Resection of adrenocortical carcinoma is less complete and local recurrence occurs sooner and more often after laparoscopic adrenalectomy than after open adrenalectomy
Division of Endocrine Surgery, Section of General Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI. Electronic address: . Surgery
(Impact Factor: 3.38).
12/2012; 152(6):1150-7. DOI: 10.1016/j.surg.2012.08.024
Controversy surrounds the use of laparoscopy for resection of adrenocortical carcinoma. We evaluated the hypothesis that outcome is equivalent in patients undergoing laparoscopic adrenalectomy versus open adrenalectomy.
This is a retrospective review of 217 patients (156 patients with stage I-III cancer) with adrenocortical carcinoma referred to a single institution between 2005 and 2011. Outcome and operative data were assessed for the subset undergoing resection with curative intent. Student t and Fisher exact tests and the Kaplan-Meier method were used to compare data (P ≤ .05 was considered statistically significant).
One hundred fifty-six patients (64% female; median age, 47 years [range, 18-80]; median follow-up, 26.5 months [range, 1-188]) were identified. Forty-six patients underwent laparoscopic adrenalectomy, and 110 underwent open adrenalectomy. Twenty-seven percent of laparoscopic adrenalectomy patients had stage III cancer. After laparoscopic adrenalectomy, 30% had positive margins or intraoperative tumor spill compared to 16% of the open adrenalectomy patients (P = .04). Overall survival for patients with stage II cancer was longer in those undergoing open adrenalectomy (P = .002). Time to visible tumor bed recurrence or peritoneal recurrence in stage II patients was shorter in laparoscopic adrenalectomy patients (P = .002).
Open adrenalectomy is superior to laparoscopic adrenalectomy for adrenocortical carcinoma based on completeness of resection, site and timing of initial tumor recurrence, and survival in stage II patients. Intraoperative evaluation is insensitive for the detection of stage III tumors.
Available from: Anthony R Glover
- "Surgery should be undertaken in a specialist center by an experienced endocrine surgeon in consultation with a multidisciplinary team.27 An open surgical approach is recommended for reoperation for locoregional recurrence due to the risk of tumor spillage, while minimally invasive surgery is inappropriate in this setting.39 "
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ABSTRACT: Adrenal cortical carcinoma (ACC) is a rare cancer that poses a number of management challenges due to the limited number of effective systemic treatments. Complete surgical resection offers the best chance of long-term survival. However, despite complete resection, ACC is associated with high recurrence rates. This review will discuss the management of recurrent ACC in adults following complete surgical resection. Management should take place in a specialist center and treatment decisions must consider the individual tumor biology of each case of recurrence. Given the fact that ACC commonly recurs, management to prevent recurrence should be considered from initial diagnosis with the use of adjuvant mitotane. Close follow up with clinical examination and imaging is important for early detection of recurrent disease. Locoregional recurrence may be isolated, and repeat surgical resection should be considered along with mitotane. The use of radiotherapy in ACC remains controversial. Systemic recurrence most often involves liver, pulmonary, and bone metastasis and is usually managed with mitotane, with or without combination chemotherapy. There is a limited role for surgical resection in systemic recurrence in selected patients. In all patients with recurrent disease, control of excessive hormone production is an important part of management. Despite intensive management of recurrent ACC, treatment failure is common and the use of clinical trials and novel treatment is an important part of management.
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ABSTRACT: Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with often unfavorable prognosis. Here we summarize the knowledge about diagnosis, epidemiology, pathophysiology and therapy of ACC. Over the recent years multidisciplinary clinics have formed and the first international treatment trials have been conducted. This review focuses on evidence gained from recent basic science and clinical research and provides perspectives from the experience of a large multidisciplinary clinic dedicated to the care of patients with ACC.
Available from: Janice Pasieka
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ABSTRACT: Cavernous hemangiomas of the adrenal gland are rare. We report a case of a cavernous hemangioma of the adrenal gland presenting as an adrenal incidentaloma suspicious for adrenal cortical carcinoma (ACC).
A 78 year old woman was admitted after a fall. Abdominal computed tomography revealed a large right adrenal lesion with features suspicious for adrenal cortical carcinoma (5.4cm×3.3cm, unilateral, tumor calcifications, average Hounsfield units 55). The tumor was removed intact by a laparoscopic approach and pathology revealed a cavernous hemangioma of the adrenal gland.
Adrenal incidentalomas are found in up to 10% of patients undergoing abdominal imaging. Differential diagnosis includes both benign and malignant lesions. Guidelines for removal of adrenal incidentalomas recommend surgery based on functional status, size, and presence of concerning features on diagnostic imaging. Cavernous hemangiomas are rare, benign vascular malformations which can be challenging to distinguish pre-operatively from malignant lesions such as ACC.
Cavernous hemangiomas of the adrenal gland are exceedingly rare. These benign tumors have imaging features which may be suggestive of adrenal cortical carcinoma. The treatment of choice is surgical excision due the difficulty of excluding malignancy.
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