Principles of ACC Resection

Localized Disease Management

Complete surgical resection is the central local treatment for adrenocortical carcinoma (ACC) and remains the only intervention with established curative potential for most patients with localized or locoregionally confined disease.¹²³ Within ACC management, resection defines local therapy, establishes pathologic stage, and strongly influences recurrence risk, adjuvant treatment decisions, and long-term surveillance planning.⁴⁵⁶ Across modern guidelines and large retrospective cohorts, the quality of the initial operation—particularly intact en bloc removal with negative margins and without tumor rupture—appears more important than many technical variations in approach.⁷⁸⁹

ACC resection is distinct from routine adrenalectomy for benign disease because suspected malignancy is generally approached as an oncologic operation from the outset. The operative objective is complete clearance of the primary tumor and any directly involved structures while preserving capsule integrity and minimizing the risk of local or peritoneal dissemination.¹⁰¹¹¹² This emphasis reflects the high recurrence rate of ACC even after apparently curative surgery and the difficulty of salvaging an inadequate first operation.⁴¹³

The evidence base is substantial but methodologically limited. Most data come from retrospective single-center series, registries, pooled observational analyses, and expert guidance rather than randomized or prospective comparative trials.¹⁴¹⁵¹⁶ As a result, major recommendations are supported mainly by consistent observational trends, with persistent confounding from tumor size, stage, local invasion, referral patterns, surgeon expertise, and selective use of open or minimally invasive techniques.¹⁷¹⁸¹⁹

Several principles are nevertheless stable across the literature. Suspected ACC is usually evaluated with endocrine testing and high-quality staging imaging, managed in multidisciplinary referral settings when feasible, and resected with planning for possible nodal, adjacent-organ, or venous extension.²⁰²¹²² Ongoing controversy chiefly concerns the boundaries of minimally invasive surgery, the therapeutic value and extent of lymphadenectomy, and the role of aggressive surgery in recurrent or more advanced presentations.²³²⁴²⁵

Diagnostic and preoperative context

Preoperative assessment in suspected ACC usually includes biochemical evaluation for hormone excess and cross-sectional imaging to define tumor size, local extension, nodal disease, distant metastases, and venous tumor thrombus.²⁶²¹²⁷ This workup has practical implications beyond diagnosis, because cortisol excess and other functional syndromes may affect perioperative optimization, and imaging findings help determine whether vascular, hepatobiliary, thoracic, or cardiac surgical support may be required.²⁸²⁹³⁰

This preoperative staging framework is well supported, but it is not completely reliable. Occult extra-adrenal invasion, nodal disease, or venous extension may still be identified only intraoperatively or on final pathology, which limits confidence in preoperative down-selection for less extensive surgery.³¹³² Clinically, imaging uncertainty generally favors planning for an oncologic resection rather than a limited adrenalectomy when ACC is a realistic possibility.⁴³³

From this staging context, the main surgical question becomes how best to achieve oncologic clearance at the first operation.

Core oncologic principles

The principal surgical goal is complete macroscopic and microscopic resection with preservation of tumor capsule integrity and avoidance of tumor spill.³⁴¹⁰¹² In ACC, margin-negative resection is one of the most consistent prognostic findings across historical and contemporary series, whereas incomplete resection, gross residual disease, and capsular disruption are repeatedly associated with earlier recurrence and worse survival.³⁵⁷⁸

This is among the most reliable conclusions in the literature. What is less certain is which technical strategy is best in every anatomic scenario, but the practical implication is clear: operative planning generally prioritizes exposure, vascular control, and intact specimen removal over short-term perioperative advantages alone.³⁶³⁷³⁸

Surgical approach

Open adrenalectomy

Open adrenalectomy remains the reference approach in most guidelines and review-based recommendations, particularly for large tumors, ENSAT stage III disease, adjacent-organ invasion, suspicious nodes, or venous thrombus.³³⁹⁶ A transabdominal open approach is commonly favored because it facilitates wide exposure, en bloc resection, regional lymphadenectomy, and vascular control when multivisceral or caval procedures are needed.⁴⁰³⁷⁹

The preference for open surgery is supported by consistent observational data, although not by randomized trials. Meta-analyses and retrospective cohorts often show lower rates of positive margins, peritoneal recurrence, or earlier relapse with open surgery, but these comparisons remain vulnerable to selection bias because more favorable tumors are often chosen for minimally invasive resection.⁴¹¹⁶⁴² In practice, open surgery remains the default when oncologic adequacy is uncertain.⁴³¹⁹

Minimally invasive approaches

Laparoscopic and robotic adrenalectomy remain controversial in ACC. Selected series suggest that minimally invasive surgery may achieve similar survival and recurrence outcomes in carefully staged, localized, noninvasive tumors—generally stage I-II disease, often 10 cm or smaller, treated in expert centers with strict adherence to oncologic technique.⁴⁴⁴⁵⁴⁶ Other studies, however, associate minimally invasive surgery with more positive margins, earlier local or peritoneal recurrence, and higher risk of peritoneal carcinomatosis.⁴⁷⁴⁸⁴⁹

Accordingly, the most defensible synthesis is that minimally invasive adrenalectomy may be acceptable only in highly selected patients and does not replace open surgery as the standard for suspected invasive ACC.⁵⁰⁵¹⁹ Preoperative selection is imperfect, and conversion from minimally invasive to open surgery has been associated in some datasets with worse outcomes, likely reflecting unrecognized complexity or compromised oncologic conditions.⁵²⁵³⁸ The practical implication is a low threshold for primary open surgery and early conversion whenever planes are unclear or intact en bloc resection may be jeopardized.⁵⁴⁵⁵⁵⁶

Approach selection then leads to questions about operative extent, especially when lymph nodes, adjacent organs, or major veins are involved.

Extent of resection

En bloc and multivisceral resection

Adjacent-organ resection may be required when ACC directly invades surrounding structures or when attempts at separation would risk capsule rupture.⁵⁷⁵⁸⁵⁹ Commonly involved or threatened structures include kidney, liver, diaphragm, spleen, pancreas, and major veins.⁶⁰⁶¹⁶²

The evidence supports selective rather than routine extension of resection. Contemporary analyses suggest that removal of uninvolved organs does not improve survival if a negative-margin adrenalectomy can otherwise be achieved.⁶³⁶⁴⁶⁵ The clinical implication is that multivisceral surgery is justified for oncologic clearance, but prophylactic organ sacrifice is not a standard objective.⁶⁶⁶⁷

Lymphadenectomy

Regional lymph node dissection is increasingly regarded as part of curative-intent ACC surgery because it improves staging and may confer therapeutic benefit.⁶⁸⁵²⁴ Retrospective registry studies and recent reviews suggest associations with lower recurrence and better survival when a planned locoregional lymphadenectomy is performed rather than removing only grossly abnormal nodes.⁶⁹⁷⁰¹²

This trend is suggestive rather than definitive. Definitions of lymphadenectomy, nodal templates, and pathology processing remain heterogeneous, so the magnitude of therapeutic benefit and the optimal field are still uncertain.⁷¹⁷² In practical terms, many expert recommendations favor intentional regional node dissection, while acknowledging that standardization remains incomplete.³²⁵

Venous tumor thrombus

Venous extension into the renal vein, inferior vena cava, or even the right atrium does not necessarily preclude curative-intent surgery in selected nonmetastatic patients.⁷³⁷⁴⁷⁵ Small series and case-based experience show that thrombectomy, caval resection, vascular reconstruction, and cardiopulmonary bypass can permit complete resection in specialized centers.⁷⁶⁷⁷⁷⁸

This is a technically feasible but high-risk area with limited generalizable evidence, because published experience is dominated by retrospective series and case reports.⁷⁹²⁹³⁰ The practical implication is that venous thrombus should prompt referral and multidisciplinary planning rather than automatic exclusion from surgery.⁸⁰⁸¹²²

Outcomes, recurrence, and reoperation

Across ACC series, completeness of resection remains the most reproducible predictor of postoperative outcome.³⁴²⁸ Margin status appears more consistently prognostic than operative access itself, although approach may influence the likelihood of achieving an intact R0 resection in difficult cases.⁸²⁸³⁸⁴

Recurrence is common even after apparently curative surgery, including in early-stage disease.¹³⁸⁵ Retrospective data suggest that repeat resection for locoregional recurrence or limited metastatic disease may benefit selected patients when complete excision is realistic and tumor biology appears favorable, whereas debulking for widely metastatic ACC has less certain value.⁸⁶⁸⁷⁸⁸ Clinically, surgery remains most compelling when it can plausibly restore macroscopic disease control.

Pitfalls, care setting, and ongoing questions

ACC resection may carry substantial operative risk because tumors are often large, hypervascular, hormonally active, locally invasive, or associated with major venous involvement.⁸⁹⁹⁰⁸⁰ Important oncologic pitfalls include capsule rupture, tumor spill, scar implantation, and peritoneal dissemination, all of which may compromise local control.⁹¹⁴⁷⁹²

The exact rates of these events vary across series, but the broad pattern is reliable: outcomes are generally better when surgery is performed in high-volume multidisciplinary centers with ACC experience.²⁰⁹³²² This supports centralization of care and early referral when imaging suggests malignancy, local invasion, or venous thrombus.

Current unresolved questions concern optimization rather than whether surgery matters. Remaining areas of debate include which localized tumors can be safely managed minimally invasively, how lymphadenectomy should be standardized, and whether neoadjuvant therapy has a role in borderline resectable disease.⁹⁴²³⁷² Until stronger prospective evidence becomes available, the dominant consensus remains expert, margin-focused oncologic resection—usually open—for suspected ACC, with more selective minimally invasive use in carefully staged low-volume disease.³⁶⁴³⁹

Included Articles

PMID 2198370: This review discusses surgical approach selection for adrenal tumors, noting that when a unilateral lesion is known preoperatively and exceeds 5 cm, malignancy including adrenocortical carcinoma should be suspected and transperitoneal or thoracoabdominal resection is preferred over less invasive posterior or lumbar approaches.⁹⁵

PMID 2743274: This case report describes successful radical resection of adrenocortical carcinoma with tumor thrombus extending from the adrenal vein through the inferior vena cava into the right atrium, using hypothermia and cardiopulmonary bypass. It argues that intravascular or intraatrial extension should not by itself preclude curative-intent surgery when carefully planned.⁷⁹

PMID 2774730: This case report describes curative-intent one-stage resection of adrenocortical carcinoma with tumor thrombus extending through the inferior vena cava, hepatic veins, and right atrium using hypothermic circulatory arrest. The authors suggest aggressive surgery may be appropriate when there is no disseminated local or distant disease.⁹⁶

PMID 8176925: In this 53-patient retrospective ACC series, complete gross surgical excision was associated with significantly longer survival than incomplete resection, supporting surgery as the main curative-intent approach for localized disease. The authors also emphasize the need for adequate exposure and careful operative technique for large adrenal tumors.³⁴

