Laparoscopic Adrenalectomy for Primary and Secondary Malignant Adrenal Tumors
NOBUO TSURU, M.D., TOMOMI USHIYAMA, M.D., and KAZUO SUZUKI, M.D.
ABSTRACT
Laparoscopic adrenalectomy is unanimously recognized as the gold standard for the treatment of adrenal tu- mors, but it is not indicated for tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. Although laparoscopic adrenalectomy for metastatic adrenal malignancy is a feasi- ble procedure, in the case of primary adrenal malignancy, it should be done very carefully. When laparo- scopic surgery is performed for adrenal tumors >6 cm or for tumors that are considered potentially malig- nant after preoperative imaging or endocrine studies, the operation should be performed only by a highly skilled laparoscopic surgeon. It is also important to inform the patient and family that the tumors may be malignant and that conversion to open surgery could be necessary. The surgeon must create a sufficiently wide working space, remove the tumor and surrounding fat en bloc, and never grasp the tumor or adrenal tissue. The ultrasonically activated scalpel or ultrasonic endoaspirator should be carefully handled so that it does not touch the tumor surface because this will create a risk of tumor-cell dissemination. It also is essen- tial not to persist unreasonably with laparoscopic procedures but to switch immediately to open surgery when laparoscopic surgery becomes difficult.
INTRODUCTION
P RIMARY ADRENAL CORTICAL CARCINOMA is a rare endocrine neoplasm with a worldwide incidence of ap- proximately 2 per 1 million population, and complete surgical resection is the only potentially curative treatment.1 Among 1891 cases reported in the English-language literature, adrenal cortical carcinomas were slightly more common in women (58.6%) than in men (41.4%).2 Incidentally discovered adrenal masses, on the other hand, are relatively common, being found in 7% of individuals at autopsy. Most commonly, they are be- nign nonfunctioning adrenocortical adenomas. Metastases to the adrenal glands from malignant solid tumors occur with mod- erate frequency.2
Laparoscopic adrenalectomy for adrenal tumors was first performed in 1992 in Japan3-5 and by Gagner et al.6 Since then, the technique has spread around the world as a minimally in- vasive option and is now considered a gold standard for the treatment of small adrenal tumors. The indications for this method have gradually been extended as surgical techniques have improved and new devices have been developed. Now,
laparoscopic surgery is also performed for pheochromocytoma and tumors ≥10 cm.7,8 However, no consensus has been reached about the indications for laparoscopic surgery in pa- tients with primary and secondary adrenal malignancies. This paper outlines the indications for and techniques of laparoscopic surgery for malignant adrenal tumors.
SURGICAL INDICATIONS IN PRIMARY CANCERS
Primary malignant adrenal tumors include adrenocortical carcinoma and malignant pheochromocytoma. It is not always easy to make a preoperative diagnosis of such tumors. The size of the mass, as measured on CT or MRI, remains the single best indicator of malignancy, and preoperative imaging or en- docrine studies rarely yield a definite diagnosis of malignancy when the diameter of the adrenal tumor is 5 to 6 cm or smaller. Moreover, it often is difficult to differentiate benign from ma- lignant tumors even by histopathologic examination of resected specimens. Hirano and associates9 measured the telomerase ac-
D
P
00
tivity of resected adrenal tumors and concluded that this test was effective for differentiating benign from malignant tumors. However, it cannot be used for preoperative diagnosis.
