ccepted Article
Received Date : 17-Jun-2016
Revised Date : 26-Jul-2016
Accepted Date : 29-Jul-2016
Article type : Original Article
Article category: Urological Oncology
SURGICAL QUALITY OF MINIMALLY INVASIVE ADRENALECTOMY FOR ADRENOCORTICAL CARCINOMA: A CONTEMPORARY ANALYSIS USING THE NATIONAL CANCER DATA BASE
Matthew J. Maurice, MDª; Matthew J. Bream, MDb; Simon P. Kim, MD, MPHb; Robert Abouassaly, MD, MSb ;*
ªDepartment of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH Urology Institute, University Hospitals Case Medical Center, Cleveland, OH
Keywords: adrenocortical carcinoma; minimally invasive surgical procedures; positive surgical margins; lymphadenectomy
*Correspondence:
Robert Abouassaly Urology Institute University Hospitals Case Medical Center 11100 Euclid Ave., Mailstop LKS 5046, Office 4565 Cleveland, OH 44106
Phone: 216-844-4831; Fax: 216-844-7735
Email: robert.abouassaly@uhhospitals.org
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/bju.13618
This article is protected by copyright. All rights reserved.
ABSTRACT
Objectives: To compare quality outcomes between open (OA) and minimally invasive (MIA) adrenalectomy for adrenocortical carcinoma.
Patients and Methods: In the National Cancer Data Base, we identified 481 patients with non-metastatic adrenocortical carcinoma who underwent adrenalectomy from 2010-2013. OA and MIA were compared on positive-surgical-margin and lymphadenectomy rates (primary outcomes) and lymph node yield, length of stay, readmission, and overall survival (secondary outcomes). Using the intention-to-treat principle, minimally-invasive-converted-to-open cases were considered MIA. Logistic regression analysis was used to identify predictors of positive margins and lymphadenectomy. Associations between approach and the outcomes were further assessed by stage and tumor size.
Results: Overall, 161 patients (33.5%) underwent MIA. MIA was used more commonly in older, comorbid patients; for smaller, localized tumors; and at lower-volume centers. In the intention-to-treat analysis, MIA independently predicted positive margins (OR 2.0, 95%CI 1.1-3.6, p =. 03) and no lymphadenectomy (OR 0.1, 95%CI 0.03-0.6, p =. 01). On subgroup analysis, the association between MIA and positive margins only held true for pT3 disease (48.7% vs. 26.7%, p =. 01). A higher rate of margin positivity was observed for tumors ≥10 cm managed with MIA vs. OA, but this difference was not significant (28.2% vs. 18.5%, p =. 16). Likewise, the association between MIA and no lymphadenectomy was only observed for male patients, tumors ≥10 cm, and cNO
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disease. After excluding minimally-invasive-converted-to-open cases, the difference in margin positivity was less pronounced and non-significant (OR 1.8, 95%CI 0.9-3.4, p =. 08). MIA was associated with significantly shorter median length of stay (3 vs. 6 days, p <. 01) and non-significantly decreased readmissions (4.4% vs. 8.8%, p =. 08) compared to OA without any difference in lymph node yield or overall survival. Conclusion: For organ-confined disease, MIA offers comparable surgical quality to OA, while expediting inpatient recovery. OA is associated with superior outcomes for locally advanced disease.
INTRODUCTION
Adrenocortical carcinoma (ACC) is a rare but deadly malignancy with an incidence of 0.72 cases per million [1, 2]. Radical surgery is the mainstay of therapy, but long-term survival is highly dependent on the completeness of resection. Complete primary resection, including regional lymph nodes and adjacent involved organs, is the only means for cure, with a 5-year survival of 5% or less for un-resected or incompletely resected disease [3-5]. Minimally invasive adrenalectomy (MIA) is used increasingly to treat adrenal masses worldwide, but its role in ACC management is controversial due to concerns over surgical quality and oncologic efficacy [6-8]. According to clinical guidelines, open adrenalectomy (OA) with regional lymphadenectomy is the recommended treatment for localized and locally advanced, non-metastatic ACC [7, 9, 10]. However, these recommendations are based on historical data from small, observational studies [11-20]. We sought to compare the surgical quality of OA versus MIA in a large contemporary cohort using the National Cancer Data Base (NCDB).