PMID 9507868: This case report argues against laparoscopic adrenalectomy for malignant adrenal tumors after adrenocortical carcinoma recurred 19 months after laparoscopic resection initially performed for presumed adenoma. The authors suggest reserving laparoscopic adrenalectomy for lesions smaller than 6 cm with smooth contour and homogeneous internal appearance.⁹⁷

PMID 9735134: This review emphasizes that potentially malignant ACC should be managed with open oncologic resection rather than laparoscopic removal when malignancy is suspected by size or imaging. Complete en bloc excision without tumor fracture or capsule disruption is presented as the key potentially curative treatment and strongest predictor of longer survival.¹⁰

PMID 9855136: This case report describes resection of a rapidly enlarging adrenal mass that proved to be ACC after failing germ-cell tumor chemotherapy. It notes successful laparoscopic adrenalectomy with negative margins in an encapsulated tumor, while emphasizing rupture risk and the need for highly skilled surgeons with readiness to convert to open surgery.⁹⁸

PMID 10096148: This review emphasizes that complete surgical resection is the only potentially curative treatment for adrenocortical carcinoma, with long-term survival linked to early stage and curative resection. It also outlines operative principles including en bloc excision when needed, avoidance of tumor violation, and steroid replacement considerations around surgery.¹

PMID 10210411: This correspondence highlights concerns about laparoscopic adrenalectomy for suspected or unsuspected ACC, describing port-site and local tumor implants after resection of a 7 cm adrenal mass. It emphasizes strict oncologic handling, en bloc retrieval in a bag, avoidance of ultrasonic devices, and conversion to open surgery when invasion or technical difficulty is encountered.⁹¹

PMID 10622495: This editorial emphasizes that complete surgical resection is the only treatment likely to prolong survival in ACC, including at recurrence, and argues that malignant adrenal tumors should generally be removed by open surgery to maximize completeness of resection. It also highlights uncertainty about the optimal extent of operation and cautions that incomplete resection worsens prognosis.⁹⁹

PMID 10681640: This case report describes early diffuse peritoneal carcinomatosis after laparoscopic transperitoneal resection of a small adrenal tumor initially interpreted as benign, raising concern that laparoscopic adrenalectomy may contribute to tumor dissemination when occult ACC is present. It highlights the risk of relying on benign-appearing size and imaging alone when planning adrenal surgery.¹⁰⁰

PMID 10931107: This case report describes peritoneal recurrence 15 months after laparoscopic adrenalectomy for a cortisol-secreting adrenal tumor later reclassified as ACC. The authors argue that laparoscopic adrenalectomy should be avoided when ACC is a possible diagnosis because intraperitoneal dissemination may occur and preoperative exclusion of malignancy is difficult.¹⁰¹

PMID 11127523: This single-center series emphasizes radical surgery as the only potentially curative treatment for resectable ACC, including selected recurrent or metastatic cases. It also highlights the importance of preoperative assessment for venous tumor thrombus because unrecognized intravascular extension may contribute to residual disease and recurrence.²⁶

PMID 11235141: This case report describes left-sided ACC with inferior vena cava tumor thrombus managed by radical en bloc surgery including adrenal tumor removal, nephrectomy, splenectomy, and thrombectomy. The report emphasizes that venous tumor thrombus can prompt aggressive resection to prevent serious complications, although prognosis may remain poor.¹⁰²

PMID 11260859: This review emphasizes surgery as the central treatment for ACC, stating that only complete resection with surrounding lymphatic tissue offers potential cure, while debulking may still be pursued in advanced stages to support adjuvant therapy. It also advises against minimally invasive adrenalectomy for malignant adrenal tumors.¹⁰³

PMID 12045859: In a retrospective series of large adrenal tumors without preoperative evidence of invasion, some patients were found to have stage II ACC after laparoscopic adrenalectomy; the authors argue laparoscopy may be considered selectively in experienced hands, but any intraoperative suspicion of local invasion should prompt conversion to open resection.¹⁰⁴

PMID 12052760: This retrospective series supports selecting laparoscopic adrenalectomy for large adrenal tumors based on CT evidence of a well-encapsulated lesion confined to the adrenal gland rather than size alone. The report also emphasizes intact specimen removal, avoidance of capsular disruption, and margin-negative resection, with one ACC later developing pulmonary metastases but no local or port-site recurrence.¹⁰⁵

PMID 12404845: In a large adrenalectomy series, open surgery was reserved for large or malignant tumors, and invasive carcinoma requiring extended excision was considered an absolute contraindication to laparoscopic adrenalectomy. For adrenal tumors larger than 5 to 6 cm, a lateral transperitoneal approach was favored when minimally invasive resection was undertaken.¹⁰⁶

PMID 12487270: This review discusses surgical selection and technique for malignant adrenal tumors, emphasizing that laparoscopic adrenalectomy is inappropriate when preoperative imaging shows local tissue invasion and that suspicious larger tumors may require prompt conversion to open surgery. It also highlights en bloc resection with surrounding fat and strict avoidance of tumor manipulation to reduce dissemination risk.¹⁰⁷

PMID 12527494: This case report describes a large nonfunctioning ACC with tumor thrombus extending through the renal vein and inferior vena cava into the right atrium. It supports aggressive curative-intent en bloc resection, including cardiopulmonary bypass when needed, and argues that intravascular extension alone should not preclude surgery in the absence of metastasis.¹⁰⁸

PMID 12853025: In ACC with inferior vena cava tumor thrombus, caval involvement should not automatically preclude surgery. The report emphasizes aggressive curative-intent resection with thrombectomy or venous resection tailored to thrombus extent, and it advises against laparoscopic surgery for bulky adrenal tumors suspected of malignancy with venous thrombus.⁷³

PMID 14733841: This review emphasizes that complete surgical excision offers the best chance of cure in ACC, with resectability as an independent favorable prognostic factor and uniformly poor outcomes after unresectable or incomplete resection. It also supports open surgery as the standard approach for suspected malignant adrenal lesions and notes possible survival benefit from repeat resection of localized recurrence or solitary metastasis.⁸⁶

PMID 15063900: This single-center surgical series supports radical transabdominal resection as the main treatment for ACC, including en bloc removal of involved adjacent organs and selected solitary metastases or locoregional recurrences when complete excision is feasible. Survival was strongly stage-dependent, but the authors argue complete resection should be pursued whenever possible, even in advanced disease.⁸⁷

PMID 15145233: This review discusses surgical approach selection for adrenal tumors that may represent ACC, emphasizing that suspected localized primary tumors without imaging evidence of invasion or metastases may be considered for laparoscopy, whereas open adrenalectomy is recommended when imaging shows local or vascular invasion, nodal disease, or distant spread.¹⁰⁹

PMID 15325615: A review summarizing 602 ACC cases reports that complete surgical resection was the only effective treatment modality. Stage at diagnosis was the strongest prognostic factor, with markedly longer median survival after complete resection than after unresected disease.²

PMID 15496569: A case report describes malignant renin-mediated hypertension after adrenalectomy for a large adrenocortical carcinoma, caused by iatrogenic occlusion of the main renal artery with resultant ischemic kidney. The report highlights a rare but preventable surgical complication that can be cured by nephrectomy when persistent renovascular hypertension develops.¹¹⁰

PMID 15541121: This retrospective single-center series suggests laparoscopic adrenalectomy may be feasible for selected adrenal malignancies without radiologic evidence of local invasion, but conversion to open surgery is necessary when peri-adrenal infiltration is encountered or oncologic principles such as intact capsule removal and adequate margins cannot be maintained.¹¹¹

PMID 15719374: This review frames surgical management of suspected adrenocortical carcinoma by favoring open adrenalectomy when preoperative imaging shows local invasion, nodal disease, or metastases, while reserving laparoscopic resection for tumors without worrisome malignant features and converting if invasion or adhesions are encountered intraoperatively.¹¹²

PMID 15820450: This comparative surgical review discusses laparoscopic adrenalectomy for adrenal malignancy, including primary adrenal carcinoma, emphasizing that radical resection can be performed laparoscopically in selected cases using open-oncologic principles, intact specimen retrieval, and avoidance of morcellation, while noting that long-term outcomes remain uncertain.¹¹³

PMID 15856491: In a single-center series of endoscopic adrenalectomy for primary adrenal tumors, selected large lesions without radiologic signs of malignancy were resected with higher conversion, blood loss, and operative time but similar overall morbidity compared with smaller tumors. The report also notes poor oncologic outcomes in the few malignant cases and recommends low-threshold conversion to open surgery when fixation or dense adhesions suggest malignancy.¹¹⁴

PMID 16053359: This comparative surgical review discusses operative selection and technique for suspected malignant adrenal tumors, emphasizing that clear local invasion on preoperative imaging favors open surgery rather than laparoscopy. For potentially malignant lesions, it stresses en bloc removal with surrounding fat, avoidance of tumor manipulation or ultrasonic contact, and prompt conversion to open surgery when needed.⁵⁴

PMID 16364713: In a 15-patient series of ACC with inferior vena cava extension, aggressive surgery using thrombectomy, caval resection, hepatic vascular exclusion, and cardiopulmonary bypass was technically feasible, including cases reaching the right atrium. Complete resection prevented recurrent intravenous involvement during follow-up, but overall survival remained poor because of metastatic progression and perioperative risk.⁷⁶

PMID 16680605: This case series addresses surgical approach selection for adrenal cortical tumors at least 6 cm when preoperative and intraoperative findings do not show invasion or metastases. It argues that laparoscopic adrenalectomy with minimal gland manipulation and removal of surrounding periadrenal fat may be acceptable in carefully selected cases, while open radical resection remains indicated when invasion is identified.¹¹⁵

PMID 16847903: This retrospective series addresses the controversial role of laparoscopic adrenalectomy in adrenal malignancies, including four ACC cases. It emphasizes that open surgery remains preferred when local invasion is present, with mandatory conversion for accurate en bloc resection, while laparoscopy may be considered when malignancy is uncertain preoperatively or for initial assessment of resectability.¹¹⁶

PMID 17192732: In a small single-institution series of right-sided ACCs larger than 15 cm, complete open en bloc resection was achieved with negative margins, sometimes requiring nephrectomy or subcapsular hepatic resection. The report emphasizes that right-sided giant tumors need wide exposure and meticulous liver-parenchymal hemostasis, favoring thoracoabdominal access when extended subcostal exposure is inadequate.⁶⁰

PMID 17237845: This case report highlights concerns about laparoscopic adrenalectomy for suspected ACC, describing rapid local recurrence with adjacent-organ invasion after initial laparoscopic R0 resection of a 6.5–7.5 cm adrenal mass. The excerpt emphasizes en bloc open resection with lymphadenectomy and conversion to open surgery when malignancy, invasion, or difficult dissection is encountered.¹¹⁷

PMID 17239320: This review emphasizes that curative-intent management of localized ACC depends on rapid diagnosis, accurate staging, and prompt complete surgical resection. It notes margin-negative resection as the key prognostic surgical goal and describes selective laparoscopic adrenalectomy as feasible for carefully chosen stage I-II tumors.¹¹⁸