It is generally considered that tumors with a diameter of ≥6 cm probably are malignant. Aso and Homma10 examined 210 Japanese patients with adrenal incidentalomas and reported that all 14 malignant tumors had a diameter of ≥6.5 cm or more. Copeland11 reported a tumor diameter of ≥6 cm in 105 of 114 adrenal cancers. In contrast, large adrenal adenomas (>6 cm) are probably uncommon, although the exact frequency is un- known. Ross and Aron12 assumed that 0.01% or 1% of adeno- mas were >6 cm in diameter, and, on the basis of this assump- tion, calculated that fewer than 1 in 10,000 adrenal neoplasms <6 cm in diameter would be a cortical carcinoma in the ab- sence of CT characteristics suggesting malignancy; i.e., irreg- ular borders or lack of homogeneity. They further estimated that the likelihood of adrenocortical carcinoma increases to 35% to 98% in patients with an adrenal mass >6 cm.12 Dackiw and colleagues2 stated that many articles in the 1990s established the routine practice of operating on patients with nonfunctioning unilateral adrenal neoplasms >6 cm and considered observa- tion in patients with smaller lesions. However, there are rea- sonable concerns over this recommendation: (1) the calcula- tions made by Ross and Aron were based on an estimate of the frequency of large (>6 cm) adrenal adenomas, a number that, although probably low, is unknown; (2) adrenocortical cancer is an aggressive malignancy, and there are no data to support the safety of observing an enlarging adrenal cancer until it reaches 6 cm; and (3) small (<5 cm) adrenocortical cancers have been documented in a number of series.13-20 Barnett et al13 reported 5 of 38 adrenal cortical carcinomas were <5 cm; imaging characteristics were suggestive of malignancy (hetero- geneity, irregular shape, irregular margins, or hemorrhage on CT; lack of fat suppression on MRI out-of-phase gradient imag- ing; heterogeneous signal intensity on T2-weighted MRI) in four of the five patients. The one patient with a <5-cm adrenocor- tical carcinoma and CT characteristics that suggested benign
disease was discovered to have a 4-cm functioning tumor.13 Therefore, clinical reality suggests that few endocrine surgeons would observe a 4- or 5-cm unilateral adrenal mass (regardless of CT characteristics) in an otherwise-healthy 40- to 50-year- old patient.2
Laparoscopic surgery has recently been performed for pri- mary adrenal cancer.21-24 However, the surgeon should be pru- dent in deciding on the indications for laparoscopic surgery be- cause many of the reported patients suffered from postoperative local recurrence or intraperitoneal dissemination. Dackiw et al2 reported on two cases of adrenocortical carcinoma that recurred 6 months after surgery. In both cases, the tumors were 4 cm in diameter and were fractured during laparoscopic adrenalec- tomy.2 We have seen a patient with Cushing’s syndrome caused by left adrenocortical cancer who developed intraperitoneal dis- semination 19 months after laparoscopic adrenalectomy.25 The tumor diameter was 5.5 cm, and preoperative CT showed a par- tially heterogeneous internal structure as well as an irregular margin (Fig. 1). The tumor was said to have been removed with- out any injury; however, Cushing syndrome recurred 19 months after the surgery (Fig. 2). During careful review of the video- tape, which includes all endoscopic procedures during the op- eration, we found that an ultrasonic endoaspirator had gently touched the tumor several times. This leads us to suspect that the use of an ultrasonic endoaspirator may sometimes be the cause of tumor recurrence.
We now consider that adrenal tumors with a diameter of about ≤12 cm are suitable for laparoscopic surgery but that tu- mors with infiltrating the surrounding tissues on preoperative imaging are not. Careful consideration should be given to tu- mors without infiltration that have a diameter of 6 cm or more and tumors with an irregular margin because such lesions have a possibility of malignancy. When performing laparoscopic sur- gery for these suspect tumors, it is important to inform the pa- tient and family that the tumor may be malignant, that laparo- scopic surgery may need to be switched to open surgery because of adhesions or bleeding, and that local recurrence may occur postoperatively. The ultrasonically activated scalpel or ultra- sonic aspirator (Cavitational Ultrasonic Aspirator [CUSA™M]; Valleylab, Boulder, CO; Ultrasonic Surgical System USU™M;
20
30
Olympus Medical Systems, Tokyo, Japan26) should be handled carefully so that it does not touch the tumor surface because of the risk of tumor-cell dissemination. It is also essential not to unreasonably persist with laparoscopic procedures but to switch immediately to open surgery when laparoscopic surgery be- comes difficult. In any case, the tumor should be removed in- tact even if it is <6 cm in diameter.
