Case Report
Thoracoscopic transdiaphragmatic adrenalectomy for isolated locally recurrent adrenal carcinoma
KAZUMASA MATSUMOTO,1 SHIN EGAWA,1 TAKEFUMI SATOH,1 NORIHIKO OKUNO,1 SHIZUKA KASEDA2 AND SHIRO BABA1
1Department of Urology, Kitasato University School of Medicine, Sagamihara and 2Department of Thoracic Surgery, Saiseikai-Kanagawaken Hospital, Yokohama, Kanagawa, Japan
Abstract A 58-year-old man who had undergone left adrenalectomy 2 years previously for adrenocortical carcinoma was diagnosed to have a left suprarenal solid mass. Thoracoscopic transdiaphragmatic excision of the tumor was conducted under the diagnosis of isolated local recurrence of adrenal carcinoma. There were no intraoperative or postoperative complications. The patient subsequently received three courses of adjuvant chemotherapy. There have been no signs of tumor recurrence during 3 years follow up after surgery. This approach provides a minimally invasive alternative to an open thoracoabdominal procedure after prior open surgery.
Key words adrenal gland, carcinoma, laparoscopy, recurrence, thoracoscopy.
Introduction
Minimally invasive surgical managements are being per- formed on the adrenal glands. Various surgical modalities to the adrenal gland have been conducted, including ante- rior, posterior, flank and thoracoabdominal approaches.1 Furthermore, transperitoneal and retroperitoneal laparo- scopic adrenalectomy currently comprise the standard procedures to these glands. Recently, a thoracoscopic transdiaphragmatic approach has been introduced for adre- nal glands as an attractive alternative after prior open sur- gery.2 We report a case of isolated local recurrence of adrenocortical carcinoma treated with thoracoscopic trans- diaphragmatic excision.
Case report
A 58-year-old man, who had undergone left adrenalectomy 2 years previously for adrenocortical carcinoma through a thoracoabdominal ninth rib incision followed by chemo- therapy, was found on magnetic resonance imaging (MRI) to have a 5 cm × 6 cm left suprarenal solid mass indicative of local recurrence (Fig. 1). Direct tumor invasion was not evident radiographically. Subsequent evaluation with computed tomography and MRI showed no additional suspicious metastases. Laboratory examinations and
Correspondence: Kazumasa Matsumoto MD, Department of Urology, Kitasato University School of Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa, 228-8555, Japan. Email: address, kazumasa@cd5.so-net.ne.jp
biochemical activity of the adrenal gland were normal preoperatively.
The patient underwent thoracoscopic transdiaphrag- matic tumor excision as described by Gill et al.2 General anesthesia was conducted leaving the ipsilateral lung not inflated. The patient was placed in the left decubitus position and approached using four transthoracic ports located from the sixth to eighth ribs (Fig. 2). A 5 cm mini- thoracotomy incision was also made at the eighth intercos- tal space posteriorly. There was mild adhesion found in the lower thoracic cavity but this was not a significant obstacle for the rest of the operative procedure. An intraoperative ultrasound probe was inserted through the port, and con- firmed the proposed line of incision on the diaphragm and overlying the adrenal mass. The diaphragm was incised horizontally from left to right, 1 cm apart from the dorsal thoracic wall along the adrenal mass. To expose the adrenal mass, an appropriate incision was done through the full thickness of the diaphragmatic wall. The left adrenal mass with, in part, adherent diaphragm was removed. The peri- tumoral tissue over the psoas muscle was found to be adhesive, suggesting possible tumor invasion. The speci- men in the plastic bag was retrieved into the thorax and evacuated through the mini-thoracotomy incision. A polyglactin mesh was used for covering a defected part of the diaphragm. Operating time was 7 h and blood loss was 650 mL. Postoperative course was uneventful.
Pathological examination revealed recurrent adrenocor- tical carcinoma compatible with the original histology of the primary tumor. Direct tumor invasion into surrounding tissue was not evident and the surgical margin was nega- tive. The patient subsequently received adjuvant chemo- therapy consisting of etoposide and cisplatin on
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postoperative day 19, followed by two more courses in every 21 days. There have been no signs of tumor recur- rence during 3 years follow up after surgery.
Discussion
Laparoscopic adrenalectomy was initially reported in 1992.3 This modality is an established procedure for benign, primary and metastatic adrenal lesions. However, this approach may be limited in patients in whom the peritoneal and retroperitoneal cavities have already been violated surgically for treating primary lesions.
In selected patients, a minimally invasive thoracoscopic transdiaphragmatic approach has a potential for overcom- ing this limitation and is attractive. Mack et al. reported the first challenge of transthoracic biopsy through the diaphragm to an adrenal gland for a metastatic lesion.4 Pompeo et al. performed left thoracoscopically transdia- phragmatic adrenalectomy in a porcine experimental model.5 They reported prolonged splenic bleeding and dif- ficulty in performing the suture of the diaphragm in animal models. Gill et al. applied this procedure to clinical cases of primary adrenal tumors and expanded the indication including right adrenalectomy.2 Transdiaphragmatic adrenalectomy was accomplished in all three cases without complications. To our knowledge, our report is the first to have applied a transthoracic transdiaphragmatic tech- nique for local recurrence of adrenocortical carcinoma. The thoracic cavity was almost clear and suitable for this approach to the suprarenal mass even after ipsilateral open adrenalectomy.
This procedure may not always be indicated for all such patients. Since, in our sole experiment, this patient did not have any abnormalities of preoperative examination which suggested heart and pulmonary diseases, we performed thoracoscopic transdiaphragmatic tumor excision in this particular case. However, this approach might have a lim- itation related to patients with cardiopulmonary disease and with prior thoracic surgery, and the necessity of sutur- ing or covering the diaphragmatic defect by artificial mesh at the end of the procedure. While the clinical application of this procedure should be critical, this approach is safe and provides a minimally invasive alternative instead of the repeat open thoracoabdominal incision after prior major surgery.
Acknowledgment
Dr Kaseda is currently Vice Director at the National Hos- pital Organization Kanagawa Hospital, Hatano, Kanagawa, Japan.
References
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2 Gill IS, Meraney AM, Thomas JC, Sung GT, Novick AC, Lieberman I. Thoracoscopic transdiaphragmatic adrena- lectomy: the initial experience. J. Urol. 2001; 165: 1875- 81.
3 Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalec- tomy in Cushing’s syndrome and pheochromocytoma. N. Engl. J. Med. 1992; 327: 1033.
4 Mack MJ, Aronoff RJ, Acuff TE, Ryan WH. Thoracoscopic transdiaphragmatic approach for adrenal biopsy. Ann. Tho- rac. Surg. 1993; 55: 772-3.
5 Pompeo E, Coosemans W, De Leyn P, Deneffe G, Van Raemdonck D, Lerut T. Thoracoscopic transdiaphragmatic left adrenalectomy. An experimental study. Surg. Endosc. 1997; 11: 390-2.