at most in their series. It is very difficult to conduct a comparative study of open vs. laparoscopic adrenalectomy for large tumors or cancers in a single center. A metaanalysis to compare all LAs vs. open adrenalectomies for ACCs or a multicenter prospective comparative study of the two operative approaches might address this important issue.
There is still no reliable preoperative diagnostic test to determine the malignant potential of adrenal tumors (17). In our series, one of six myelolipomas was not diagnosed preoperatively because of no obvious fat-containing part in that tumor. Two patients in our series whose tumors had fat-containing parts (thought to be myelolipomas preoperatively) had a final diagnosis of ACC and ganglioneuroma, respectively.
Several investigators (16, 18, 19) documented that aggressive laparoscopic resection of adrenal metastasis, when done in patients with a solitary resectable disease, can result in prolonged patient survival without significant risk of port-site metastasis. In our series, none of the four patients with metastatic cancers had local recurrence after LA, which proved that LA is feasible for en-bloc local resection.
Hand-assisted LA is a minimally invasive surgical alternative (20). The series by Walz et al. (8) and Naya et al. (9) noticed that LA for patients with larger tumors (>6 and 7.5 cm, respectively) had longer operating time and greater intraoperative blood loss. Hence, we used a HAD whenever the tumor was greater than 8 cm, dissection was difficult, or uncontrollable bleeding was encountered with pure laparoscopic technique. The addition of tactile sensation and better exposure provided a more rapid and direct dissection. It also ensured intact specimen removal at the end of surgery, especially for cases with high malignant potential.
Conclusions
Laparoscopic adrenalectomy is a reasonable procedure for selected large adrenal tumors when a complete resection is technically feasible and there is no evidence of local invasion. A hand-assisted laparoscopic procedure is a good option before an open conversion is considered, especially when difficult dissections are encountered intraoperatively.
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Footnotes |
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Abbreviations: ACC, Adrenocortical carcinoma; HAD, hand-assisted device; HCC, hepatocellular carcinoma; LA, laparoscopic adrenalectomy; RCC, renal cell carcinoma; SCC, squamous cell carcinoma.
Received November 4, 2005.
Accepted May 12, 2006.
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TopAbstractIntroductionPatients and MethodsResultsDiscussionReferences |
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