SURGICAL TECHNIQUES
The transperitoneal lateral approach is appropriate for pri- mary adrenal tumors with a diameter of ≥6 cm because it pro- vides a wide operating field and clearly exposes the adrenal gland.27,28
Left adrenalectomy
The patient is placed in the full lateral position. A skin in- cision of about 2 cm is created in the midclavicular line slightly below the costal arch to place the first trocar. A laparoscope is inserted to inspect the peritoneal cavity and determine whether laparoscopic surgery is possible. If the decision is made to pro- ceed laparoscopically, three 5-mm trocars are placed along the costal arch under laparoscopic monitoring (Fig. 3A). The phrenocolic ligament is incised, and the incision of the peri- toneum and Gerota’s fascia is extended upward along the lat-
eral border of the spleen until the greater curvature of the stom- ach is seen (Fig. 4). The spleen is allowed to fall away in the medial direction until the posterior surface of the pancreas is exposed. These procedures expose the adrenal gland at the front of the surgical field. The diaphragm is exposed at the lateral and superior aspects of the spleen. The fat around the upper pole of the adrenal gland is dissected along the diaphragm. The superior adrenal vein draining into the inferior phrenic vein at the upper side of the adrenal gland is exposed and transected. The upper pole of the kidney is detached from the adrenal gland. After dissection of the whole circumference of the adrenal gland, the surrounding fat is grasped to lift the gland, which is detached caudally and medially. Finally, the adrenal vein is ex- posed, clipped, and cut.
When the incision of the peritoneum and Gerota’s fascia is fully extended upward along the outer border of the spleen un- til the greater curvature of the stomach can be seen, the spleen is displaced in the medial direction by its own weight to pro- vide a clear visual field. The pointers to this surgical technique are to expose the diaphragm first and to start gradually dis- secting the adrenal gland from an easy site.
Right adrenalectomy
The patient is placed in the full lateral position. Trocars are placed symmetrically to the arrangement used for left adrenal- ectomy (see Fig. 3B). First, the hepatocolic ligament is incised,
A
A
0
B
scope
scope
C
B
C
MCL
MCL
· 5 mm
10 mm
A
B
and the incision is extended along the liver from the lateral to the upper surfaces. The diaphragm is exposed at the lateral bor- der of the liver and the liver detached along the diaphragm. The hepatic triangular ligament is incised to allow the right lobe of the liver to fall away in the medial direction (Fig. 4). This will allow medial mobilization of the liver by pressure to a position near the inferior vena cava, thereby providing a wide visual field. When the upper pole of the adrenal gland is impacted by, or strongly adherent to, the inferior surface of the liver, the sur- geon should not try to dissect it. Instead, the lateral border of the adrenal gland is detached, and dissection of the upper pole is left until the last step. The fat surrounding the adrenal gland on the superior and lateral borders of the gland is dissected along the diaphragm. The upper pole of the kidney is separated from the adrenal gland. After the inferior and posterior adrenal vessels at the lower pole of the adrenal gland have been dealt with, the inferior vena cava is carefully dissected to expose the adrenal vein at the level of the short hepatic vein. After this vein is cut, the adrenal gland is dissected in the cranial direc- tion along the inferior vena cava to reach the superior adrenal vein and the upper pole of the gland.
It is important to extend the incision of the hepatocolic lig- ament as far as the lateral border of the liver in order to expose the diaphragm at the superior and lateral surfaces of the adrenal gland and to use the diaphragm as a landmark when dissecting the adrenal gland. When the tumor is large, it is necessary to incise the triangular ligament to mobilize the liver in the me- dial direction. Because the right adrenal vein is short and en- ters the inferior vena cava directly, it should be carefully iden- tified and dissected.
For both left and right adrenalectomy, it is important to re- flect the intestines, liver, and spleen medially so as to obtain a wide field of view, to dissect the adrenal gland en bloc with the surrounding fat, and never to touch the tumor or the normal adrenal tissue. Use of ultrasonic coagulating shears or an ul- trasonic aspirator requires extreme care to avoid touching the tumor surface because of the risk of disseminating tumor cells.
