Letters to the Editor
RE: A CASE OF CUSHING’S SYNDROME DUE TO ADRENOCORTICAL CARCINOMA WITH RECURRENCE 19 MONTHS AFTER LAPAROSCOPIC ADRENALECTOMY
T. Ushiyama, K. Suzuki, S. Kageyama, K. Fujita, Y. Oki and T. Yoshimi
J. Urol., 157: 2239, 1997
RE: RE: A CASE OF CUSHING’S SYNDROME DUE TO ADRENOCORTICAL CARCINOMA WITH RECURRENCE 19 MONTHS AFTER LAPAROSCOPIC ADRENALECTOMY
J. B. Nelson, L. R. Kavoussi and M. N. Walther J. Urol., 159: 1310, 1998
To the Editor. We treated a case similar to that described by Ushiyama et al but the cancer recurrence seemed to be much more associated with the laparoscopic technique. A 53-year-old man with a right adrenal mass 7 cm. in diameter presented with a pre- Cushing’s humoral and scintigraphic pattern in the absence of any sign of malignancy on computerized tomography (CT). The tumor was laparoscopically removed without any rupture in its capsule and no signs of extra-adrenal invasion were noted. Histology revealed adrenocortical carcinoma, and the patient was given mitotane adju- vant therapy and monitored closely.
CT 26 months later revealed cancer recurrence consisting of a 5 cm. multilobular mass in the adrenal space infiltrating the right kidney and marginally the VI hepatic segment. A 3 cm. nodule was also present below the scar of a port site within the muscles (see figure). Traditional surgery was performed successfully, and the mass was removed en bloc with the right kidney and a slice of the liver. In addition, 2 implants in the triangular ligament and 3 im- plants in trocar sites were removed. One of these nodules exactly corresponded to the ultrasonographic image. Histology confirmed that all nodules were adrenocortical carcinoma implants.
Nelson et al advocate that the recurrence of adrenocortical carci- noma, such as the case described by Ushiyama et al, cannot be considered necessarily a result of the laparoscopic procedure. We agree completely with Nelson et al about the validity of the laparo- scopic approach to adrenal malignancies but we report our case to emphasize caution during laparoscopic resection of such an aggres- sive tumor. Neoplastic seeding at the port site is related to the technique.1
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The objection that we risk “confusing the natural history of the disease with poor technique” might be slightly misleading, as indeed more than 100 laparoscopic adrenalectomies have been successfully performed in our unit with minimal morbidity.2 Among these cases 8 malignancies have also been removed, including 3 primitive and 5 secondary lesions. Although tumor seeding occurred only in the present case, we do not believe that it was simply due to the natural aggressiveness of the disease or some technical error. We must assume that these masses are carefully handled using an endoscopic bag because all experienced surgeons know that incidentalomas larger than 3.5 cm. should be regarded as potential cortical carci- noma despite the radiological appearance.3 Therefore, we believe that tumor implant at 3 different port sites is more likely related to redistribution of malignant cells due to contaminated instruments, insufflation gasses or other factors related to the laparoscopic pro- cedures4 than to the high incidence rate of local recurrence typical of this disease.5
Respectfully, Pietro Iacconi, Cino Bendinelli, Paolo Miccoli and Gian Paolo Bernini Dipartimento di Chirurgia Dipartimento di Medicina Interna Universita di Pisa Via Roma 67 Pisa 56100, Italy
1. Nduka, C. C., Monson, J. R. T., Menzies-Gow, N. and Darzi, A .: Abdominal wall metastases following laparoscopy. Brit. J. Surg., 81: 648, 1994.
2. Miccoli, P., Iacconi, P., Conte, M., Goletti, O. and Buccianti, P .: Laparoscopic adrenalectomy. J. Laparoendosc. Surg., 5: 221, 1995.
3. Belldegrun, A., Hussain, S., Seltzer, S. E., Loughlin, K. R., Gittes, R. F. and Richie, J. P .: Incidentally discovered mass of the adrenal gland. Surg., Gynec. & Obst., 163: 203, 1986.
4. Neuhaus, S. J., Texler, M., Hewett, P. J. and Watson, D. I .: Port-site metastases following laparoscopic surgery. Brit. J. Surg., 85: 735, 1998.
5. Pommier, R. F. and Brennan, M. F .: An eleven-year experience with adrenocortical carcinoma. Surgery, 112: 963, 1992.
Reply by Ushiyama et al. We believe that a laparoscopic procedure may be performed even when a malignant adrenal tumor is sus- pected but laparoscopic adrenalectomy is not indicated for patients with large tumors invading surrounding structures. Laparoscopic adrenalectomy should only be performed by skilled laparoscopic sur- geons and only after informed consent has been obtained. We agree that the tumor should be carefully handled, removed en bloc and retrieved with an endoscopic bag. Ultrasonic surgical devices should not be used if a malignant tumor is suspected because they may induce tumor cell seeding, which is what we think occurred in our case, although the tumor was removed without any macroscopic rupture. Also, if difficulties are encountered, the laparoscopic proce- dure should be abandoned and the operation changed to open sur- gery.
Reply by Nelson et al. Iacconi et al report another case of recurrent and metastatic carcinoma following laparoscopic adrenalectomy for a 7 cm. mass. For metastases to develop postoperatively, tumor spill- age must occur or previous micrometastases need to be present at the time of primary tumor removal. Thus, this patient either had unrec- ognized disease outside of the adrenal gland or violation of basic oncologic surgical principles occurred while removing the tumor. Although the authors have an admirable experience removing 100 adrenal glands, they had experience with removing only 3 previous primary adrenal cancers. Removing malignancy requires a different technical approach than removing benign disease.
Due to the magnification and operative techniques, there may