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MATERIALS AND METHODS
Data source
The NCDB is a joint project of the American Cancer Society and the Commission on Cancer of the American College of Surgeons. It is a comprehensive clinical oncology dataset that includes data on 70% of new cancer diagnoses in the USA annually. After obtaining institutional-review-board approval, the dataset for endocrine cancers was used.
Study population
We identified 527 adult patients diagnosed with clinically non-metastatic (cM0/x) ACC of the adrenal gland between 2010 and 2013 who underwent adrenalectomy. The study period was chosen because data on surgical approach (open, laparoscopic, or robotic) was only available during these years. We excluded patients with indeterminate or unknown surgical margin status (n=46). Excluded patients did not differ significantly from study patients aside from higher comorbidity burden.
Study covariates
Surgical approach
Surgical approach is coded in the NCDB as open, laparoscopic, laparoscopic- converted-to-open, robotic, and robotic-converted-to-open. Laparoscopic-converted-to- open (n=22) and robotic-converted-to-open (n=2) cases were reclassified as laparoscopic and robotic, respectively, to assess the effect of intended approach on outcomes using the intention-to-treat principle, as previously described for observational
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data [21]. Due to few robotic cases (n=30), laparoscopic and robotic cases were reclassified as MIA.
Other variables
Patient age at diagnosis, gender, race, Charlson-Deyo comorbidity index (CCI), tumor size, grade, laterality, pathological (pT) and clinical N (cN) stage, hospital type, and hospital volume were assigned using data in the NCDB. Based on the bimodal distribution, age was categorized as <60 or ≥60 years. Race was reclassified as non- Hispanic white and other. CCI was reclassified as 0 and >1. Tumor size was categorized as <5, 5-9, or ≥ 10 cm. Grade was reclassified as low-grade (G1-2), high- grade (G3-4), and unclassified. pT stage was assigned based on American Joint Committee on Cancer pT stage, tumor size, and tumor extension codes. Hospital type, which is designated by the Commission on Cancer, was classified as academic/research and other cancer centers. Hospital volume was classified as low and high based on an annual surgical case load for primary adrenal malignancy of <3 or ≥3, respectively, with high-volume centers corresponding to the 90th percentile for volume.
Study outcomes.
The primary outcomes were positive surgical margins (PSM) and performance of a locoregional lymph node dissection (LND). LND was defined as the removal of ≥4 lymph nodes, based on a previously established threshold, to differentiate intentional lymphadenectomy (LND group) from accidental lymph node removal (no-LND group) [22]. The secondary outcomes were LND yield (the number of lymph nodes removed), hospital length of stay, 30-day readmission, and overall survival (OS). OS was
calculated from the date of diagnosis to the date of death from all causes or censored at the date of last contact. Cancer-specific survival information is not available in the NCDB.
Statistical analyses.
Using multivariable logistic regression, we adjusted for age, gender, race, CCI, tumor laterality, tumor size, tumor grade, pT stage, cN stage, hospital type, surgical volume, and approach to identify independent predictors of PSM and LND. To further evaluate the impact of approach on the primary outcomes, the chi-square and Fisher exact tests were used to test associations between PSM and surgical approach by pT stage and tumor size and between LND and surgical approach by gender, tumor size and cN stage. The chi-square and Wilcoxon-Mann-Whitney tests were used to investigate associations between surgical approach and the secondary outcomes. Three-year OS analysis comparing MIA and OA was performed using the Kaplan-Meier method and log-rank test. Multivariable Cox proportional hazard regression analysis was used to identify independent predictors of death. Patients with concomitant non- adrenal primary malignancy (n=44) were excluded from the OS analyses to avoid confounding. Statistical tests were performed using SAS® University Edition (SAS Institute Inc., Cary, NC, USA). All tests were two-sided, and statistical significance was considered at p <0.05.
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RESULTS
There were 481 patients in the final cohort, 320 (66.5%) treated by OA and 161 (33.5%) treated by MIA. The MIA group was older and had greater comorbidity burden than the OA group, while tumors in the MIA group were smaller and less likely to involve adjacent organs (Table 1). The median tumor size was 7.5 (IQR 5.2-9.8) cm for MIAs versus 11.7 (IQR 8.5-16) cm for OAs (p <. 01). MIAs were less likely performed at high- volume centers than OAs (7.5% vs. 17.2%, p <. 01).