LAPAROSCOPIC SURGERY FOR METASTATIC CANCER
Surgical indications
Laparoscopic adrenalectomy for metastatic adrenal cancer has been reported recently.29-35 Sarela and colleagues36 re- ported on 41 patients who underwent either open adrenalec- tomy (N = 30) or laparoscopic adrenalectomy (N = 11) for me- tastasis to the adrenal gland. Those authors concluded that the oncologic outcome of laparoscopic adrenalectomy appears sim- ilar to that of open surgery because there was no difference in the incidence of positive resection margins or survival between the two groups. Miccoli and associates37 evaluated 22 patients who underwent laparoscopic adrenalectomy for suspected adrenal metastases. The primary tumors were from the lung in 14 cases, colon in 2, kidney in 3, thyroid in 2, and breast in 1. Laparoscopic adrenalectomy was successful in all but three cases. In 13 patients, 14 fine-needle aspiration biopsies were performed: 8 cases proved to be true positive, 4 true negative, and 2 false negative. Final histology examination showed six
cortical adenomas. Local relapse occurred in only one patient, who died after 14 months. Of the patients with adrenal metas- tases, 8 were still alive and free of disease after a mean follow- up of 39 months. The authors concluded that the absence of false positives and the fairly high number of true positives did not justify the effort of routine fine-needle aspiration biopsy. Indeed, laparoscopic exploration, being simple and quick, al- lows optimal diagnosis at a low cost, even when histologic def- inition cannot be obtained.37 The majority of the reported pa- tients had metastases from lung cancer or renal-cell carcinoma. Complete resection of the tumor was achieved in almost all of the reported cases, and laparoscopic surgery was described as useful for adrenal metastases. However, care should be taken when preoperative imaging shows an unclear border between the tumor and the surrounding tissue or possible infiltration.
We treated a patient with metastatic cancer, in whom lapa- roscopic surgery was switched to open surgery.38 The patient was a 62-year-old man who had metastasis of lung cancer (poorly differentiated adenocarcinoma) to the adrenal gland. The MR imaging showed a tumor measuring 5.5 × 4.0 cm in the left adrenal gland with possible infiltration of the surround- ing tissue (Fig. 5A). Although retroperitoneoscopic adrenalec- tomy was performed, it had to be switched to open surgery be- cause the tumor adhered strongly to the upper pole of the kidney and could not be separated from it even at open surgery, even- tually being and removed en bloc with the upper renal pole. This patient died of systemic lung-cancer metastases 8 months after surgery. On the other hand, we saw a patient with meta- static cancer that was removed completely by laparoscopic sur- gery. The patient was a 49-year-old man with metastasis of lung cancer to the left adrenal gland. The MR imaging showed a 4.5 × 4.0-cm tumor that was relatively well demarcated from the surrounding tissue (Fig. 5B). After obtaining informed con- sent from the patient and his family, we performed laparoscopic
Liver
cut line
cut line
Spleen
Splenocolic ligament
Right kidney
Left kidney
Phrenocolic ligament
Colon (hepatic flexure)
Colon (splenic flexure)
13:5
」
1
174
A
B
adrenalectomy. The tumor could be completely excised and was histologically a poorly differentiated lung adenocarcinoma. The operating time was 151 minutes, and the estimated blood loss was 50 mL. There were no complications. He has subsequently survived for 36 months postoperatively without tumor recurrence.
Thus, laparoscopic surgery is a worthwhile option for me- tastasis to the adrenal gland from lung or renal cancer. How- ever, it is not indicated when preoperative imaging shows pos- sible infiltration of the surrounding tissues, as described above. It is important to inform the patient and family that laparoscopic
| Series | Year | No. of pts | Median follow-up | Local recurrence (%) |
|---|---|---|---|---|
| Primary tumors | ||||
| Pommier & Brennan19 | 1992 | 53 | 28 mos | 45 (84.9) |
| Icard et al17 | 1992 | 41 | 33 mos | 7 (17.1) |
| Zografos et al16 | 1994 | 38 | 30 mos | 15 (39.5) |
| Ushiyama et al25a | 1997 | 1 | 19 mos | 1 |
| Hamoir et al22a | 1998 | 1 | 6 mos | 1 |
| Kebebew et al41a | 2002 | 6 | 3.3 yrs | 3 (50) |
| Metastatic tumors | ||||
| Sarela et al36 | 2003 | 41 | 16 mos | NRb (margin positive: 7) |
| Miccoli et al37a | 2004 | 16 | 15 mos | 1 (6.3) |
| Kebebew et al41a | 2002 | 13 | 3.3 yrs | 0 |
| Rassweiler et al42a | 2003 | 11 | 58 mos | 1 (9.1) |
ªLaparoscopic adrenalectomy.
bNR = not reported.