PMID 17277000: In a small series of stage III-IV ACC, aggressive en bloc surgery including liver and inferior vena cava resection achieved microscopically clear margins in all patients with no operative mortality and 29% morbidity. The report supports selected use of multivisceral resection to pursue R0 resection and avoid tumor spillage in locally advanced disease.⁵⁷

PMID 17293663: This case report describes en bloc resection of a massive left adrenocortical carcinoma with infrahepatic inferior vena cava thrombus complicated by inadvertent superior mesenteric artery injury from tumor-related vascular distortion. It emphasizes the need for meticulous vascular identification, possible value of preoperative 3-D CT vascular mapping, and immediate arterial reconstruction when injury occurs.⁸⁹

PMID 17387560: A small surgical series suggests that selected patients with stage III or IV right-sided ACC involving the liver and inferior vena cava can undergo en bloc partial hepatectomy with segmental or partial IVC resection to achieve negative margins, with zero perioperative mortality but substantial morbidity and frequent recurrence.¹¹⁹

PMID 17505152: This surgical series on adrenal incidentalomas reports that laparoscopic adrenalectomy was used for lesions that were hyperfunctioning, radiologically suspicious, enlarging, or at least 4 cm, including some lesions larger than 6 cm. One small nonfunctioning ACC with suspicious imaging was identified, and the authors describe laparoscopic resection as feasible and safe in selected cases.¹²⁰

PMID 17532597: This retrospective surgical series suggests that selected adrenal tumors 60-100 mm without preoperative imaging or intraoperative evidence of malignancy may be approached laparoscopically, with conversion to open surgery if invasion is identified. Known or suspected ACC and tumors with gross malignant features were managed with open adrenalectomy.¹²¹

PMID 17645596: In this small retrospective ACC series, complete surgical resection was associated with markedly better survival than stage IV disease or incomplete removal, supporting surgery as the mainstay of treatment. The authors also note that ipsilateral nephrectomy identified occult perinephric fat invasion in some long-term survivors.³⁵

PMID 17710049: In patients with colorectal cancer and a synchronous adrenal mass suspicious for metastasis, this case series reports that synchronous laparoscopic adrenal resection was technically feasible with no operative mortality. The excerpt also notes that imaging could not reliably distinguish adrenal adenoma from metastasis, supporting resection when no other metastases are present.¹²²

PMID 17879074: This surgical series states that minimally invasive adrenalectomy is appropriate for adrenal tumors without suspicion of malignancy, while large tumors, interval growth, pain, capsular or surrounding tissue infiltration, and central necrosis favor a primary open approach because capsule rupture can worsen recurrence and prognosis.¹²³

PMID 17892430: This review discusses surgical management of ACC with emphasis on the controversy over laparoscopic adrenalectomy versus open resection. It highlights tumor size, suspected local invasion, organ confinement, and surgeon experience as key selection factors, while stressing en bloc oncologic resection, avoidance of tumor violation, and readiness to convert to open surgery.¹²⁴

PMID 18049399: This single-center adrenalectomy series states that laparoscopic adrenalectomy is appropriate for adrenal lesions with benign imaging features and no virilization, regardless of size, while suspected or invasive adrenocortical carcinoma should preferentially undergo open surgery to permit radical en bloc resection and avoid local recurrence risk.¹²⁵

PMID 18266573: This retrospective single-center comparison suggests laparoscopic adrenalectomy may be feasible for carefully selected adrenal malignancies, including some ACCs, with lower blood loss and shorter hospital stay than open surgery. The report emphasizes avoiding laparoscopy for obvious local invasion, relying on preoperative staging, maintaining oncologic principles, and converting early when adequate resection is uncertain.¹²⁶

PMID 18377235: This report describes the first robot-assisted laparoscopic adrenalectomy for primary adrenocortical carcinoma in a patient with an incidentally discovered 8-cm adrenal mass. It emphasizes feasibility, wide resection with surrounding fat and negative margins, while noting that any advantage over standard laparoscopy remains uncertain.¹²⁷

PMID 18536881: In a small series of adrenal masses larger than 5 cm, including five adrenocortical carcinomas, laparoscopic adrenalectomy was reported as feasible in selected patients without radiographic or intraoperative evidence of local invasion. The authors favored a transperitoneal approach for larger tumors and advised low-threshold conversion to open surgery when invasive features are present.¹²⁸

PMID 18563692: This comparative surgical series reports that ACC was more often managed with conventional open adrenalectomy than with endoscopic approaches, particularly when multivisceral resection was needed. The excerpt frames open transabdominal en bloc resection with lymph node dissection and removal of adherent structures as the standard approach for suspected or advanced ACC to achieve complete resection and avoid tumor spill.⁴⁰

PMID 18996792: For ACC with inferior vena cava invasion or tumor thrombus, the article emphasizes that attempted complete en bloc resection should still be considered, using preoperative assessment of thrombus extent to plan vascular control, possible cardiopulmonary bypass, and vena cava reconstruction when needed.⁷⁴

PMID 19357579: This case report argues that when preoperative imaging suggests possible adrenocortical malignancy, laparoscopic adrenalectomy should be avoided in favor of a more cautious surgical approach because of risks including port-site metastasis and tumor seeding. It also emphasizes techniques to minimize intraoperative spread when laparoscopy is undertaken.¹²⁹

PMID 19635227: This review emphasizes curative-intent surgery for localized ACC, favoring gross total resection without capsular breach and en bloc removal of involved adjacent organs when necessary. Laparoscopic adrenalectomy is reserved for small lesions thought likely benign or only borderline malignant, with prompt conversion to open surgery if concerns arise.¹³⁰

PMID 19660215: This review addresses surgical approach selection for primary adrenal malignancies including ACC, emphasizing that curative treatment depends on complete resection with an intact capsule. It advises cautious use of laparoscopy only for localized tumors when oncologic principles can be maintained, with early conversion to open surgery for large, invasive, or potentially nonresectable lesions.¹³¹

PMID 20070018: This case report describes curative-intent open resection of a 19 cm nonfunctional ACC that compressed the inferior vena cava and was affixed to the right kidney, requiring en bloc nephrectomy. The article emphasizes preoperative imaging to define vascular involvement and avoidance of laparoscopic resection for a very large, locally adherent tumor.¹³²

PMID 20348273: In a retrospective ACC cohort, laparoscopic adrenalectomy was associated with a higher risk of peritoneal carcinomatosis during follow-up than open adrenalectomy, while tumor size, stage, functional status, completeness of surgery, and therapeutic mitotane levels were not. The findings support caution about minimally invasive resection for ACC and emphasize the importance of surgical approach and expertise.⁴⁷

PMID 20372905: In a retrospective ACC cohort, laparoscopic adrenalectomy was associated with more positive margins or intraoperative tumor spill and a shorter time to recurrence than open resection, despite generally smaller and lower-stage tumors. The study concludes that suspected or known ACC should be managed with careful open resection rather than a laparoscopic approach.⁴⁸

PMID 20580485: In a retrospective registry analysis of 152 patients with localized ACC measuring 10 cm or less, laparoscopic adrenalectomy performed by experienced surgeons was not associated with worse disease-specific or recurrence-free survival than open adrenalectomy. Capsule violation, peritoneal carcinomatosis, and R0 resection rates were also similar, although conversion to open surgery occurred in about one-third of laparoscopic cases.⁴⁴

PMID 20864252: This letter argues that complete R0 resection remains the only potentially curative treatment for adrenocortical carcinoma and that the quality of the initial operation is a major prognostic factor. It cautions against laparoscopic adrenalectomy until open-surgery oncologic standards and surgical principles are better defined and standardized.¹³³

PMID 21129649: This guideline emphasizes that ACC treatment is primarily surgical, favoring wide en bloc resection without capsular rupture for tumors larger than 5 cm and noting that incomplete initial surgery is usually not salvageable. Laparoscopy is considered only for stage I-II tumors without imaging evidence of local invasion and in experienced hands.⁴

PMID 21167380: This review emphasizes surgery as the primary curative treatment for ACC and also supports resection at recurrence when feasible. It argues that suspected or known ACC should generally be managed with open resection rather than laparoscopic adrenalectomy because of concern for tumor spill and peritoneal seeding.¹³⁴

PMID 21703051: This case review describes curative-intent resection of a testosterone-secreting ACC with tumor thrombus extending from the inferior vena cava to the right atrium and right pulmonary artery. It emphasizes technical principles for complex surgery, including early renal artery ligation, hepatic mobilization off the vena cava, and minimizing cardiopulmonary bypass time to avoid deep hypothermic circulatory arrest.¹³⁵

PMID 21757864: This single-institution series describes adrenal tumors with venous thrombosis as rare lesions typically managed with open radical surgery, sometimes requiring nephrectomy for renal vein involvement or direct invasion. Within the mixed adrenal tumor cohort, malignant cases showed poor postoperative outcomes despite resection.¹³⁶

PMID 21947510: This systematic review examines surgical approach in ACC, emphasizing that complete en bloc R0 resection without tumor rupture is the key curative principle. It supports open surgery for locally invasive disease, while suggesting laparoscopy may be acceptable for carefully selected stage 1-2 tumors under 10 cm when oncologic technique can be preserved.⁵⁰

PMID 22124842: This review debates laparoscopic versus open adrenalectomy for ACC and emphasizes that curative surgery depends on strict oncologic technique, including en bloc resection, margin preservation, avoidance of capsule rupture, and performance in specialized centers. It highlights that retrospective comparisons are methodologically weak and that inadequate surgery worsens local and peritoneal recurrence risk.¹⁴

PMID 22134748: A multicentre ESES survey describes surgery for ACC with inferior vena cava invasion, a technically demanding stage III presentation. Open adrenalectomy, often with en bloc resection of adjacent organs and specialized vascular control, achieved R0 resection in many patients despite 13% 30-day mortality, supporting surgery in experienced centers when complete resection appears feasible.⁷⁵

PMID 22143204: In a retrospective German ACC registry study of 283 patients with ENSAT stage I-III disease who underwent complete resection, intended locoregional lymphadenectomy during primary adrenalectomy was associated with improved staging and lower adjusted risks of recurrence and disease-specific death versus no intended lymphadenectomy.⁶⁸

PMID 22203016: An ESES position statement notes that evidence comparing open and laparoscopic adrenalectomy for ACC is limited and oncologic outcomes are equivocal. It recommends open surgery when local invasion is present to maximize the chance of R0 resection, while reserving laparoscopic resection for carefully selected stage 1-2 tumors smaller than 10 cm if capsule rupture can be avoided.¹⁷

PMID 22306837: This review proposes standardized surgical management for primary ACC, emphasizing that complete initial resection is the key curative intervention. It recommends ipsilateral regional lymphadenectomy of first-order drainage nodes, avoids routine nephrectomy without gross invasion, and supports en bloc resection of involved organs or major veins when an R0 resection is feasible.⁶⁶

PMID 22487802: This retrospective single-center series supports stage-adapted surgical management in ACC: complete resection was associated with the best outcomes in stages I-II, repeat surgery was used for local recurrence, and extensive surgery was favored in stage III, whereas surgery did not improve prognosis in stage IV disease.⁸⁸