The rate of PSM was 20% for MIA versus 17% for OA (p =. 42). After adjusting for covariates on multivariable analysis (Table 2), approach was found to be an independent predictor of PSM. Specifically, MIA was associated with 2.0-fold higher odds of PSM (OR 2.0, 95%CI 1.1-3.6, p =. 03). The only other predictor of PSM was pT stage, such that the odds of PSM increased with increasing pT stage (p <. 01). To further adjust for the effect of pT stage on PSM, we compared PSM rates between approaches by pT stage (Table 3). For pT3 disease, PSM rates were significantly higher for MIA compared to OA (48.7% vs. 26.7%, p =. 01); however, for pT1, pT2, and pT4 disease, PSM rates were not significantly different. After further stratifying pT3 stage by tumor size, no significant difference in PSM rates were detected between groups based on tumor size.
LND was performed in 1.2% of MIAs and 13% of OAs (p <. 01). On multivariable analysis, approach was an independent predictor of LND, such that the odds of LND were 90% lower with MIA compared to OA (OR 0.1, 95%CI 0.03-0.6, p =. 01). Other independent predictors of LND were male gender, tumor size, and cN stage. The odds of LND were 2.2-fold higher in men (OR 2.2, 95%CI 1.1-4.5, p =. 02), 2.9-fold higher for
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tumors ≥10 cm (OR 2.9, 95%CI 1.2-6.6, p =. 01), and 11-fold higher in the presence of clinical lymph node involvement (OR 11.1, 95%CI 3.0-41, p <. 01). In order to better understand the influence of gender on LND, we assessed the association between gender and tumor size, finding that men had significantly larger tumors than women (median tumor size, 11.0 [IQR 7.5-15.0] cm vs. 9.5 [IQR 6.5-13.5] cm, p =. 03). To further adjust for the effects of gender, tumor size, and cN stage on the decision to perform LND, we compared LND rates between approaches on the basis of these variables (Table 3). The rate of LND was significantly lower for MIA versus OA in men (18.6% vs. 1.8%, p<.01), in tumors ≥10 cm (16.5% vs. 0%, p=.01), and in cN0 disease (12.3% vs. 0.7%, p <. 01). However, when a LND was performed, the median lymph node yield did not differ significantly between the OA (8 [IQR 6-14]) and MIA (7 [5-9]) approaches (p =. 22).
LOS was significantly shorter for MIA versus OA (median LOS, 3 (IQR 2-5) days vs. 6 (IQR 4-8) days, p <. 01) (Table 4). We also observed a lower rate of readmission for MIA compared to OA, but this difference was not statistically significant (4.4% vs. 8.8%, p =. 08).
On univariable analysis, there was no significant difference in 3-year OS between MIA and OA (58.0% vs. 62.1%, p =. 42) (Figure 1), even when stratified by pT stage. After adjusting for age, CCI, tumor size, pT stage, cN stage, and surgical margin status on multivariable analysis (Table 5), approach was still not a significant predictor of death (p =. 05).
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Approximately 15% of MIA cases required conversion to the open approach, including 9 (10.2%) for pT1, 7 (28.0%) for pT2, 7 (18.0%) for pT3, and 1 (11.1%) for pT4 disease. In terms of tumor size, 15 (12.3%) cases were converted to open for tumors <10 cm and 9 (23.0%) for tumors ≥10 cm. Neither tumor stage nor tumor size was significantly associated with the need for conversion (p =. 15 and p =. 10, respectively). In a subgroup analysis, MIA cases requiring open conversion were excluded, in order to assess the outcomes of cases performed start-to-finish using only one approach. After this exclusion, the difference in PSM rates was less pronounced, 18% for MIA versus 17% for OA, and was no longer significant on multivariable analysis (OR 1.8, 95%CI 0.9-3.4, p =. 08). Otherwise, the results paralleled those obtained from the intention-to-treat analysis (Table 6; Table 7; Table 8).
DISCUSSION
MIA is not recommended for the treatment of known or suspected ACC due to concerns about its surgical quality and oncologic efficacy [7, 9, 10]. However, these recommendations are based on weak evidence, largely from small, single-center studies and historic data. In these studies, the average number of OA and MIA cases analyzed per study was 62 and 26, respectively, with study periods spanning, on average, 14 years (range, 1985 to 2012) [11-20]. In light of the technical refinement and growing experience with MIA, we sought to perform a contemporary comparative analysis of surgical outcomes between OA and MIA for ACC [6, 23, 24].