LAPAROSCOPIC ADRENALECTOMY
surgery may be converted to open surgery and to switch im- mediately when the laparoscopic procedure is difficult, as is done for primary malignant adrenal tumors.
Surgical technique
As is the case with primary adrenal tumors, the transperi- toneal approach seems suitable for radical surgery, that is, when the primary tumor has been completely eliminated and the adrenal metastasis is the only residual tumor. The extraperi- toneal approach is occasionally feasible when the tumor is rel- atively small (<3-4 cm) or the primary objective is to make a histopathologic diagnosis that can be achieved by partial resec- tion or biopsy of the tumor, depending on the situation. The surgical technique for retroperitoneoscopic adrenalectomy is outlined below. Refer to our previous article for more details.39
The patient is placed in the full lateral position. The first tro- car is inserted in the midaxillary line slightly below the costal arch using open laparoscopy. Then two trocars are inserted along the costal margin. The additional trocar for mobilization of the kidney is inserted at the level of the umbilicus in the an- terior axillary line. Gerota’s fascia is incised widely to detach the fat around the kidney and adrenal gland en bloc. Then, the fat is incised between the upper pole of the kidney and the adrenal gland. After exposure of the upper pole of the kidney, it is detached from the adrenal gland using the renal surface as a landmark for dissection. After the kidney has been freed from the adrenal gland, the gland is elevated by grasping the attached fat to expose the inferior vena cava (right) and to cut the adrenal vein. Adrenal metastases adhere to the surrounding tissues and bleed readily because of their vascularity. Bipolar hemostatic forceps are useful for hemostasis. Use of laparoscopic coagu- lating shears to dissect the tissue surrounding the tumor requires special care to avoid touching the tumor surface, as is the case in primary adrenal tumors. When the patient is obese, it is dif- ficult to locate the adrenal gland because the gland and the up- per pole of the kidney are buried in fat. Attempts to locate the adrenal gland directly by pushing the fat aside will disturb the field of view because of bleeding and lead to disorientation. The pointer for this surgical technique it not to try to locate the adrenal gland directly but rather to manage the tissue sur- rounding the gland first.
DISCUSSION
The local-recurrence rates in published series of adrenalec- tomies for primary and metastatic cancers are summarized in Table 1.
In general, malignant adrenal tumors have abundant vascu- larity, often adhere to the surrounding tissues, and are likely to cause profuse bleeding during surgery. Gagner et al.40 stated that open surgery should be chosen for pheochromocytoma that is suspected to be malignant by preoperative imaging. As de- scribed above, we saw a patient with Cushing’s syndrome treated by laparoscopic adrenalectomy in whom intraperitoneal dissemination and local recurrence appeared 19 months after surgery despite a pathologic diagnosis of adrenocortical ade- noma. The outcome would have been the same if she had been treated by open surgery because the tumor was not damaged
and was removed en bloc. However, the ultrasonic aspirator may have caused dissemination of tumor cells.
Laparoscopic surgery is not indicated for primary adrenal tu- mors of any size when preoperative imaging shows infiltration of the surrounding tissue. Careful dissection is required for tu- mors with a diameter of ≥6 cm even when no malignant fea- tures are observed preoperatively because there remains a pos- sibility of malignancy. Although metastatic cancer with a diameter of no more than 7 to 8 cm is considered to be indi- cated for laparoscopic surgery, metastatic tumors with obvious infiltration of the surrounding tissues are not suitable, as is the case for primary adrenal tumors. The transperitoneal approach is appropriate when laparoscopic surgery is aimed at radical re- section of the tumor, while the extraperitoneal approach is ap- propriate when the aim of surgery is to make a histopathologic diagnosis.
In either case, only experienced surgeons should perform lap- aroscopic adrenalectomy for malignant or potentially malignant adrenal tumors and only after informing the patient and family that a large amount of bleeding may occur, that the laparoscopic procedure may be switched to open surgery, and that the tumor can recur locally. During surgery, it is important to pay special attention to bleeding and not to persist with laparoscopy but to switch to open surgery immediately if the laparoscopic proce- dure becomes difficult.