PMID 22543230: This case report describes curative-intent surgery for ACC with tumor thrombus extending from the left renal vein into the infrahepatic inferior vena cava. It emphasizes that intracaval extension is not an absolute contraindication to resection, and that kidney-sparing en bloc resection with cavotomy thrombectomy may be feasible without cardiopulmonary bypass in selected patients.¹³⁷

PMID 22585346: This review of German ACC registry data emphasizes that complete resection is the only curative option for nonmetastatic ACC and should be performed in specialized centers by experienced surgeons. Open surgery remains standard, while selective laparoscopic resection may be considered for small tumors with uncertain malignancy, and loco-regional lymphadenectomy is recommended as part of primary surgery.¹³⁸

PMID 22684259: This case report describes a giant nonfunctioning ACC with extensive arterial supply from adrenal and adjacent visceral vessels, in which preoperative transarterial embolization was used before adrenalectomy. The authors suggest embolization may help reduce operative bleeding in selected highly vascular, bulky tumors when difficult resection or multiorgan involvement is anticipated.¹³⁹

PMID 22703895: A national Dutch ACC registry analysis found that complete resection was associated with longer overall survival, and surgery performed in specialized network centers was independently associated with better overall survival than surgery in local hospitals. The study supports centralized expert surgery and multidisciplinary preoperative planning for operable ACC.²⁰

PMID 22959492: This review examines laparoscopic versus open adrenalectomy for ACC, emphasizing that complete oncologic resection without capsule rupture or tumor spillage is the key curative principle. Available retrospective studies are conflicting, but the authors advise avoiding laparoscopic resection for known or suspected ACC until clearer surgical standards are established.¹⁴⁰

PMID 22989893: A decision-model analysis of nonfunctional adrenal incidentalomas found adrenalectomy to be cost-effective versus surveillance for lesions larger than 4 cm and in patients younger than 65 years, largely because missed ACC carries substantial mortality risk from delayed diagnosis.¹⁴¹

PMID 22997446: These guidelines emphasize that curative-intent ACC surgery should be performed in experienced high-volume centers, with open transperitoneal resection as standard for localized and locally advanced disease when complete removal is feasible. Margin-negative resection is the key prognostic surgical goal, often requiring en bloc adjacent-organ resection, while locoregional lymphadenectomy is recommended for staging and possible oncologic benefit.³

PMID 23068084: In a multiinstitutional Italian series of 156 patients with stage I/II ACC who achieved R0 resection, endoscopic adrenalectomy showed no significant differences from open adrenalectomy in local recurrence, time to recurrence, disease-free survival, or overall survival, while shortening hospital stay. The authors emphasize that outcomes depend on respecting oncologic principles such as en bloc resection and avoidance of capsule rupture.¹⁴²

PMID 23125857: This review emphasizes that complete en bloc R0 resection is the only curative treatment for ACC, ideally performed by experienced multidisciplinary teams using an open transabdominal approach to preserve capsule integrity and manage vascular involvement. It also highlights controversy around laparoscopic adrenalectomy, with concerns about higher local recurrence and peritoneal carcinomatosis in some series.¹¹

PMID 23158185: In a retrospective single-center comparison of curative-intent resections for stage I-III ACC, open adrenalectomy was associated with fewer positive margins or tumor spill than laparoscopic adrenalectomy and, in stage II disease, longer survival with later tumor bed or peritoneal recurrence. The study also found that presumed stage II tumors were frequently upstaged to stage III only after pathology.³¹

PMID 23184291: In a single high-volume center retrospective comparison, laparoscopic adrenalectomy for primary ACC showed a nonstatistically significant trend toward higher recurrence and mortality than open adrenalectomy after adjustment for clinical stage. The authors conclude that patients with suspected ACC should generally be considered for open resection.¹⁴³

PMID 23315992: This review appraises laparoscopic versus open adrenalectomy for suspected localized ACC and concludes that open adrenalectomy remains the standard approach. Laparoscopic adrenalectomy may be considered only for limited-size tumors without invasive features when performed in specialized centers with strict adherence to oncologic principles such as margin-negative resection and avoidance of tumor spillage.⁵⁵

PMID 23355166: This retrospective single-center series of laparoscopic adrenalectomy for malignant adrenal lesions included five ACC cases and emphasizes oncologic surgical principles: en bloc resection of surrounding suprarenal fat, minimal-touch handling to preserve capsule integrity, specimen retrieval in a bag, and a low threshold for conversion to open surgery.¹⁴⁴

PMID 23398621: In a retrospective single-center comparison of 32 patients with stage I-III ACC resected with curative intent, laparoscopic surgery was associated with shorter operations, less blood loss, fewer postoperative complications, and shorter hospitalization, while R0 rates, relapse patterns, progression-free survival, and overall survival were not significantly different from open surgery.¹⁴⁵

PMID 23404146: In a single-center adrenalectomy series, preoperative adrenocortical carcinoma strongly predicted selection of an open rather than laparoscopic approach, alongside larger tumor size and need for concomitant procedures. Open surgery, conversion, and tumors larger than 6 cm were also associated with higher 30-day morbidity.¹⁴⁶

PMID 23426352: This correspondence discusses regional lymphadenectomy during ACC resection, noting retrospective data that removal of more than five lymph nodes was associated with lower recurrence and disease-related death, while emphasizing uncertainty about the true therapeutic benefit, optimal nodal field, and the need for precise en bloc operative documentation.⁷¹

PMID 23470511: This reply discusses locoregional lymphadenectomy during ACC surgery, noting that lymph node-positive patients had higher Ki-67 values and poorer biology, while retrospective data suggested a possible trend toward later local recurrence after lymph node dissection despite major limitations in surgical and pathology standardization.¹⁴⁷

PMID 23479277: A surgical commentary on stage I-III ACC reports that laparoscopic adrenalectomy was associated with more incomplete resection or tumor spillage, earlier and more frequent local or peritoneal recurrence, and worse stage II survival than open surgery. It recommends primary open resection for adrenal tumors larger than 5 cm with suspicious imaging.¹⁴⁸

PMID 23765427: In a retrospective cohort of patients undergoing curative-intent resection for nonmetastatic ACC, laparoscopic adrenalectomy was associated with more frequent peritoneal recurrence and worse stage-adjusted recurrence-free and overall survival than open surgery, despite smaller tumors in the laparoscopic group. The findings support open resection for known or suspected ACC to optimize exposure, margin control, and avoidance of tumor spill.⁴¹

PMID 23783027: This case report emphasizes that complete R0 resection is the key management goal in ACC, even for giant locally advanced tumors. It highlights the technical importance of wide exposure, vascular control, and consideration of en bloc resection with adjacent organs to avoid capsule violation and major hemorrhage.¹⁴⁹

PMID 24046101: In a retrospective referral-center cohort limited to ENSAT stage I/II ACC smaller than 10 cm without radiologic extra-adrenal invasion and with R0 resection, laparoscopic adrenalectomy had shorter hospital stay and similar long-term disease-specific and disease-free survival compared with open adrenalectomy.⁴⁵

PMID 24160811: A population-based SEER analysis of stage III and IV ACC found substantially better survival in patients who underwent cancer-directed surgery than in those managed without surgery, and the authors argue that aggressive resection should be considered even in advanced disease. Lymphadenectomy was infrequently performed but was advocated as part of surgical management.¹⁵⁰

PMID 24615603: This single-institution retrospective study proposes a borderline resectable ACC category defined by adverse anatomy, potentially resectable oligometastatic or indeterminate metastatic disease, or reversible comorbidity and poor performance status. In selected patients, preoperative mitotane-based chemotherapy enabled resection in most cases with survival outcomes similar to upfront surgery despite more advanced disease.⁹⁴

PMID 24637859: This review emphasizes that suspected adrenocortical carcinoma requires careful preoperative biochemical and imaging assessment to guide operative planning, and highlights ongoing controversy over minimally invasive versus open adrenalectomy for malignant disease, including management of invasive or recurrent tumors.²¹

PMID 24765408: This case report describes isolated abdominal wall scar recurrence 1.5 years after open resection of a large nonfunctioning ACC, despite reported intact capsule removal. The article emphasizes operative principles to avoid tumor spillage, supports open adrenalectomy for large or locally advanced tumors, and raises possible biopsy-related seeding as a cause of recurrence.⁹²

PMID 24778080: In a tertiary-center series of adrenal tumors 6 cm or larger, surgery was recommended for symptomatic, hormone-secreting, or radiologically suspicious masses, while some asymptomatic benign lesions were observed. Large or potentially malignant tumors, especially with local invasion, were generally managed with open surgery rather than laparoscopy.¹⁵¹

PMID 24803899: This case report emphasizes that curative-intent management of locally advanced ACC centers on open en bloc resection to achieve negative margins, even when adjacent organs and vena cava thrombectomy are required. It also notes that complete R0 resection is a major prognostic factor and the main route to long-term survival.¹⁵²

PMID 25129428: In a multi-institutional adrenalectomy cohort, ACC lesions were larger than other adrenal pathologies and were treated predominantly with open adrenalectomy. The study reports that open rather than endoscopic adrenalectomy was the main driver of worse perioperative outcomes, while noting the authors’ practice preference for open surgery in ACC because of perceived oncologic advantage.¹⁵³

PMID 25158548: In this seven-patient single-center series, long-term survival was observed after complete resection, including en bloc removal of adjacent organs for locally advanced tumors. The authors conclude that achieving maximal complete surgical resection at diagnosis is the most important management principle in ACC.¹⁵⁴

PMID 25287882: For adrenal tumors suspected to be stage 1 or 2 adrenocortical carcinoma without local invasion, laparoscopic adrenalectomy is described as controversial and, if undertaken, should include en bloc removal with periadrenal fat while avoiding capsular disruption or tumor effraction.¹⁵⁵

PMID 25390555: This review addresses surgical management of small, localized ACC, emphasizing that cure depends on margin-negative en bloc resection with the retroperitoneal fat pad and avoidance of tumor rupture. It concludes that minimally invasive adrenalectomy may be acceptable for selected tumors smaller than 8-10 cm without invasion when performed at experienced referral centers, while open surgery remains preferred for invasive disease.¹⁵⁶

PMID 25456949: A population-based registry study found that surgery was associated with improved survival in ACC, including regional and selected metastatic disease, and that combined surgery plus chemotherapy and/or radiation was linked to better outcomes than no treatment. The study also reported low 30-day postoperative mortality, supporting surgery as part of multimodality care in appropriately selected patients.¹⁵⁷

PMID 25526921: In a tertiary-center series of cortical adrenal tumors larger than 8 cm, 84% were adrenocortical carcinomas. The authors emphasize open adrenalectomy with en bloc or multivisceral resection when needed to avoid capsule disruption and local recurrence, noting early recurrence after laparoscopic resection in stage II ACC.¹⁵⁸