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Our study is the largest contemporary study to compare the surgical quality of OA and MIA in terms of PSM and LND rates. After adjusting for inherent differences in the OA and MIA groups (age, CCI, tumor size, T stage, surgical volume) and other covariates, we found that MIA was independently associated with a higher rate of positive surgical margins; however, this association was highly stage dependent. In fact, T3 stage accounted for the only significant difference in PSM rates between approaches, with MIA associated with a 22% higher rate of PSM for T3 disease than OA. This finding, however, does not necessarily mean that MIA is technically inferior to OA for T3 disease.
The higher rate of PSM seen with MIA may be due to several factors, namely incorrect preoperative diagnosis or pathological upstaging. Unfortunately, data on preoperative diagnosis is not available in the NCDB; therefore, it is unclear if the surgeon suspected ACC at the time of surgery. Since MIA is often performed for small adrenal masses, especially when benign disease is suspected, it is plausible that the MIA surgeon may not adhere to the oncological principles of en bloc resection and wide local excision in these cases, increasing the risk of PSM when ACC is found in the periadrenal fat (T3 stage) on final pathology [6]. In support of this theory, nearly 25% of
MIA cases for T3 disease in which a PSM occurred were for adrenal masses ≤6 cm, the traditional size cutoff for benign versus malignant disease [25]. Preoperative fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) imaging, which helps distinguish benign from malignant adrenal lesions, may help inform surgical decision- making and avoid incomplete resection. However, even if the diagnosis of ACC is known preoperatively, fat invasion may not be apparent on preoperative imaging, and
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this clinical understaging may lead to less careful management of the periadrenal fat and ultimately incomplete resection of the primary tumor. Due to incomplete clinical T stage data in the NCDB, we were unable to evaluate the effect of pathological upstaging on the incidence of PSM. Certainly, treating all adrenal masses as potentially malignant with en bloc excision of periadrenal fat, may help reduce the risk of PSM regardless of approach. It is noteworthy to mention that although MIA was more frequently performed at lower-volume centers than OA, surgical volume was not an independent predictor of surgical quality in our study, and therefore does not explain the difference in PSM rates between approaches.
It is important to point out that PSM rates were higher, though not significantly so, for large tumors (≥10 cm) managed with MIA versus OA, both overall and for T3 disease. With larger sample sizes, these differences may have been significant. Therefore, clinical practice guidelines that recommend MIA only for tumors <10 cm may have merit [7, 8].
Based on long-term data, PSM status after adrenalectomy is associated with worse recurrence-free and overall survival [26]. In spite of the higher rate of PSM associated with MIA, we did not detect a difference in OS between approaches, even after stratifying by stage. This suggests that either no association exists, follow-up was insufficient, or the study was underpowered. In a recent meta-analysis of nine contemporary observational studies, Autorino et al. obtained similar results, finding no difference in time to recurrence or OS between approaches [27]. In a prior study using the NCDB with a similarly sized cohort (N=423) and similar follow-up, Huynh et al. found no difference in OS between MIA and OA in the overall cohort but did observe worse
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OS associated with MIA in the subgroup of patients with tumors >5 cm [28]. Unlike our study, this study did not exclude patients with concomitant malignancy nor did it adjust for the imbalance in comorbidity burden between approaches; therefore, its results may have been influenced by bias.
Locoregional LND, which has been shown to decrease the risk of local recurrence, provide more accurate cancer staging, and potentially improve long-term survival, is recommended for all patients with ACC at the time of adrenalectomy [4, 7, 10, 29, 30]. The overall LND rate in our study was 9%, which is consistent with the 8% rate observed in a recent analysis of the Surveillance, Epidemiology, and End Results database, reflecting the low utilization of LND for ACC in the USA regardless of approach [22]. LND rates differed significantly by approach in favor of OA (19% vs. 2%, p <. 01). This difference was primarily due to a higher LND rate for cNO stage in the OA group (12% vs. 1%, p <. 01), while LND rates did not differ significantly for cN1 stage (43% vs. 50%, p =. 85). In the literature, LND use tends to be higher in patients with cN1 disease (33-41%) versus those with cNO disease (3-7%), and this tendency was also seen in our study [22, 29]. Therefore, the discrepancy in LND utilization between approaches may be partially explained by selection bias.