CONCLUSION
Laparoscopic adrenalectomy for metastatic adrenal lesions seems to be a feasible procedure, but it should be done very carefully for the treatment of primary adrenal malignancy. A first priority is intact removal of the tumor without tearing it. Only a highly skilled laparoscopic surgeon should perform the operation, and ultrasonic devices should be handled carefully so that they do not touch the tumor surface and increase the risk of tumor-cell dissemination. It also is essential not to per- sist unreasonably with laparoscopic procedures if they become difficult but to switch immediately to open surgery.
REFERENCES
1. Wooten MD, King DK. Adrenal cortical carcinoma: Epidemiology and treatment with mitotane and a review of the literature. Cancer 1993;72:3145-3155.
2. Dackiw AP, Lee JE, Gagel RF, Evans DB. Adrenal cortical carci- noma. World J Surg 2001;25:914-926.
3. Go H, Takeda M, Takahashi H, et al. Laparoscopic adrenalectomy for primary aldosteronism: A new operative method. J Laparoen- dosc Surg 1993;3:455-459.
4. Suzuki K, Kageyama S, Ueda D, Yshiyama T, Kawabe K, Tajima A, Aso Y. Laparoscopic adrenalectomy: Clinical experience with 12 cases. J Urol 1993;150:1099-1102.
5. Higashihara E, Tanaka Y, Horie S, Aruga S, Nutahara K, Mi- nowada S, Aso Y. Laparoscopic adrenalectomy: The initial 3 cases. J Urol 1993;149:973-976.
6. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 1992; 327:1033.
7. Gagner M, Pomp A, Heniford BT, Pharand D, Lacroix A. Laparo-
scopic adrenalectomy: Lessons learned from 100 consecutive pro- cedures. Ann Surg 1997;226:238-246.
8. Henry JF, Defechereux T, Gramatica L, Raffaelli M. Should lapa- roscopic approach be proposed for large and/or potentially malig- nant adrenal tumors? Langenbecks Arch Surg 1999;384:366-369.
9. Hirano Y, Fujita K, Suzuki K, Ushiyama T, Ohtawara Y, Tsuda F. Telomerase activity as an indicator of potentially malignant adrenal tumors. Cancer 1998;83:772-776.
10. Aso Y, Homma Y. A survey on incidental adrenal tumors in Japan. J Urol 1992;147:1478-1481.
11. Copeland PM. The incidentally discovered adrenal mass. Ann Surg 1984;199;116-122.
12. Ross NS, Aron DC. Hormonal evaluation of the patient with an in- cidentally discovered adrenal mass. N Engl J Med 1990;323:1401- 1405.
13. Barnett CC Jr, Varma DG, El-Naggar AK, et al. Limitations of size as a criterion in the evaluation of adrenal tumors. Surgery 2000; 128:973-983.
14. Angeli A, Osella G, Ali A, Terzolo M. Adrenal incidentaloma: An overview of clinical and epidemiological data from the National Italian Study Group. Horm Res 1997;47:279-283.
15. Linos DA, Stylopoulos N, Raptis SA. Adrenaloma: A call for more aggressive management. World J Surg 1996;20:788-793.
16. Zografos GC, Driscoll DL, Karakousis CP, Huben RP. Adrenal adenocarcinoma: A review of 53 cases. J Surg Oncol 1994;55: 160-164.
17. Icard P, Louvel A, Chapuis Y. Survival rates and prognostic fac- tors in adrenocortical carcinoma. World J Surg 1992;16:753-758.
18. Yamakita N, Saitoh M, Mercado-Asis LB, Kitada M, Morita H, Yasuda K, Miura K. Asymptomatic adrenal tumor: 386 cases in Japan including our 7 cases. Endocrinol Jpn 1990;37:671-684.
19. Pommier RF, Brennan MF. An eleven-year experience with adrenocortical carcinoma. Surgery 1992;112:963-971.
20. Favia G, Lumachi F, Basso S, D’Amico DF. Management of inci- dentally discovered adrenal masses and risk of malignancy. Sur- gery 2000;128:918-924.
21. Deckers S, Derdelinckx L, Col V, Hamels J, Maiter D. Peritoneal carcinomatosis following laparoscopic resection of an adrenocor- tical tumor causing primary hyperaldosteronism. Horm Res 1999; 52:97-100.