PMID 25536088: A meta-analysis of four comparative retrospective studies in stage I/II ACC found no significant differences between laparoscopic and open adrenalectomy in postoperative complications, R0 resection, or disease-free survival, but five-year overall survival favored open surgery. The authors emphasize that evidence is limited and nonrandomized.¹⁵

PMID 25689291: This review emphasizes that complete surgical resection is the only potentially curative treatment for non-metastatic ACC. It highlights open adrenalectomy as standard management, notes persistent controversy over laparoscopic resection for selected small localized tumors, and supports referral-center surgery because outcomes are better in specialized centers.¹⁵⁹

PMID 25862874: This case report describes a giant non-secretory ACC causing compression symptoms that was treated with en bloc multivisceral resection to achieve negative margins. The report emphasizes that aggressive surgery with capsule preservation and lymph node dissection may be justified when preoperative assessment suggests complete resectability, even in an older patient.¹⁶⁰

PMID 25885103: This review addresses surgical decision-making for adrenal tumors with suspected primary malignancy, emphasizing that open resection is preferred for large lesions with possible local invasion or tumors larger than 10 cm, while a laparoscopic start may be reasonable for selected 4-10 cm masses if prompt conversion allows curative resection.¹⁶¹

PMID 26029297: This single-center technical series describes a high supra-10th-rib retroperitoneal extrapleural open adrenalectomy for suspected medium-sized ACCs measuring 5 to 10 cm, reporting complete gross resection without tumor spillage in 10 patients. The article frames open surgery as preferred for suspected ACC, with this approach proposed for selected medium-sized tumors while larger or invasive lesions were managed through transperitoneal open surgery.¹⁶²

PMID 26038210: This review emphasizes that complete surgical resection is the first-line treatment for ACC and identifies open adrenalectomy as the preferred approach for most malignant primary adrenal tumors. It also stresses multidisciplinary preoperative assessment, biochemical evaluation before surgery, and avoidance of procedures that may disrupt the tumor capsule.¹⁶³

PMID 26175553: This systematic review examines laparoscopic versus open adrenalectomy for ACC, emphasizing that complete resection with negative margins is the key determinant of outcome. It highlights persistent controversy over minimally invasive surgery, with more favorable use generally limited to selected stage I-II tumors smaller than 10 cm in experienced centers.¹⁸

PMID 26223672: In adrenal cortical tumors larger than 8 cm, this commentary highlights a very high observed ACC frequency, frequent need for multivisceral resection, and earlier recurrence after laparoscopic than open adrenalectomy among the small ACC subset. It supports a general preference for open surgery in these large tumors.¹⁶⁴

PMID 26286195: In a multicenter cohort of adults undergoing curative-intent resection for localized ACC, microscopically positive margins were associated with substantially worse overall survival, supporting operative planning and technique aimed at achieving R0 resection. The study also notes capsular invasion was linked to R1 resection risk.⁷

PMID 26328113: A single-center adrenalectomy series reports one incidental ACC among 35 laparoscopic adrenal mass resections and cites retrospective comparative studies suggesting laparoscopic adrenalectomy may have similar oncologic outcomes to open surgery in selected localized stage I/II ACC or tumors up to 10 cm.¹⁶⁵

PMID 26355237: This case report describes locally advanced right-sided ACC with tumor thrombus extending through the inferior vena cava and left renal vein into the right atrium, managed by urgent adrenalectomy and thrombectomy using cardiopulmonary bypass and hypothermia. It emphasizes that complete negative-margin resection is the only curative option and that kidney-sparing surgery is preferred unless there is renal invasion.¹⁶⁶

PMID 26466307: This case report describes locally advanced functional ACC with inferior vena cava tumor thrombus managed by extensive en bloc resection and thrombectomy. Intraoperative transesophageal echocardiography identified residual caval thrombus, altered the operative plan by prompting a second cavotomy, and helped support complete resection.¹⁶⁷

PMID 26468756: This case report discusses surgical approach selection for a large adrenal mass initially thought benign, emphasizing that laparoscopic adrenalectomy was chosen only after endocrine workup and CT showed no features suggestive of ACC such as periadrenal infiltration or vascular invasion; suspected local invasion would favor open surgery or conversion.¹⁶⁸

PMID 26477988: This case-based review emphasizes that resectable ACC should be managed with complete surgical excision, after staging excludes local organ invasion and distant metastases. It highlights multidisciplinary discussion and the importance of removing the tumor intact, with complete resection linked to better outcomes than incomplete surgery.¹⁶⁹

PMID 26480850: A meta-analysis comparing laparoscopic with open adrenalectomy for ACC found shorter hospital stay with laparoscopy but a higher risk of peritoneal carcinomatosis, while overall recurrence, time to recurrence, margin status, and cancer-specific mortality did not differ significantly. The authors conclude open adrenalectomy remains the standard, with laparoscopy reserved for carefully selected small, localized, noninvasive tumors in experienced centers.⁴⁹

PMID 26558005: This review states that laparoscopic adrenalectomy is standard for most appropriately sized adrenal lesions without surrounding tissue invasion, but its use for adrenal malignancy should be cautious. Imaging evidence of local invasion is presented as a contraindication to laparoscopic resection, with open surgery favored when oncologic principles or patient safety may be compromised.¹⁷⁰

PMID 26595492: This case report describes ACC with uncommon renal vein and inferior vena cava tumor thrombus, managed with aggressive surgery including adrenalectomy, nephrectomy, lymphadenectomy, and thrombectomy. The review portion emphasizes that venous extension can complicate resection, while complete surgical removal is presented as the main management strategy despite poor outcomes in advanced disease.¹⁷¹

PMID 26610780: This review emphasizes that curative-intent management of localized ACC centers on complete open resection with negative margins, often requiring en bloc removal of involved adjacent structures or venous tumor thrombectomy. It advises against routine removal of uninvolved organs and notes a possible staging or survival benefit from regional lymphadenectomy.⁵⁸

PMID 26684865: This case report highlights adrenohepatic fusion as an occult finding in giant right-sided ACC that can compromise resectability if mistaken for simple adhesion. It supports planned en bloc adrenal-hepatic resection, sometimes with major hepatectomy and vascular control, by an experienced multidisciplinary surgical team to maximize margin-negative resection and disease-free survival.¹⁷²

PMID 26712261: This review emphasizes that complete open surgical resection with negative margins is the treatment of choice for localized or locally advanced ACC. It highlights en bloc multi-organ resection when adjacent organs are involved, the need to preserve capsule integrity and avoid tumor spillage, and the value of experienced surgical teams.¹⁷³

PMID 26728469: This review synthesizes evolving surgical management principles in ACC, including possible neoadjuvant therapy for borderline resectable disease, unresolved questions about formal lymphadenectomy, and careful selection for reoperation or metastasectomy based on resectability and recurrence timing.¹⁷⁴

PMID 26926087: This review notes that robotic-assisted adrenalectomy is feasible and generally safe, but ACC experience is limited to a few case reports. It also states that adrenocortical cancer remains a relative contraindication to minimally invasive adrenal surgery because of concerns including malignancy risk and capsular disruption with tumor seeding.¹⁷⁵

PMID 27173070: A single tertiary-center surgical series included one adrenocortical carcinoma with tumor thrombus extending through the inferior vena cava into the right atrium, managed by en bloc resection with cardiopulmonary bypass and deep hypothermic circulatory arrest. The report frames complete surgical resection as the mainstay for selected intraabdominal tumors with cavoatrial extension, despite substantial perioperative morbidity and mortality.¹⁷⁶

PMID 27256402: In a multicenter retrospective laparoscopic adrenalectomy series, all seven adrenocortical carcinomas were resected with negative surgical margins and no local recurrence during a mean 19.5-month follow-up, while positive margins were more common in metastatic adrenal tumors. The study presents laparoscopy as feasible for selected adrenal malignancies, though its role in ACC remains debated.¹⁷⁷

PMID 27412357: This single-center retrospective series argues that curative-intent ACC surgery should prioritize complete margin-negative resection and capsule preservation over the choice of laparoscopic versus open access. Preoperative staging and tumor characteristics were used to tailor surgery, with multiorgan open resection favored for large or potentially invasive tumors and selected smaller tumors managed by laparoscopic radical adrenalectomy.⁸²

PMID 27488744: A contemporary NCDB analysis of non-metastatic ACC found minimally invasive adrenalectomy was associated with higher odds of positive margins and much lower rates of lymphadenectomy overall, while open adrenalectomy showed superior surgical quality for locally advanced disease. For organ-confined tumors, minimally invasive surgery had similar overall survival and shorter hospital stay.¹⁷⁸

PMID 27590329: In adults with localized, nonmetastatic ACC undergoing margin-negative resection, surgeon-intended peritumoral lymphadenectomy was independently associated with improved overall survival without a clear increase in perioperative mortality or major complications. The study supports planning systematic regional nodal dissection during curative-intent surgery rather than limiting node removal to grossly suspicious nodes.⁶⁹

PMID 27742785: This editorial argues that surgery remains the only proven curative treatment for adrenocortical carcinoma and should be strongly considered at initial presentation and relapse. It highlights a markedly higher rate of extensive peritoneal dissemination after laparoscopic versus open resection in a retrospective NCI series, supporting avoidance of laparoscopic resection.¹⁷⁹

PMID 27770290: In a multicenter retrospective cohort of curative-intent resections for primary ACC, minimally invasive adrenalectomy was not associated with worse margin status, perioperative morbidity, overall survival, or disease-free survival compared with open surgery in selected patients. The study supports considering minimally invasive resection for preoperatively localized tumors 10 cm or smaller, while recommending open surgery when local invasion or enlarged lymph nodes are suspected.¹⁸⁰

PMID 27900213: For localized adrenocortical carcinoma, complete open surgical resection with negative margins is presented as the only curative option. The review emphasizes preoperative planning for hormone excess, adjacent organ invasion or venous thrombus, selective nephrectomy only when directly involved, and generally recommends regional lymphadenectomy.¹⁸¹

PMID 27928434: In adrenocortical carcinoma presenting with Cushing’s syndrome, adrenalectomy is described as first-line therapy, with open adrenalectomy preferred for malignant, locally invasive, or large tumors. The excerpt emphasizes careful preoperative staging, surgeon expertise, and achieving disease-free resection margins as important determinants of prognosis.¹⁸²

PMID 28031665: A case report describes open en bloc resection of a large recurrent left ACC involving the left renal artery, with partial diaphragm resection and splenorenal arterial bypass used to preserve the ipsilateral kidney when nephrectomy posed major renal risk. Pathology showed negative margins.¹⁸³

PMID 28127186: This review notes that suspected ACC should generally be managed with open adrenalectomy rather than laparoscopic resection because of concerns about incomplete excision, capsule violation, tumor spillage, and higher local or peritoneal recurrence. It also emphasizes avoiding biopsy in surgical candidates with suspected ACC due to spillage risk.¹⁸⁴

PMID 28199015: Consensus surgical guidance for ACC emphasizes radical en bloc resection as the best curative option, favoring an open approach for confirmed or highly suspected disease and avoiding capsule rupture, spillage, enucleation, or partial adrenal resection. Laparoscopic surgery is reserved only for carefully selected small, noninvasive tumors in high-volume referral centers.³⁶