The feasibility of MIA for ACC also deserves mention. Notably, 24% of MIA cases required open conversion. Although the reasons for conversion are not recorded in the NCDB, tumor size appears to be the most important factor. Open conversion was required almost twice as often for tumors ≥10 cm than for those <10 cm, likely due to the mass effect and intraabdominal space constraints associated with very large adrenal tumors (Figure 2). Importantly, open conversion was not stage-dependent, with
the highest rate occurring in T2 tumors (28%).
We were unable to examine outcomes specific to robotic MIA due to its low utilization during the study period (through 2013). The robotic approach is increasingly being used to treat adrenal disease [6]. Given recent advances in robotic retroperitoneal surgery, including en bloc resection of adjacent organs and locoregional lymphadenectomy, the surgical quality and feasibility of robotic MIA for ACC deserves future investigation [31].
Altogether, MIA affords comparable local control to OA for T1-2 disease but inferior local control for T3 disease. Aside from small (<3 cm) adenomas, adrenal myelolipomas, and pheochromocytomas, which can be diagnosed clinically with good specificity, all other adrenal masses should be considered potentially malignant and treated accordingly, following the oncological principles of en bloc resection, avoidance of tumor spillage, and wide local excision including locoregional lymph nodes [3, 4, 29]. Although surgical volume was not an independent predictor of surgical quality in our study, probably due to the higher cancer specialization of NCDB centers, surgical outcomes for ACC surgery are best when undertaken by experienced surgeons at high- volume centers [32].
Our study has some limitations inherent to the NCDB. Due to its retrospective observational design, our study is susceptible to selection bias. The absence of data on cancer-specific survival and disease recurrence prevented us from analyzing these outcomes. In addition, it is difficult to know how the surgical intent of the operation, i.e. for benign versus malignant disease, may have influenced outcomes. Nonetheless, the NCDB is one of the best resources for studying rare malignancies like ACC, which
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cannot be studied well in most single-center studies due to the low volume of cases [33].
CONCLUSIONS
For localized (T1-2) ACC, MIA offers comparable surgical quality to OA, in terms of surgical margin status and inclusion of locoregional lymphadenectomy, and reduces inpatient convalescence. For T3 disease, OA achieves better oncologic outcomes.
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FIGURE LEGENDS
Figure 1 - Three-year OS after adrenalectomy for adrenocortical carcinoma by approach. OS did not differ significantly between OA and MIA (62.1% vs. 58.0%, p =. 42). OA = open adrenalectomy; OS = overall survival; MIA = minimally invasive adrenalectomy.
Figure 2 - Select axial and coronal images from magnetic resonance imaging of a 26- cm, pT3N0 right-sided primary adrenocortical carcinoma that was managed with open adrenalectomy, nephrectomy, and lymph node dissection through an extended subcostal incision. A minimally invasive approach was not attempted due to the massive size of the tumor and limited space within the abdominal cavity.
FUNDING: None
DISCLOSURES: None
ACKNOWLEDGEMENTS: None
DISCLAIMER: The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator.
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| Variables | OA | MIA | p value | ||
|---|---|---|---|---|---|
| Overall, n (%) | 320 | (66.5) | 161 | (33.5) | |
| Median age, yr (IQR) | 56 | (43-67) | 61 | (50-69) | 0.01 |
| Female, n (%) | 196 | (61.3) | 106 | (65.8) | 0.33 |
| White, n (%) | 262 | (81.9) | 135 | (83.9) | 0.59 |
| CCI >1, n (%) | 65 | (20.3) | 55 | (34.2) | <0.01 |
| Left-sided tumor, n (%) | 163 | (50.9) | 85 | (52.8) | 0.70 |
| Tumor size | <0.01 | ||||
| <10 cm | 114 | (35.6) | 122 | (75.8) | |
| ≥10 cm | 206 | (64.4) | 39 | (24.2) | |
| Grade | 0.64 | ||||
| Low, n (%) | 22 | (6.9) | 8 | (5.0) | |
| High, n (%) | 52 | (16.3) | 24 | (14.9) | |
| Unclassified, n (%) | 246 | (76.9) | 129 | (80.1) | |
| T stage | <0.01 | ||||
| 1, n (%) | 131 | (40.9) | 88 | (54.7) | |
| 2, n (%) | 47 | (14.7) | 25 | (15.5) | |
| 3, n (%) | 90 | (28.1) | 39 | (24.2) | |
| 4, n (%) | 52 | (16.3) | 9 | (5.6) | |
| Clinical N stage | 0.08 | ||||
| 0, n (%) | 260 | (81.3) | 142 | (88.2) | |
| 1, n (%) | 14 | (4.4) | 2 | (1.2) | |
| X, n (%) | 46 | (14.4) | 17 | (10.6) | |
| Academic center, n (%) | 160 | (50.0) | 81 | (50.3) | 0.95 |
| High-volume center, n (%) | 55 | (17.2) | 12 | (7.5) | <0.01 |
| Open conversion, n (%) | - | - | 24 | (14.9) | |
| Median follow-up, mo (IQR) | 25.0 | (16.7-36.4) | 23.6 | (14.6-33.8) | 0.36 |
IQR = interquartile range; MIA = minimally invasive adrenalectomy; OA = open adrenalectomy.