22. Hamoir E, Meurisse M, Defechereux T. Is laparoscopic resection of a malignant corticoadrenaloma feasible? Care report of early, diffuse and massive peritoneal recurrence after attempted laparo- scopic resection. Ann Chir 1998;52:364-368.
23. Hofle G, Gasser RW, Lhotta K, Janetschek G, Kreczy A, Finken- stedt G. Adrenocortical carcinoma evolving after diagnosis of pre- clinical Cushing’s syndrome in an adrenal incidentalomas: A case report. Horm Res 1998;50:237-242.
24. Inoue T, Terai A, Terachi T, Souma T, Yoshida O. Synchronous testicular seminoma and adrenocortical carcinoma: A case report. Int J Urol 1998;5:615-617.
25. Ushiyama T, Suzuki K, Kageyama S, Fujita K, Oki Y, Yoshimi T. A case of Cushing’s syndrome due to adrenocortical carcinoma with recurrence 19 months after laparoscopic adrenalectomy. J Urol 1997;157:2239.
26. Suzuki K, Fujita K, Ushiyama T, Mugiya S, Kageyama S, Ishikawa A. Efficacy of an ultrasonic surgical system for laparoscopic adrenalectomy. J Urol 1995;154:484-486.
27. Suzuki K. Laparoscopic adrenalectomy. In: Hemal AK (ed): Lap- aroscopic Urologic Surgery. New Delhi: BI Churchill Livingstone, 2000, pp 109-123.
28. Suzuki K, Kageyama S, Hirano Y, Ushiyama T, Rajamahanty S, Fujita K. Comparison of 3 surgical approaches to laparoscopic adrenalectomy: A nonrandomized, background matched analysis. J Urol 2001;166:437-443.
29. Bendinelli C, Lucchi M, Buccianti P, Iacconi P, Angeletti CA, Mic-
coli P. Adrenal masses in non-small cell lung carcinoma patients: Is there any role for laparoscopic procedures? J Laparoendosc Adv Surg Tech A 1998;8:119-124.
30. Breton X, Corbi P, Fare JP, Jailed C, Richer JP, Meurice JC, Tourani JM, Kraimps JL. Operable lung cancer and synchronous adrenal masses: Role of laparoscopic adrenalectomy combined with pulmonary resection. Ann Chir 2002;127:193-197.
31. Elashry OM, Clayman RV, Soble JJ, McDougall EM. Laparoscopic adrenalectomy for solitary metachronous contralateral adrenal me- tastasis from renal cell carcinoma. J Urol 1997;157:1217-1222.
32. Gill IS, Meraney AM, Thomas JC, Sung GT, Novick AC, Lieber- man I. Thoracoscopic transdiaphragmatic adrenalectomy: The ini- tial experience. J Urol 2001;165:1875-1881.
33. Linos DA, Avlonitis VS, Iliadis K. Laparoscopic resection of soli- tary adrenal metastasis from lung carcinoma: A case report. JSLS 1998;2:291-293.
34. Tsuji Y, Yasuhuku M, Haryu T, Watanabe Y, Ataka K, Okada M. Laparoscopic adrenalectomy for solitary metachronous adrenal me- tastasis from lung cancer: Report of a case. Surg Today 1999;29: 1277-1279.
35. Valeri A, Borrelli A, Presenti L, Lucchese M, Venneri F, Mannelli M, Regio S, Borrelli D. Adrenal masses in neoplastic patients: The role of laparoscopic procedure. Surg Endosc 2001;15:90-93.
36. Sarela AI, Murphy I, Coit DG, Conlon KC. Metastasis to the adrenal gland: The emerging role of laparoscopic surgery. Ann Surg Oncol 200;10:1191-1196.
37. Miccoli P, Materazzi G, Mussi A, Lucchi M, Massi M, Berti P. A reappraisal of the indications for laparoscopic treatment of adrenal metastases. J Laparoendosc Adv Surg Tech A 2004;14:139-145.
38. Suzuki K, Ushiyama T, Mugiya S, Kageyama S, Saisu K, Fujita K. Hazards of laparoscopic adrenalectomy in patients with adrenal malignancy. J Urol 1997;158:2227.