PMID 28497219: This review discusses surgical approach selection for adrenal tumors and notes that large adrenal tumors, including adrenocortical carcinoma, carry risks of capsular effraction and possible local recurrence during minimally invasive resection. It emphasizes endocrine surgeon expertise, acceptance of conversion to laparotomy when needed, and preference for a transperitoneal approach over robotic retroperitoneal surgery for larger tumors.¹⁸⁵

PMID 28723392: This systematic review found that for adequately staged localized ACC, laparoscopic adrenalectomy can achieve similar margin status, disease-free survival, and overall survival as open adrenalectomy when strict oncologic principles are maintained. It also supports referral to high-volume centers and favors open surgery with lymph node dissection for locally advanced or metastatic disease requiring extensive resection.²³

PMID 28754418: This review emphasizes that complete radical en bloc resection is the only potentially curative treatment for resectable ACC, with open surgery generally favored and laparoscopy considered only for carefully selected stage I or small stage II tumors under 6 cm in expert centers. It also highlights debated operative issues including lymphadenectomy extent, management of locally advanced disease, and the importance of referral-center multidisciplinary care.¹⁸⁶

PMID 29078892: Among patients undergoing adrenalectomy for nonfunctional primary adrenal tumors, malignant pathology was independently associated with higher perioperative complications, longer hospitalization, and higher in-hospital mortality after open surgery. Treatment at higher-volume adrenalectomy hospitals was associated with fewer complications, supporting careful preoperative optimization and experienced surgical care.⁹⁰

PMID 29135271: This case series reports laparoscopic transperitoneal adrenalectomy for giant adrenal tumors, including two adrenocortical carcinomas, with R0 resection, no perioperative complications, short hospitalization, and no recurrence during 24 months of follow-up in carefully selected patients without radiologic extracapsular spread or metastases.¹⁸⁷

PMID 29147267: This case report emphasizes that complete surgical resection remains the main curative-intent treatment for ACC, even in an unusually long-standing large tumor without metastases. It illustrates use of an open en bloc adrenalectomy with adjacent diaphragm and liver capsule resection to achieve R0 removal when local adherence raises concern for malignancy.¹⁸⁸

PMID 29225829: This case report describes locally advanced ACC with inferior vena cava invasion managed by open radical en bloc resection, including partial liver resection, caval segmentectomy, and prosthetic IVC reconstruction with cardiopulmonary bypass, achieving an R0 resection. The accompanying review emphasizes surgery as the key treatment and recommends expert high-volume multidisciplinary surgical care for suspected adjacent organ or venous invasion.²⁹

PMID 29313128: This review summarizes surgical management of non-metastatic ACC, emphasizing that ENSAT stage I-III disease should undergo curative-intent resection with R0 margins and avoidance of capsule rupture. It also discusses en bloc resection principles, selective lymphadenectomy, center and surgeon expertise, and when minimally invasive adrenalectomy may be acceptable in stage I-II tumors.¹⁸⁹

PMID 29319399: This review of adults with ENSAT I-III primary ACC found that laparoscopic adrenalectomy had similar R0 resection, recurrence, disease-free survival, and overall survival outcomes to open adrenalectomy in selected patients, while emphasizing that complete margin-negative resection is the key surgical objective.¹⁹⁰

PMID 29345155: This review emphasizes that for localized or locally advanced ACC, complete en bloc resection with negative margins is the only potentially curative treatment. It highlights meticulous tumor handling, avoidance of capsular violation, and generally favors experienced open resection over minimally invasive approaches because oncologic adequacy with MIS remains uncertain.¹⁹¹

PMID 29868977: In resectable nonmetastatic ACC, en bloc removal of adjacent organs during index adrenalectomy was commonly used for larger, more advanced tumors and when venous involvement was suspected. However, if a negative-margin resection could otherwise be achieved, additional organ resection did not improve survival, supporting its selective use to avoid capsule violation or tumor rupture.⁶³

PMID 29943065: This retrospective adrenalectomy series reports that near-infrared indocyanine green fluorescence can provide real-time visualization of adrenal tissue planes and vascular pedicles during laparoscopic resection. The authors note that further evaluation is needed for adrenocortical malignancy, while emphasizing oncologic surgical principles when malignancy is possible.¹⁹²

PMID 29967985: This review emphasizes that when ACC is suspected preoperatively, open adrenalectomy is generally preferred over laparoscopic resection because it better supports en bloc resection and preservation of tumor capsule integrity. CT findings such as tumor size, heterogeneity, calcification, necrosis, and local invasion help guide operative approach selection.³³

PMID 30019302: This case report describes operative strategies for advanced adrenal malignancies with liver and inferior vena cava invasion, including caval wall resection and repair, thrombectomy with veno-venous bypass, and en bloc caval resection with graft reconstruction to support radical resection while reducing bleeding and embolic risk.¹⁹³

PMID 30159583: This review emphasizes that complete R0 resection with preservation of capsule integrity is the only potentially curative treatment for ACC. It supports center-based surgery, routine locoregional lymphadenectomy, en bloc resection of involved adjacent organs when needed, and selective minimally invasive adrenalectomy only when oncologic principles can be maintained.⁵

PMID 30173707: This surgical video article illustrates curative-intent management of a right-sided ACC with hepatic invasion and inferior vena cava tumor thrombus using en bloc adrenalectomy, nephrectomy, right hepatectomy, extended lymphadenectomy, and caval thrombectomy. It emphasizes consensus surgical principles of avoiding tumor violation and performing en bloc resection for locally advanced disease.⁶¹

PMID 30217968: This case report and review describes successful laparoscopic lateral transabdominal adrenalectomy for a 12 cm adrenal oncocytic carcinoma selected because imaging showed a clear cleavage plane and no adjacent organ, vascular, or nodal invasion. It emphasizes complete en bloc resection without capsule rupture, while noting open adrenalectomy remains the usual standard for large or primary malignant adrenal tumors.¹⁹⁴

PMID 30225834: This editorial emphasizes that suspected or indeterminate adrenal masses should be managed operatively as ACC until proven otherwise, favoring open adrenalectomy with strict oncologic technique. It highlights the risks of capsule disruption, occult periadrenal extension, and inadequate margins, arguing for en bloc resection including surrounding retroperitoneal fat.¹⁹⁵

PMID 30229419: This review emphasizes that curative treatment for locoregional adrenocortical carcinoma depends on margin-negative resection, with accumulating evidence supporting regional lymphadenectomy. It presents open adrenalectomy by experienced adrenal surgeons as the operative gold standard, while noting ongoing controversy and selection bias around laparoscopic approaches for small, noninvasive tumors.⁷⁰

PMID 30266443: In a retrospective single-center comparison of ENSAT stage I/II ACC smaller than 10 cm, laparoscopic adrenalectomy shortened postoperative stay but was associated with higher and earlier local or peritoneal recurrence than open adrenalectomy, while overall and recurrence-free survival were similar. The authors conclude open adrenalectomy should remain the standard approach for localized ACC.¹⁹⁶

PMID 30324471: In localized ACC surgery, en bloc resection of adjacent organs may be appropriate when T4 disease is suspected, negative margins cannot otherwise be achieved, or tumor rupture must be avoided. Routine additional organ removal, including nephrectomy, showed no added survival benefit when margin-negative adrenalectomy was otherwise feasible.⁶⁴

PMID 30443830: A retrospective ENSAT registry study mapped first lymph node recurrence sites after R0 resection of nonmetastatic ACC, showing frequent recurrence in perirenal fat, renal hilum, para-aortic, and interaortocaval regions. The findings support considering more extensive locoregional lymphadenectomy during primary surgery, while acknowledging uncertainty about the optimal dissection extent.¹⁹⁷

PMID 30710432: This single-center ACC series emphasizes curative-intent management with complete en bloc resection when feasible, identifies complete resection as a key survival correlate, and warns that suboptimal initial surgery, including unsuspected laparoscopic cases, may compromise oncologic clearance. The authors recommend conversion to open surgery for functional adrenal masses larger than 6 cm when invasion, difficult planes, or marked vascularity are encountered intraoperatively.¹⁹⁸

PMID 30798468: This review emphasizes that curative-intent surgery is the cornerstone of localized ACC management, best performed at high-volume centers with the goal of R0 resection. It favors open adrenalectomy when ACC is suspected, especially for masses larger than 6 cm, because retrospective data suggest worse locoregional and peritoneal recurrence after laparoscopic resection.³⁷

PMID 30851831: This review argues that minimally invasive adrenalectomy should generally be avoided for primary ACC because friable tumors are at risk of capsular disruption, fragmentation, incomplete resection, local-regional recurrence, and peritoneal carcinomatosis. It notes that minimally invasive resection may be considered only for selected, moderately sized lesions by highly experienced surgeons.¹⁹⁹

PMID 30863550: This case report emphasizes surgery as the only potentially curative treatment for localized ACC and outlines operative decision factors based on tumor size, functionality, and suspicious imaging features. It also notes concern that laparoscopic adrenalectomy may carry risks of tumor seeding, local recurrence, and peritoneal carcinomatosis.²⁰⁰

PMID 31246598: This report highlights operative management considerations for ACC with inferior vena cava extension into the right atrium or right ventricle. It emphasizes detailed preoperative imaging to define cranial extent, intraoperative transesophageal echocardiography to monitor embolic complications, and readiness for cardiopulmonary bypass in high-risk resections.⁸⁰

PMID 31255205: This review emphasizes that curative treatment for early-stage adrenocortical carcinoma is surgery, with open adrenalectomy preferred when ACC is known or strongly suspected. It highlights en bloc resection of involved structures, margin preservation, and avoidance of tumor rupture or spill because these factors affect recurrence and outcomes.²⁷

PMID 31404193: This review discusses adrenal NOTES as an experimental extension of minimally invasive adrenalectomy and notes that minimally invasive surgery is preferred mainly for benign adrenal masses under 6 cm, while its use for large lesions and adrenocortical carcinoma remains debatable. It emphasizes that new approaches should not compromise operative safety or oncologic outcomes.²⁰¹

PMID 31420622: In a small series of massive adrenal tumors with venous tumor thrombus, the ACC cases showed fragile capsules and unclear tissue planes, and tumor plus thrombus resection was performed using either open surgery for higher IVC thrombus or selected retroperitoneal laparoscopic approaches for limited venous involvement after careful preoperative assessment.²⁰²

PMID 31545579: This case series describes four ACC cases with tumor thrombus extending through the inferior vena cava into the right atrium, managed surgically with cardiopulmonary bypass and deep hypothermic circulatory arrest. It emphasizes that complete resection may be feasible in selected patients through coordinated urologic and cardiac surgical management, despite poor overall outcomes.⁷⁷

PMID 31670638: This single-team adrenalectomy series notes that the role of laparoscopy for malignant adrenal tumors remains controversial, and recommends open surgery when tumors are larger than 6 cm, show local invasion, or have suspicious nodal disease. If malignancy or invasion is recognized intraoperatively, conversion is advised to maximize the chance of R0 resection.²⁰³