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| A. PSM | B. LND | |||||||
|---|---|---|---|---|---|---|---|---|
| Variables | OR | 95% CI | p value | OR | 95% | CI | p value | |
| Approach, MIA vs. OA | 2.0 | 1.1 - 3.6 | 0.03 | 0.1 | 0.03 - | 0.6 | 0.01 | |
| Age, ≥60 vs .< 60 yr | 1.5 | 0.9 - 2.6 | 0.14 | 1.1 | 0.5 - | 2.3 | 0.82 | |
| Male vs. female | 0.8 | 0.5 1.4 | 0.42 | 2.2 | 1.1 - | 4.5 | 0.02 | |
| Non-white vs. white | 1.9 | 1.0 - 3.6 | 0.06 | 0.5 | 0.1 - | 1.4 | 0.18 | |
| CCI ≥1 vs. 0 | 1.0 | 0.5 - 1.8 | 0.98 | 1.2 | 0.5 - | 2.7 | 0.69 | |
| Left- vs. right-sided tumor | 0.9 | 0.5 - 1.5 | 0.62 | 2.0 | 1.0 - | 4.3 | 0.06 | |
| Tumor size ≥10 vs. < 10 cm | 1.3 | 0.7 - 2.3 | 0.37 | 2.9 | 1.2 - | 6.6 | 0.01 | |
| Grade | 0.52 | 0.71 | ||||||
| High vs. low | 1.6 | 0.5 - 5.6 | 0.6 | 0.1 - | 2.9 | |||
| Unclassified vs. low | 1.1 | 0.4 - 3.4 | 0.9 | 0.2 - | 3.4 | |||
| T stage | <0.01 | 0.31 | ||||||
| 2 vs. 1 | 2.5 | 1.0 - 6.3 | 2.5 | 0.9 - | 6.5 | |||
| 3 vs. 1 | 9.1 | 4.4 - 19 | 1.2 | 0.5 - | 2.9 | |||
| 4 vs. 1 | 9.8 | 4.2 - 23 | 1.1 | 0.4 - | 3.4 | |||
| Clinical N stage | 0.19 | <0.01 | ||||||
| 1 vs. 0 | 2.8 | 0.9 - 8.5 | 11.1 | 3.0 - | 41 | |||
| x VS. 0 | 1.1 | 0.5 - 2.4 | 0.9 | 0.3 - | 2.7 | |||
| Non-academic vs. academic hospital | 1.4 | 0.8 - 2.3 | 0.28 | 0.6 | 0.3 - | 1.2 | 0.14 | |
| High vs. low surgical volume | 0.8 | 0.4 - 1.8 | 0.58 | 0.8 | 0.3 | - | 2.0 | 0.61 |
CI = confidence interval; LND = locoregional lymph node dissection; MIA = minimally invasive adrenalectomy; OA = open adrenalectomy; OR = odds ratio; PSM = positive surgical margins.