39. Suzuki K. Laparoscopic adrenalectomy: Retroperitoneal approach. Urol Clin North Am 2001;28:85-95.
40. Gagner M, Breton G, Pharand D, Pomp A. Is laparoscopic adrena- lectomy indicated for pheochromocytomas? Surgery 1996;120: 1076-1079.
41. Kebebew E, Siperstein AE, Clark OH, Duh QY. Results of lapa- roscopic adrenalectomy for suspected and unsuspected malignant adrenal neoplasms. Arch Surg 2002;137:948-951.
42. Rassweiler J, Tsivian A, Kumar AV, Lymberakis C, Schulze M, Seeman O, Frede T. Oncological safety of laparoscopic surgery for urological malignancy: Experience with more than 1,000 opera- tions. J Urol 2003;169:2072-2075.
Address reprint requests to: Kazuo Suzuki, M.D. Dept. of Urology Hamamatsu University School of Medicine 1-20-1 Handayama, Hamamatsu-shi 431-3192 Japan E-mail: heijosin@hama-med.ac.jp
EDITORIAL COMMENT
Adrenocortical carcinoma is a rare malignancy that can oc- cur at all ages, from early infancy to the 8th decade of life. Un- fortunately, the prognosis is generally poor, although pediatric patients seem to do better, probably because of their earlier pre- sentation from a hormonal syndrome. The majority of adreno- cortical carcinomas are functional, with Cushing’s syndrome being most common manifestation.1
LAPAROSCOPIC ADRENALECTOMY
The overriding tenet for the treatment of adrenocortical car- cinoma is complete surgical excision if a chance for a cure is to be considered. In one series, the 5-year survival rate of adrenocortical carcinoma after surgery was 55% following complete removal with negative margins. This is in contrast to a 5-year survival rate of 5% with incomplete removal.2 There- fore, the urologic surgeon must choose the approach that will give the patient the greatest chance of negative surgical mar- gins. This of course may involve en bloc resection of the tu- mor with surrounding kidney, spleen, colon, and/or other or- gans that are infiltrated.
The traditional teaching has been that such an operation be approached in an open fashion. This is the gold standard! How- ever, experienced urologists with advanced skills in laparo- scopic genitourinary surgery are quite capable of performing an associated radical nephrectomy. In conjunction with a skilled laparoscopic general surgeon, splenectomy, partial pancreatec- tomy, colon resection, or some combination may now become routine. Therefore, under the correct circumstance and with ap- propriate planning, a laparoscopic “radical adrenalectomy” may today be considered. However, as the authors of this paper em- phasize, such an undertaking must be in the hands of very skilled and experienced laparoscopic surgeons. The ability to remove the lesion completely should not be compromised solely to decrease patient morbidity. The additional morbidity endured after an open surgical procedure is insignificant if a more thor- ough excision is possible.
Melanoma and breast or lung cancer account for the major- ity of metastatic lesions in the adrenal glands. Solitary metas-
tases from renal-cell carcinoma may present in the adrenal gland in upward of 40% of cases. In situations where patient survival may be improved, the metastatic focus is solitary, and the pri- mary cancer has been resected or clinically eradicated, removal of the adrenal gland is justified.
Laparoscopic removal of metastatic tumors in the adrenal gland has been reported and is considered a safe procedure in experienced and skilled hands.3 However, many of these pa- tients will already have undergone ipsilateral open-abdominal surgery, which complicates the laparoscopic approach. Such surgery may be further complicated by the expected distortion of normal tissue planes caused by the malignant-tumor infil- tration. Conversion to open surgery may be prudent in certain circumstances where severe visceral or vascular injury is highly imminent.
Howard N. Winfield, M.D. University of Iowa Iowa City, Iowa
REFERENCES
1. Ng L, Libertino JM. Adrenocortical carcinoma: Diagnosis, evalua- tion and treatment. J Urol 2003;169:5-11.
2. Schulick RD, Brennan MF. Long-term survival after complete re- section and repeat resection in patients with adrenocortical carci- noma. Ann Surg Oncol 1999;6:719-726.
3. Heniford BT, Arca MJ, Walsh RM, et al. Laparoscopic adrenalec- tomy for cancer. Semin Surg Oncol 1999;16:293-306.