Urologia Internationalis
Urol Int 2007;78:46-49 DOI: 10.1159/000096934
Received: November 10, 2005 Revised and accepted: May 5, 2006
Open Surgical Treatment of Right-Sided Adrenal Carcinomas >15 cm
Ubirajara Ferreira Renato Nardi Pedro Wagner Eduardo Matheus Alessandro Prudente Gustavo Mendonça Borges Nelson Rodrigues Netto Jr.
Division of Uro-Oncology, Department of Urology, Hospital de Clínicas de Campinas, State University of Campinas, UNICAMP, Campinas, Brazil
Key Words
Adrenal carcinomas >15 cm · Open surgical treatment, adrenal carcinomas . Right-sided ‘giant’ adrenal tumors
Abstract
Introduction: Adrenal carcinomas are rare and are associ- ated with a very poor prognosis. The incidence is estimated to be 1 in 1.7 million which represents 0.02% of all cancers and 0.2% of all cancer mortality. The 5-year survival rate is 38%. The purpose of this paper is to present a single-institu- tion experience in excising right-sided giant adrenal carcino- mas, discussing the difficulties and the usage of special sur- gical devices to facilitate the procedure. Patients and Methods: During June 2001 to June 2003, 18 patients with right-sided adrenal tumors were treated at the State Univer- sity of Campinas Hospital - UNICAMP. 4 out of the 18 patients presented lesions >15 cm, representing the study group. The mean age was 37 (range 26-65) years, 3 patients were young- er than 35 years, and 2 patients were men. A right-sided ex- tended subcostal incision was the surgical access in 1 patient (case 1) and a right-sided thoracoabdominal incision in the other 3 patients. Results: Adrenal cortical carcinoma was the histological diagnosis according to the Weiss criteria; no pos- itive surgical margin was detected, even in those patients with invasion of the hepatic capsule. The median follow-up period was 15 (range 6-30) months. Conclusions: A subcos-
tal extended incision can accomplish broad exposure, if ar- ticulated costal retractors are available (used in liver trans- plantation), otherwise a thoracoabdominal incision is the best option. The most important feature of surgery is to ac- complish an efficient hemostasis of the liver parenchyma. Suture and stitches are not suitable for minor vascular struc- tures, and electrocauterization sometimes promotes hepat- ic lesions and does not provide bleeding control. Thus, the need for special hemostatic means is real, and they should be avaiable in these situations.
Copyright @ 2007 S. Karger AG, Basel
Introduction
Adrenal carcinomas are rare and are associated with a very poor prognosis. The incidence is estimated to be 1 in 1.7 million which represents 0.02% of all cancers and 0.2% of all cancer-related mortality. At the time of the diagnosis, hematogenic dissemination or local invasion can be detected in a significant proportion of the patients. The 5-year survival rate is 38% [1]. The etiology is not yet clearly defined [2].
Metastases are most commonly seen in lungs (60%), liver (50%), lymph nodes (48%), and bone (24%) [3]. Fur- ther, these tumors are prone to invade surrounding or- gans such as liver, kidney, spleen, and vena cava. Treat-
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ment consists of en bloc resection: excision of the prima- ry lesion along with the compromised organs and lymph nodes [4]. Radiotherapy is an option for palliation [5]. Chemotherapeutic agents have a very limited role. De- spite a 35% response rate for mitotane [6], chemotherapy does not improve the 5-year survival rate [7]. Chemo- therapeutic agents help to decrease the devastating effects
of high serum levels of corticosteroids and aldosterone which are usually produced by adrenal carcinomas. The surgical procedure challenges the surgeon, mainly when giant tumors invade vascular structures or important or- gans.
The purpose of this paper is to report the surgical tech- nique in excising right-sided adrenal carcinomas >15 cm, focusing on the anatomic peculiarities of the right adre- nal gland.
Patients and Methods
During June 2001 to June 2003, 18 patients with right-sided adrenal tumors were treated at the State University of Campinas Hospital - UNICAMP. The tumor size ranged from 3 to 18.6 cm in diameter. 4 out of 18 patients presented lesions >15 cm, repre- senting the study group. The mean age was 37 (range 26-65) years, 3 patients were younger than 35 years, and 2 patients were men.
Regarding the clinical features, 3 patients (75%) presented symptoms of abnormal hormone secretion. All patients had in- creased serum coriticosteroid levels, 1 patient had also a high se- rum aldosterone concentration, and another patient had also high androgens levels.
The most common clinical manifestations were hypertension (50%), Cushing’s syndrome (50%), virilization (25%), and ab- dominal mass (25%). The suggestive diagnosis was established by ultrasonography and confirmed by computerized tomography (CT). Magnetic resonance imaging (fig. 1) was indicated in 2 pa- tients for better assessment of the liver invasion. The mean tumor size was 16.4 (range 15-18.6) cm. Metastatic workup consisted of bone scan (negative in all cases) and thorax CT (positive in 1 case).
A right extended subcostal incision was the surgical access in 1 patient (case 1) and right thoracoabdominal incision in the oth- er 3 patients (fig. 2). In case 1 a subcostal retractor was used; this device is routinely used in liver transplantation, providing good exposure of the operative field.