Accepted Article
| Outcomes | OA | MIA | p value | ||
|---|---|---|---|---|---|
| A. PSM, n (%) | 54 | (16.9) | 32 | (19.9) | 0.42 |
| T stage | |||||
| 1 | 5 | (3.8) | 7 | (8.0) | 0.23 |
| 2 | 6 | (12.8) | 3 | (12.0) | 1.00 |
| 3 | 24 | (26.7) | 19 | (48.7) | 0.01 |
| 4 | 19 | (36.5) | 3 | (33.3) | 1.00 |
| T3 stage | |||||
| <10 cm | 10 | (34.5) | 13 | (50.0) | 0.24 |
| ≥10 cm | 14 | (23.0) | 6 | (46.2) | 0.16 |
| Tumor size | |||||
| <10 cm | 16 | (14.0) | 21 | (17.2) | 0.50 |
| ≥10 cm | 38 | (18.5) | 11 | (28.2) | 0.16 |
| B. LND, n (%) | 42 | (13.1) | 2 | (1.2) | <0.01 |
| Male | 23 | (18.6) | 1 | (1.8) | <0.01 |
| Tumor size | |||||
| <10 cm | 8 | (7.0) | 2 | (1.6) | 0.05 |
| ≥10 cm | 34 | (16.5) | 0 | - | 0.01 |
| Clinical N stage | |||||
| 0 | 32 | (12.3) | 1 | (0.7) | <0.01 |
| 1 | 6 | (42.9) | 1 | (50.0) | 0.85 |
| x | 4 | (8.7) | 0 | - | 0.27 |
LND = locoregional lymph node dissection; MIA = minimally invasive adrenalectomy; OA = open adrenalectomy; PSM = positive surgical margins.
Accented Article
| OA | MIA | p value | |||
|---|---|---|---|---|---|
| Median LND yield (IQR) | 8 | (6-14) | 7 | (5-9) | 0.22 |
| Median LOS, d (IQR) | 6 | (4-8) | 3 | (2-5) | <0.01 |
| 30-day readmission, n (%) | 28 | (8.8) | 7 | (4.4) | 0.08 |
| 30-day mortality, n (%) | 6 | (2.5) | 1 | (0.8) | 0.43 |
| 90-day mortality, n (%) | 8 | (3.3) | 4 | (3.4) | 1.00 |
IQR = interquartile range; LND = locoregional lymph node dissection; LOS = length of stay; MIA = minimally invasive adrenalectomy; OA = open adrenalectomy.
| Variables | HR | 95% CI | p value |
|---|---|---|---|
| Approach, MIA vs. OA | 1.2 | 0.8 1.8 - | 0.34 |
| Age, ≥60 vs .< 60 yr | 1.2 | 0.8 - 1.8 | 0.05 |
| CCI ≥1 vs. 0 | 1.0 | 0.6 - 1.6 | 0.96 |
| Tumor size ≥10 vs. < 10 cm | 1.6 | 1.1 - 2.5 | 0.02 |
| T stage | 0.13 | ||
| 2 vs. 1 | 1.6 | 1.0 - 2.8 | |
| 3 vs. 1 | 1.6 | 1.0 - 2.6 | |
| 4 vs. 1 | 1.5 | 0.8 - 2.9 | |
| Clinical N stage | 0.46 | ||
| 1 vs. 0 | 1.6 | 0.7 - 3.6 | |
| x vs. 0 | 1.2 | 0.7 - 2.1 | |
| PSM | 1.4 | 0.9 - 2.3 | 0.16 |
CI = confidence interval; HR = hazard ratio; MIA = minimally invasive adrenalectomy; OA = open adrenalectomy; OR = odds ratio; PSM = positive surgical margins.
Accepted Article
| A. PSM | B. LND | |||||||
|---|---|---|---|---|---|---|---|---|
| Variables | OR | 95% | CI | p value | OR | 95% CI | p value | |
| Approach, MIA vs. open | 1.8 | 0.9 - | 3.4 | 0.08 | 0.1 | 0.03 - | 0.7 | 0.01 |
| Age, ≥60 vs .< 60 yr | 1.4 | 0.8 - | 2.5 | 0.25 | 1.1 | 0.5 - | 2.3 | 0.81 |
| Male vs. female | 0.7 | 0.4 - | 1.2 | 0.21 | 2.2 | 1.1 - | 4.5 | 0.02 |
| Non-white vs. white | 1.9 | 0.9 - | 3.8 | 0.07 | 0.5 | 0.1 - | 1.4 | 0.18 |
| CCI ≥1 vs. 0 | 1.0 | 0.5 - | 1.9 | 0.99 | 1.2 | 0.5 - | 2.7 | 0.70 |
