available at www.sciencedirect.com journal homepage: www.europeanurology.com
e European Association of Urology
EUROPEAN UROLOGY
Surgery n
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2008 Impact 6.5121
EU-ACIAL
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Letter to the Editor
Re: David Brix, Bruno Allolio, Wiebke Fenske, et al. Laparoscopic Versus Open Adrenalectomy for Adreno- cortical Carcinoma: Surgical and Oncologic Outcome in 152 Patients. Eur Urol 2010;58:609-15
We read with interest the article by Brix et al. [1] and would like to congratulate them for bringing this controversial issue into focus. This study suggests that laparoscopic adrenalectomy for localized adrenocortical carcinoma with a diameter ≤10 cm carries the same oncologic results as an open approach-but, in our opinion, the same poor results. Overall recurrence (local and metastatic) is 70%, as in most of the published series.
In adrenocortical carcinoma, R0 surgery continues to be the only potentially curative option, and the quality and completeness of the initial surgical resection remains one of the most powerful prognostic factors. This has been shown previously at the MD Anderson Cancer Center [2], where overall survival was shown to be significantly better for patients undergoing resection in this high-volume center compared with those referred after primary resection. At the Memorial Sloan-Kettering Cancer Center, it was demonstrated that complete surgical resection is the primary and only potentially curative treatment [3].
Nevertheless, the surgical management and prognosis of adrenocortical carcinoma has not appreciably evolved over time [4]. The overall 5-yr survival rate is about 40%, and standards of surgical care remain undefined, particularly with regard to the necessity and extent of lymphadenecto- my or the need for nephrectomy. To date, no recommenda- tions have been made available by national or international associations, societies, or networks in the Western hemi- sphere. In multicenter trials, the discrepancy in surgical management is significant, as reported in a large French multicentric study where lymphadenectomy was per- formed only in one-third of the patients [5]. This lack of standardization underscores the point that a standard of surgical care as well as a clear definition of surgical oncologic principles for adrenal malignancy are necessary.
In this setting, and in our opinion, a laparoscopic approach for adrenocortical carcinoma should be avoided, at least until such time as a clear standard of surgical care has been achieved and established for the open approach. This methodology was previously used in colon, prostate,
and kidney cancers, for which the laparoscopic approach is now widely accepted but was used only after the oncologic surgical principle of this surgery had been clearly defined and consensus achieved. Solving the controversy regarding the open or laparoscopic approach would only be relevant after a clearly definitive standard of surgical care with an open approach has been achieved. At this time, the question to be answered is whether the same procedure and results could be achieved using the laparoscopic approach.
The surgical community should organize an efficient international collaborative working group to define stan- dards of surgical care for adrenocortical carcinoma, with the purpose of devising an international, prospective, multi- centric study, as the medical community did regarding treatment of unresectable tumors in the First International Randomized Trial in Locally Advanced and Metastatic Adrenocortical Cancer Treatment (FIRM-ACT).
Conflicts of interest: The authors have nothing to disclose.
References
[1] Brix D, Allolio B, Fenske W, et al. Laparoscopic versus open adre- nalectomy for adrenocortical carcinoma: surgical and oncologic outcome in 152 patients. Eur Urol 2010;58:609-15.
[2] Grubbs EG, Callender GG, Xing Y, et al. Recurrence of adrenal cortical carcinoma following resection: surgery alone can achieve results equal to surgery plus mitotane. Ann Surg Oncol 2010;17:263-70.
[3] Schulick RD, Brennan MF. Long-term survival after complete resec- tion and repeat resection in patients with adrenocortical carcino- ma. Ann Surg Oncol 1999;6:719-26.
[4] Bilimoria KY, Shen WT, Elaraj D, et al. Adrenocortical carcinoma in the United States: treatment utilization and prognostic factors. Cancer 2008;113:3130-6.
[5] Icard P, Goudet P, Charpenay C, et al. Adrenocortical carcinomas: surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group. World J Surg 2001; 25:891-7.
Sebastien Gaujoux Stephane Bonnet Bertrand Dousset*
Department of Digestive and Endocrine Surgery, Cochin Hospital, AP-HP, Paris, France
*Corresponding author.
E-mail address: bertrand.dousset@cch.aphp.fr (B. Dousset)
September 2, 2010
Published online on September 15, 2010