Results
There was no intraoperative mortality. The mean op- erative time was 352 (range 270-420) min; complete tu- mor resection was accomplished in all cases. Vena cava dissection revealed that the tumor dislocated, but did not invade its wall, and the separation was possible without difficulties. In contrast, kidney dissection was usually difficult due to tumor invasion and adhesions. In 2 cases (50%) right nephrectomy was necessary to remove the entire tumor mass. The surgical challenge focused on the boundaries of liver and tumor mass. The dissection re- quired time and surgical skills. In 2 patients, there was a
distinct cleavage between adrenal tumor and hepatic cap- sule, just as shown in the workup CT scans. In the other 2 patients, the tumor invaded the hepatic capsule, so that a subcapsular hepatic resection was performed to accom- plish entire tumor excision. Hemostasis required argon laser, biological glue (fibrin/fibrinogen), and Surgicel®. The blood loss was intense; however, argon laser and bio- logical glue enabled a precise and efficient bleeding con- trol. All patients made a quite good recovery. Pneumonia and prolonged chest tube drainage were the early post- surgical complications in 3 patients. Their outcomes were uneventful afterwards. Adrenal cortical carcinoma was the histological diagnosis according to the criteria of Weiss; no positive surgical margin was detected, even in those with invasion of the hepatic capsule. The median follow-up period was 15 (range 6-30) months. One pa- tient had tumor recurrence (liver) and died 8 months af- ter surgery. The other patient, whose metastatic workup revealed thoracic nodules, had additional treatment based on excision of all metastases, and, subsequently, chemo- therapy completed the treatment. This patient had a dis- ease-free interval of 24 months. Two patients (50%) had 5- and 6-month follow-up visits, respectively, without signs of local or distant recurrence.
Discussion
The incidence of incidentally discovered asymptom- atic adrenal masses (incidentalomas) has been increasing during the technological development of diagnostic de- vices. The prevalences of the ‘incidentalomas’ found by CT and magnetic resonance imaging are estimated to be 0.35 and 1.5%, respectively. The great majority (95%) cor- respond to nonfunctioning cortical adenomas <5 cm in size.
On the other hand, adrenal lesions may cause symp- toms secondary to hormone production or the size of the gland (compressive syndrome). Diagnostic workup con- sists of the radiological confirmation of the clinical sus- picion [8]. All patients included in this study had symp- toms. The diagnosis of an adrenal tumor had been con- firmed by CT after a thorough anamnesis and physical examination.
Ultrasonography can detect adrenal masses of 2 cm in diameter, it is less expensive, and is generally well accept- ed by the patients. However, morphological features and anatomical relations are much better investigated by CT; these aspects are of great importance for the surgical strategy. CT is the gold standard method for the diagno-
sis. Perinephric fat allows the identification of the adrenal gland, and lesions <10 mm can be evident. The sensitiv- ity reaches 100% [9]. Magnetic resonance is required when CT did not clearly demonstrate the limits of the tu- mor. It facilitates the diagnosis of adjacent organ invasion because of high-quality images.
Once the diagnosis of an adrenal lesion is made, labo- ratory workup is indicated. Serum corticosteroid, aldo- sterone, catecholamine, and androgen levels are mea- sured. It is important to identify which of these hormones are altered, for better management of the patient prior to, during, and after surgery.
After complete radiological and laboratory workup, surgery can be planned. A subcostal extended incision can accomplish broad exposure of the operative field, if articulated costal retractors are available (used in liver transplantation); otherwise, a thoracoabdominal inci- sion is the best option.
Following a broad exposure, the Cattell maneuver al- lows the presentation of the retroperitoneal structures. Right kidney, vena cava, and adrenal tumor are then vi- sualized. Usually the tumor presses medially against the vena cava, but spares it from invasion. In all 4 cases the vena cava was not invaded, and dissection could be per- formed easily. The renal pedicle also can be exposed with this maneuver; nephrectomy is indicated only, if the renal parenchyma is invaded by the adrenal tumor.
Dissection of the adrenal vein was difficult to perform in our patients because of the tumor volume. Mobiliza- tion of the lesion required caution, mainly near the he- patic hilum, in all cases. Dissection between tumor and liver was easy to perform in 2 patients, and no evidence of invasion was noticed. When liver invasion was evident, a great effort was undertaken creating a subcapsular path. Invasion in these cases was not neoplastic, but inflamma- tory, and the surgical margins were negative. It is of ut- most importance to accomplish an efficient hemostasis of the liver parenchyma. Sutures or stitches are not useful in minor vascular structures, and electrocauterization sometimes increases the occurrence of hepatic lesions and does not provide bleeding control. Hence, special he- mostatic means are needed.
An argon laser was used, with successful bleeding con- trol; subsequently, biological glue (fibrin/fibrinogen) was directly applied, forming a ‘crust’. Without these means, surgery would probably take more time, and the patient recovery would be negatively influenced. Argon laser and biological glue provided confidence to the surgeon, and they are easy to handle; as a consequence, the procedures became much better feasible.
The patient outcomes confirmed the aggressiveness of this carcinoma. One patient died within <1 year, and an- other had an inoperable distant metastasis after 24 months of follow-up.
According to the literature [1, 3, 5], in adrenal tumors surgery is always indicated, even if a distant metastasis is identified. Improvement of survival rates and a better quality of life are possible with this policy. Today, surgical resection is the single most important treatment for ad- renal carcinomas [8].
Conclusions
Adrenalectomy for ‘giant’ adrenal tumors, mainly when on the right side, is a challenge to the surgeon. The major difficulty is the dissection between tumor and liv- er. Hemostasis of the decapsulated liver requires special means. Argon laser and biological glue (fibrin/fibrino- gen) are easy to handle and provide efficient bleeding control. Complete en bloc resection can be performed with confidence, allowing a better recovery.
References
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