| Left- vs. right-sided tumor | 1.0 | 0.6 - | 1.7 | 0.95 | 2.0 | 1.0 - | 4.3 | 0.06 |
| Tumor size ≥10 vs. < 10 cm | 1.1 | 0.6 - | 2.0 | 0.76 | 2.9 | 1.3 - | 6.7 | 0.01 |
| Grade | 0.75 | 0.71 | ||||||
| High vs. low | 1.4 | 0.4 - | 5.2 | 0.6 | 0.1 - | 2.9 | ||
| Unclassified vs. low | 1.1 | 0.4 - | 3.5 | 0.9 | 0.2 - | 3.4 | ||
| pT stage | <0.01 | 0.30 | ||||||
| 2 vs. 1 | 2.5 | 0.9 - | 6.9 | 2.5 | 1.0 - | 6.6 | ||
| 3 vs. 1 | 11 | 4.8 - | 23 | 1.2 | 0.5 - | 2.9 | ||
| 4 vs. 1 | 12 | 5.1 - | 30 | 1.1 | 0.4 - 3.4 | |||
| cN stage | 0.18 | <0.01 | ||||||
| 1 vs. 0 | 2.8 | 0.9 - | 8. | 11.0 | 3.0 - | 40 | ||
| x vs. 0 | 1.2 | 0.5 - | 2.6 | 0.9 | 0.3 3 . | 2.7 | ||
| Non-academic vs. academic hospital | 1.4 4 | 0.8 - | 2.4 | 0.29 | 0.6 | 0.3 - | 1.2 | 0.15 |
| High vs. low surgical volume | 0.8 | 0.4 4 - | 1.8 | 0.62 | 0.8 | 0.3 - | 2.0 | 0.60 |
CI = confidence interval; LND = locoregional lymph node dissection; MIA = minimally invasive adrenalectomy; OA = open adrenalectomy; OR = odds ratio; PSM = positive surgical margins.
Accepted Article
| Outcomes | OA | MIA | p value | ||
|---|---|---|---|---|---|
| A. PSM, n (%) | 54 | (16.9) | 25 | (18.3) | 0.72 |
| pT stage | |||||
| 1 | 5 | (3.8) | 5 | (6.3) | 0.51 |
| 2 | 6 | (12.8) | 1 | (5.6) | 0.66 |
| 3 | 24 | (26.7) | 16 | (50.0) | 0.02 |
| 4 | 19 | (36.5) | 3 | (37.5) | 1.00 |
| pT3 stage | |||||
| <10 cm | 10 | (34.5) | 12 | (52.2) | 0.20 |
| ≥10 cm | 14 | (23.0) | 4 | (44.4) | 0.17 |
| Tumor size | |||||
| <10 cm | 16 | (14.0) | 19 | (17.8) | 0.45 |
| ≥10 cm | 38 | (18.5) | 6 | (20.0) | 0.84 |
| B. LND, n (%) | 42 | (13.1) | 2 | (1.5) | <0.01 |
| Male | 23 | (18.6) | 1 | (2.2) | <0.01 |
| Tumor size | |||||
| <10 cm | 8 | (7.0) | 2 | (1.9) | 0.10 |
| ≥10 cm | 34 | (16.5) | 0 | - | 0.01 |
| cN stage | |||||
| 0 | 32 | (12.3) | 1 | (0.8) | <0.01 |
| 1 | 6 | (42.9) | 1 | (50.0) | 1.00 |
| x | 4 | (8.7) | 0 | - | 0.57 |
LND = locoregional lymph node dissection; MIA = minimally invasive adrenalectomy; OA = open adrenalectomy; PSM = positive surgical margins.
| OA | MIA | p value | |||
|---|---|---|---|---|---|
| Median LND yield (IQR) | 8 | (6-14) | 7 | (5-9) | 0.19 |
| Median LOS, d (IQR) | 6 | (4-8) | 2 | (1-5) | <0.01 |
| 30-day readmission, n (%) | 28 | (8.8) | 6 | (4.4) | 0.10 |
| 30-day mortality, n (%) | 6 | (2.5) | 1 | (0.9) | 0.44 |
| 90-day mortality, n (%) | 8 | (3.3) | 4 | (3.8) | 0.76 |
IQR = interquartile range; LND = locoregional lymph node dissection; LOS = length of stay; MIA = minimally invasive adrenalectomy; OA = open adrenalectomy.
Accepted Article
1.0
0.8
Survival Probability
P .42
0.6
0.4
0.2
00
0
12
24
36
48
60
Follow-up, months
Number at Risk
| OA | 229 | 190 | 127 | 64 | 17 | 0 |
| MTA | 112 | 88 | 58 | 27 | 7 | 0 |