PMID 31672303: This review emphasizes that complete R0 resection is the only potentially curative treatment for ACC and that open radical adrenalectomy by experienced adrenal or oncologic surgeons is the preferred approach. It highlights the need for en bloc multivisceral resection, lymph node assessment, and avoidance of capsule disruption when local invasion is suspected.²⁰⁴

PMID 31722787: This review emphasizes that surgery is the only potentially curative treatment for adrenocortical carcinoma and that operative quality strongly influences overall and recurrence-free survival. It highlights the importance of achieving R0 resection, supports lymph node dissection, and argues against routine adjacent-organ resection without suspected extra-adrenal invasion.⁶⁷

PMID 31918158: This case report emphasizes that complete open radical adrenalectomy with negative margins is the curative-intent treatment for localized stage II ACC, while noting controversy around laparoscopic resection and the importance of multidisciplinary discussion after surgery.²⁰⁵

PMID 31976120: This case report highlights surgical management of a large myxoid ACC resected by robot-assisted laparoscopic adrenalectomy, while emphasizing that open adrenalectomy remains the preferred standard for invasive disease. It stresses wide resection, intact specimen extraction, and a low threshold to convert to open surgery when malignancy or difficult dissection is encountered.²⁰⁶

PMID 32117492: This retrospective series of laparoscopic adrenalectomy for adrenal masses, including lesions 6 cm or larger, suggests that size alone may not mandate an open approach when there is no evidence of invasion. The authors emphasize minimal tumor handling, specimen retrieval protection, multidisciplinary selection, and prompt conversion to open en bloc resection when local invasion is suspected.²⁰⁷

PMID 32265101: This review emphasizes that complete en bloc R0 resection is the key determinant of outcome in localized ACC. It supports open adrenalectomy for confirmed or strongly suspected ACC, avoidance of capsule rupture, and management by high-volume surgeons and centers, with extended en bloc resection when adjacent organs or major veins are involved.²⁰⁸

PMID 32277316: This meta-analysis compares minimally invasive and open adrenalectomy for ACC. Minimally invasive surgery was associated with less blood loss and shorter hospital stay but also with more positive margins, earlier recurrence, and more peritoneal recurrence, supporting open adrenalectomy as standard while reserving minimally invasive approaches for selected cases in experienced hands.¹⁶

PMID 32277318: This meta-analysis reflection discusses surgical management of localized ACC, emphasizing complete tumor resection as the cornerstone of cure. It notes that minimally invasive adrenalectomy may offer fewer postoperative complications and faster recovery in selected patients, but open adrenalectomy remains the usual standard because of concerns about margin control, tumor spillage, and oncologic adequacy.²⁰⁹

PMID 32421867: In a retrospective referral-center cohort of ENSAT stage I-III ACC with R0 resection, laparoscopic adrenalectomy for localized tumors without extra-adrenal invasion showed recurrence-free and overall survival similar to open adrenalectomy. The article emphasizes careful patient selection, adherence to oncologic surgical principles, and performance in experienced specialized centers.⁴⁶

PMID 32627365: A retrospective Western Australia series found that open en bloc resection for suspected adrenocortical carcinoma was associated with higher R0 rates and markedly lower local recurrence than non-en-bloc or laparoscopic approaches. The report also supports low-threshold multivisceral resection and treatment by higher-volume surgeons to improve operative outcomes.²¹⁰

PMID 32656720: In a National Cancer Database analysis of nonmetastatic ACC resections, attempted minimally invasive adrenalectomy that required conversion to open surgery occurred in about one-fifth of cases and was independently associated with worse overall survival than successful minimally invasive surgery or matched planned open resection. The findings support open adrenalectomy as the standard approach for known or suspected ACC.⁵²

PMID 32671423: This surgical review states that suspected or questionable malignant adrenocortical tumors can be approached minimally invasively only in selected cases, whereas large malignant adrenal tumors with adjacent organ infiltration or proven lymph node metastases should undergo primary open adrenalectomy aiming for R0 resection and avoidance of capsule rupture.²¹¹

PMID 32691339: For ENSAT stage I-III ACC, margin-negative resection is emphasized as critical, and attempted minimally invasive adrenalectomy with conversion to open surgery was associated with higher margin positivity and worse overall survival than successful minimally invasive surgery or planned open resection. Larger tumors and right-sided lesions predicted conversion.⁵³

PMID 32945919: A registry analysis of adrenal surgery in specialized German-speaking centers found that 27.8% of ACC resections were started minimally invasively, with a 20% conversion rate to open surgery; among tumors larger than 5 cm, laparoscopic attempts were uncommon and frequently converted. The report highlights discordance between real-world surgical practice and guideline recommendations for ACC.²¹²

PMID 33244737: This case report describes multidisciplinary management of a large 15 cm right adrenal oncocytic carcinoma with transabdominal laparoscopic adrenalectomy, emphasizing that surgery is the treatment of choice and that selection of open versus laparoscopic approach should depend on tumor size and surgeon experience.²¹³

PMID 33543578: In a small surgical series of large adrenal tumors with hepatic invasion or indeterminate adreno-hepatic origin, two ACC cases underwent concurrent adrenalectomy and liver resection with R0 resection. The report suggests anterior approach hepatectomy with hanging manoeuvre can be a feasible option when right hepatectomy is required for locally advanced adrenal tumors.²¹⁴

PMID 33577722: In resected localized ACC from a national database, tumor size alone was not independently associated with margin positivity or overall survival, whereas local invasion and conversion from minimally invasive to open adrenalectomy were linked to higher positive-margin risk and worse survival. The findings support prioritizing complete oncologic resection and selective minimally invasive surgery mainly for small, carefully chosen tumors.²¹⁵

PMID 33773281: This single-center surgical series describes aggressive curative-intent resection of large adrenal tumors, including ACC with inferior vena cava tumor thrombus, using transplant-based exposure and vascular-control techniques. Complete resection was achieved in all cases, with selected level IV thrombi requiring cardiopulmonary bypass for atrial or pulmonary artery extension.⁸¹

PMID 33813589: This case report describes a giant nonfunctioning ACC managed with extended open radical resection, including en bloc removal of adherent organs to achieve clear margins. It also reports repeat resection for local recurrence with short-term disease-free follow-up, reinforcing surgery as the main curative-intent strategy for large or invasive-appearing tumors.²¹⁶

PMID 34159107: This review summarizes retrospective evidence and guideline recommendations indicating that open adrenalectomy remains the standard approach for suspected adrenocortical carcinoma, prioritizing oncologic control, negative margins, and avoidance of tumor spillage. Minimally invasive adrenalectomy may reduce perioperative morbidity, but long-term recurrence and survival outcomes remain uncertain and often favor open surgery.⁴³

PMID 34440112: This review synthesizes retrospective evidence on ACC surgery, supporting open adrenalectomy as the gold standard to maximize complete en bloc R0 resection and avoid capsule rupture. Minimally invasive adrenalectomy may be feasible in carefully selected ENSAT stage I-II tumors smaller than 10 cm without local invasion, nodal disease, or metastases, preferably at high-volume centers.⁵¹

PMID 34605409: This single-center retrospective series of 19 patients with localized or locally advanced ACC supports surgery as the main curative-intent treatment, with predominantly open adrenalectomy, 89.5% complete resection, and 78.9% disease-free status after surgery alone despite ongoing recurrence risk.²¹⁷

PMID 35053453: This systematic review and meta-analysis suggests that locoregional lymphadenectomy during curative-intent surgery is associated with improved survival in localized ACC stage I–III, without a clear increase in postoperative mortality or length of stay. Evidence remains limited by retrospective study design and heterogeneous definitions of lymphadenectomy.²⁴

PMID 35055415: In ENSAT stage I–III ACC, surgery at a high-volume expert center was associated with lower recurrence, longer recurrence-free survival, and fewer local or peritoneal recurrences than surgery at low-volume centers. The findings support centralization of curative-intent adrenal surgery to experienced multidisciplinary teams.⁹³

PMID 35077671: This case report describes a two-stage surgical strategy for ACC with tumor thrombus extending through the inferior vena cava into the right atrium, using initial atrial thrombectomy followed by portal vein embolization and delayed radical abdominal resection with caval replacement. The authors suggest this approach may be considered when en bloc surgery is too risky because of urgent intracardiac threat, anticoagulation-related bleeding risk, or need for future liver remnant hypertrophy.²¹⁸

PMID 35137673: This case report highlights curative-intent management of a giant hormonally active ACC with extensive open en bloc resection, including adjacent organ and vena cava resection to achieve negative margins. It underscores that even very large locally invasive tumors may be approached with aggressive multidisciplinary surgery as the central treatment strategy.⁶²

PMID 35246741: In stage I-III adrenocortical carcinoma undergoing adrenalectomy, negative-margin resection was more likely at higher-volume centers and less likely with laparoscopic than with open surgery after adjustment, while robotic surgery did not differ significantly from open. The findings support operative planning that prioritizes margin-negative resection and experienced centers.⁸³

PMID 35286718: A National Cancer Database analysis of 1,599 surgically resected ACC cases found that negative resection margins were independently associated with better overall survival, while positive margins predicted worse outcomes. Conversion from minimally invasive surgery to open surgery was associated with worse survival, underscoring the importance of operative planning and margin-preserving resection.⁸

PMID 35618598: For nonmetastatic ACC selected for resection, open adrenalectomy remains the standard approach, but minimally invasive adrenalectomy may be considered in appropriately selected patients. In this NCDB analysis, minimally invasive surgery showed similar overall survival, margin status, lymph node yield, and adjuvant treatment use, with shorter length of stay and fewer readmissions.²¹⁹

PMID 35725937: A propensity-matched NCDB review of clinically localized nonmetastatic ACC found no significant difference between minimally invasive and open adrenalectomy in positive margin rates or overall survival across tumor size strata up to 20 cm. The authors conclude that careful patient selection and preservation of oncologic surgical integrity should guide approach choice more than a strict 6 cm cutoff.²²⁰

PMID 35780533: A nationwide analysis of resected ACC found increasing use of minimally invasive surgery from 2010 to 2017, with no worse overall survival, no higher margin positivity, shorter length of stay, and similar outcomes even for tumors larger than 6 cm in selected patients.²²¹

PMID 35788865: This review argues that open adrenalectomy remains the surgical standard for ACC, particularly for ENSAT III disease, local organ invasion, venous tumor thrombus, or nodal metastases. It emphasizes en bloc R0 resection with avoidance of capsule rupture and notes retrospective data suggesting worse recurrence patterns and survival with minimally invasive approaches in some early-stage cases.³⁹

PMID 35976622: These endocrine surgery guidelines state that patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be managed at high-volume multidisciplinary centers, with surgery aimed at complete R0 resection without tumor disruption and en bloc radical resection when needed.²²

PMID 36090946: This case report highlights that large right-sided ACC may harbor inferior vena cava tumor thrombus not detected on standard preoperative CT or MRI, leading to intraoperative conversion from laparoscopic to open adrenalectomy. The authors argue that possible venous tumor thrombus should influence surgical planning, favoring open surgery when thrombus or local invasion is suspected.³²

PMID 36233622: This review supports open adrenalectomy as the standard surgical approach for localized ACC because complete resection with negative margins is critical for cure. Minimally invasive adrenalectomy may be appropriate only in carefully selected patients without local invasion, ideally at high-volume centers with experienced surgeons, but evidence remains retrospective and conflicting.¹⁹

PMID 36344710: A systematic review and meta-analysis comparing laparoscopic versus open surgery for ACC found open surgery was associated with lower positive margin rates and better 3-year overall and recurrence-free outcomes, while laparoscopy shortened hospital stay. The review concludes open surgery remains the standard approach, with laparoscopy reserved for selected cases in experienced hands.⁴²

PMID 36410918: This review notes that minimally invasive adrenalectomy is appropriate for benign or functional adrenal tumors, whereas an open surgical approach is preferred when there is concern for a potential primary adrenal malignancy such as adrenocortical carcinoma.²²²

PMID 36444650: This review emphasizes that complete margin-negative resection is the only potentially curative treatment for ACC and that surgery should follow strict oncologic principles. It supports expert-center open resection for most localized or locally advanced cases, en bloc removal when needed, avoidance of tumor rupture, selective laparoscopic use in small noninvasive tumors, and routine regional lymphadenectomy.¹²

PMID 36625975: This multicenter retrospective series examined ACC with venous tumor invasion undergoing adrenalectomy and thrombectomy, reporting that minimally invasive surgery was feasible in carefully selected patients. Open and mini-invasive groups had similar perioperative outcomes, but selection bias favored less aggressive disease in the mini-invasive cohort.²²³

PMID 37297891: In a referral-center retrospective study of ENSAT stage I-II ACC, open adrenalectomy remained the standard approach, with similar 5-year overall survival but better 3-year disease-free survival than laparoscopic adrenalectomy. The report emphasizes careful preoperative selection, multidisciplinary review, and avoidance of capsule rupture or incomplete resection.²²⁴

PMID 37386332: This review compares open, laparoscopic, and robotic adrenalectomy for primary ACC, emphasizing that complete R0 resection remains central to outcomes in ENSAT I-III disease. Open adrenalectomy is presented as the standard approach, while laparoscopic surgery may shorten hospitalization but is linked to worse recurrence-related oncologic outcomes in localized disease.²²⁵

PMID 37993746: This commentary summarizes retrospective data in non-metastatic ACC suggesting that complete oncologic resection is the key curative principle, while routine en bloc multiorgan resection may be unnecessary without local invasion. Minimally invasive surgery was associated with worse outcomes mainly in stage III disease, whereas stage I-II outcomes were similar by approach.⁶⁵

PMID 38024438: This single-center retrospective series describes robot-assisted adrenalectomy for adrenal masses, including three ACC cases, and emphasizes patient selection and oncologic technique. For lesions suspicious for ACC, it recommends en bloc resection with surrounding tissue, consideration of locoregional lymphadenectomy, and early conversion to open surgery if infiltration, capsule violation, or inability to achieve negative margins is encountered.⁵⁶

PMID 38037311: A national database study of curative-intent ACC resections found that minimally invasive surgery did not have higher overall margin-positive rates than open surgery, but risk of non-curative resection during minimally invasive cases increased with older age, non-academic center, cT3-cT4 stage, and right-sided tumors. The authors developed a preoperative nomogram to help select patients for minimally invasive versus open resection.⁸⁴

PMID 38415268: This case report describes curative-intent en bloc resection of a large left ACC with pancreatic adherence and tumor thrombus extending from the left renal vein into the inferior vena cava, showing that venous thrombus and adjacent organ involvement did not preclude radical surgery in a selected patient.²²⁶

PMID 39107063: This review emphasizes that potentially curative ACC treatment is open en bloc resection in an expert high-volume center, with the goal of R0 margins and avoidance of capsular rupture. It also supports associated lymphadenectomy and selective multiorgan resection when adjacent structures are involved.³⁸

PMID 39370320: This systematic review and cadaveric anatomical study addresses how lymph node dissection should be performed during primary ACC resection. It highlights heterogeneous current practice and proposes side-specific lymphadenectomy fields, centered on capsular and renal hilar nodes plus para-caval/inter-aortocaval stations on the right and para-aortic/inter-aortocaval stations on the left.⁷²

PMID 39416880: In a retrospective cohort of 38 patients with stage 1-2 ACC after curative-intent adrenalectomy, recurrence remained frequent despite early stage disease. Recurrence was numerically higher after minimally invasive surgery than open adrenalectomy, and indeterminate or nonclear resection margins were associated with high recurrence, underscoring the importance of surgical approach and margin preservation.¹³

PMID 39835669: In a retrospective propensity-matched single-center cohort of stage I-II ACC, minimally invasive adrenalectomy performed by an experienced adrenal surgery team was associated with shorter operative time, less blood loss, fewer postoperative complications, and no significant recurrence-free survival difference versus open surgery over median 20.5-month follow-up.²²⁷

PMID 39916677: This case demonstrates that ACC with extensive local invasion, caval tumor thrombus, and Budd-Chiari syndrome may still be approached with aggressive en bloc surgery, including nephro-adrenalectomy, right hepatectomy, and caval thrombectomy, aiming for R0 resection and requiring highly experienced multidisciplinary operative teams.³⁰

PMID 40086465: This practical review emphasizes that curative-intent ACC surgery requires complete R0 resection by experienced high-volume teams, avoidance of enucleation or partial adrenalectomy, and generally an open or oncologically sound en bloc approach with lymphadenectomy despite uncertainty about the optimal nodal extent.²⁵

PMID 40317410: In a tertiary referral-center retrospective cohort, ENSAT stage III ACC treated with open multivisceral en bloc R0 resection had postoperative morbidity, disease-free survival, and overall survival comparable to stage I/II cases, supporting aggressive curative-intent surgery for locally advanced nonmetastatic disease when complete resection is feasible.⁸⁵

PMID 40549414: This review frames ACC surgery within individualized adrenalectomy planning, noting that open transabdominal adrenalectomy is generally used for large tumors and for suspected or known malignant lesions with invasion of surrounding organs or major vessels when en bloc resection is required.²²⁸

PMID 40879871: In large adrenal tumors including ACC, open adrenalectomy remains favored when malignancy or local invasion is suspected, but timely conversion from minimally invasive to open surgery can be used to preserve oncologic safety. In this retrospective series, hybrid conversion had more minor complications than purely minimally invasive surgery but outcomes were otherwise similar to planned open surgery.²²⁹

PMID 40897300: This case report and review emphasizes that suspected localized ACC, even when extremely large and nonfunctioning, may remain surgically resectable. It supports upfront open adrenalectomy with locoregional lymphadenectomy and indicates that tumor size alone should not preclude curative-intent surgery.²³⁰

PMID 41156080: In a retrospective single-center cohort, multivisceral resection for suspected locally advanced ACC achieved R0 resection in most confirmed cases and showed no significant overall survival difference versus isolated adrenalectomy despite larger, higher-stage tumors. The study supports open multivisceral surgery in specialized centers when negative-margin resection is technically achievable.⁵⁹

PMID 41224440: This review emphasizes that curative-intent management of resectable ACC depends on expert-center surgery, with open adrenalectomy as the standard approach for stages I to III, en bloc resection and regional lymphadenectomy when appropriate, and strict avoidance of tumor rupture or spillage. Minimally invasive adrenalectomy remains controversial and should be limited to carefully selected small noninvasive tumors in high-volume centers.⁶

PMID 41318839: This single-center series evaluates posterior retroperitoneoscopic adrenalectomy for primary ACC, reporting technical feasibility in selected patients but a 25% conversion rate, vascular and size-related challenges, and limited margin assessment. The findings underscore ongoing controversy over minimally invasive surgery and the need for careful case selection when pursuing curative-intent resection.²³¹

PMID 41465840: This case report revisits virilizing adrenal tumors with discordant clinical, hormonal, and imaging signals, emphasizing that definitive diagnosis came from surgical specimen histopathology. It also argues that very large adrenal masses should be managed seriously and removed via an open approach to reduce risk of intraoperative dissemination.²³²

PMID 41597289: In this tertiary referral adrenalectomy series, ACC was usually managed with open adrenalectomy, while laparoscopic resection was used only in two carefully selected ACC cases without radiologic evidence of local invasion. The authors frame open surgery as the preferred approach for malignant or advanced adrenal tumors requiring comprehensive oncologic resection.²³³

PMID 41627430: This review emphasizes that complete first-operation R0 resection without capsule rupture is the key curative principle in ACC. It supports open adrenalectomy as the standard approach, with minimally invasive surgery reserved for highly selected small noninvasive tumors in expert high-volume centers and immediate conversion to open surgery if oncologic safety is uncertain.⁹

PMID 41835703: In selected abdominal tumors including ACC with inferior vena cava or right atrial tumor thrombus, radical en bloc resection with thrombectomy using cardiopulmonary bypass and hypothermic circulatory arrest was feasible but carried substantial perioperative risk. The report emphasizes multidisciplinary planning at a tertiary referral center for these technically complex resections.⁷⁸

PMID 11204483: A veterinary multi-institution case series of canine adrenocortical tumors found frequent long-term clinical improvement after adrenalectomy but notable perioperative mortality, with incomplete resection chiefly occurring in tumors with vena caval invasion; its relevance to human ACC is indirect and comparative rather than practice-defining.²³⁴

PMID 28753758: This erratum corrected study date ranges in a prior systematic review and meta-analysis of ACC surgical management without changing the substantive interpretation of findings on laparoscopic surgery, lymphadenectomy, or surgical volume.²³⁵

PMID 15349564: A 2004 general adrenal surgery review supports the note’s existing emphasis on biochemical evaluation, cross-sectional imaging, and preoperative planning for metastatic spread, adjacent-organ resection, and possible vena caval involvement in adrenal carcinoma.²⁸

Quartz 4

Explorer

principles_of_acc_resection

Principles of ACC Resection

Diagnostic and preoperative context

Core oncologic principles

Surgical approach

Open adrenalectomy

Minimally invasive approaches

Extent of resection

En bloc and multivisceral resection

Lymphadenectomy

Venous tumor thrombus

Outcomes, recurrence, and reoperation

Pitfalls, care setting, and ongoing questions

Included Articles

References

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Table of Contents

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Quartz 4

Explorer

principles_of_acc_resection

Principles of ACC Resection

Diagnostic and preoperative context

Core oncologic principles

Surgical approach

Open adrenalectomy

Minimally invasive approaches

Extent of resection

En bloc and multivisceral resection

Lymphadenectomy

Venous tumor thrombus

Outcomes, recurrence, and reoperation

Pitfalls, care setting, and ongoing questions

Included Articles

References

Footnotes

Graph View

Table of Contents

Backlinks