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Laparoscopic surgery is safe for large adrenal lesions


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  • Chief Cushie

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Laparoscopic surgery is safe for large adrenal lesions

 

P.S.H. Soona, d, M.W. Yehb, L.W. Delbridgea, C.P. Bambacha, M.S. Sywaka, B.G. Robinsonc, d and S.B. Sidhua, d, Corresponding Author Contact Information, E-mail The Corresponding Author

aUniversity of Sydney Endocrine Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia

bUCLA Endocrine Surgery, University of California Los Angeles, Los Angeles CA, USA

cDepartment of Endocrinology, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia

dKolling Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia

Accepted 7 March 2007. Available online 29 May 2007.

 

Abstract

Introduction

 

Laparoscopic adrenalectomy has surpassed open adrenalectomy as the gold standard for excision of benign adrenal lesions. The size threshold for offering laparoscopic adrenalectomy is controversial as the prevalence of adrenocortical carcinoma increases with increasing tumour size. The aim of this paper was to assess the safety of laparoscopoic adrenalectomy for large adrenal tumours (tumours ?60 mm).

Methods

 

A retrospective cohort study of patients who underwent adrenalectomy in a single unit during the period 1995?2005 was undertaken.

 

Results

 

One hundred and seventy patients with 173 tumours were included in this study. Of these, 29 were ?60 mm in size, and 16 of these patients underwent laparoscopic adrenalectomy. There were 8 adrenocortical carcinomas in the group with tumours ?60 mm in size. Five of these patients underwent an open adrenalectomy, while 2 and 1 patients had laparoscopic and laparoscopic converted to open adrenalectomy respectively. Four of the patients undergoing open adrenalectomy died of their disease while 1 is alive with recurrence 3 years later. The 3 patients who underwent either laparoscopic or laparoscopic converted to open adrenalectomy are alive without evidence of disease after 18 months follow up.

 

Conclusion

 

Our data show that patients with tumours ?60 mm with no preoperative or intraoperative evidence of malignancy can undergo laparoscopic adrenalectomy without evidence of recurrence on short term follow up. These findings are concordant with the growing body of literature supporting laparoscopic adrenalectomy for potentially malignant tumours ?60 mm in size without preoperative or intraoperative features of malignancy.

 

Keywords: Laparoscopic adrenalectomy; Open adrenalectomy; Adrenal tumours

 

 

Introduction

 

Since its introduction in the 1990s, laparoscopic adrenalectomy has surpassed open adrenalectomy as the gold standard for excision of benign adrenal lesions. Patients undergoing laparoscopic adrenalectomy benefit from reductions in perioperative morbidity, analgesic requirement, length of hospitalization, and interval to normal dietary intake, as well as improved cosmetic results when compared to patients undergoing open adrenalectomy.[1], [2], [3], [4] and [5]

 

Open adrenalectomy is recommended for excision of malignant primary adrenal lesions.[6], [7] and [8] Because the prevalence of adrenocortical carcinoma varies directly with adrenal tumour size, the size threshold above which laparoscopic adrenalectomy should not be offered remains controversial. According to the NIH consensus statement for the management of the clinically inapparent adrenal mass, the incidence of adrenocortical carcinomas increases from 2% in tumours ?40 mm, to 6% in tumours 41?60 mm in size, to 25% in tumours >60 mm.9

 

Laparoscopic adrenalectomy was first introduced in our unit in 1995. The aim of this paper was to assess the safety of laparoscopic adrenalectomy for large adrenal tumours (tumours ?60 mm).

 

Patients and methods

 

A retrospective review of all patients undergoing adrenalectomy at the University of Sydney Endocrine Surgical Unit at the Royal North Shore Hospital between January 1995 and December 2005 was undertaken. All patients gave informed consent to the storage and use of data from the database and collection was approved by the Northern Sydney Human Research Ethics Committee. Patients were identified by searching the prospectively maintained University of Sydney Endocrine Surgical database. Data collected included patient demographics, presentation, operative management, length of operation (time from entry to exit from the operating theatre), histological size and histopathology. Laparoscopic adrenalectomy was performed using the lateral transperitoneal approach as previously described.5

 

One hundred and seventy-seven adrenalectomies were performed in 174 patients. Four patients did not have size of the tumour recorded on their pathology report, resulting in the exclusion of these patients and leaving a total study group of 173 tumours.

 

Statistical analysis was performed using the Stata 8 statistical software package (College Station Texas, USA). Categorical data were analysed using Fisher's exact test. Continuous data variables were compared using the unpaired t-test. Statistical significance was defined as a two-sided p-value

 

Results

Patient groups

 

One hundred and forty tumours were removed laparoscopically; 7 underwent laparoscopy converted to open adrenalectomy and 26 underwent open adrenalectomy respectively. The mean age of the patients was 51 and the female to male ratio was 1.6:1. Patient demographics, mean tumour size, type of procedures undertaken and indications for surgery are summarized in Table 1.

 

Table 1.

 

Summary of patient demographics, mean tumour size, type of operative procedure and indication for operation

Number of patients 170

Number of adrenalectomies 173

Age in years 51 ? 14

Female:male ratio 1.6:1

 

Operative procedures

Laparoscopic adrenalectomy 140

Laparoscopic to open adrenalectomy 7

Open adrenalectomy 26

 

Mean tumour size in mm (95% CI)a

Laparoscopic adrenalectomy 31 (28, 34)

Laparoscopic to open adrenalectomy 57 (29, 85)

Open adrenalectomy 68 (50, 87)

 

Mean operative time in minutesb

Laparoscopic adrenalectomy 154 (147, 162)

Laparoscopic to open adrenalectomy 214 (172, 257)

Open adrenalectomy 138 (118, 159)

 

Indication for operation

Hyperaldosteronism 62

Incidentaloma 38

Phaeochromocytoma 36

Cushing's syndrome 25

Adrenocortical carcinoma 2

Subclinical Cushing's syndrome 1

Virilization 1

Hyperoestrogenism 1

Other 4

 

a Tumour size significantly less for lap v open (p

b Operative time significantly less for lap v conversion (p

 

Twenty-nine of the adrenal tumours resected in this study were ?60 mm and of these, 16 were resected laparoscopically. Of the 144 adrenal tumours

 

Table 2.

 

Comparison of the groups with tumours

Laparoscopic adrenalectomy Open adrenalectomy

Number of tumours 131 16 13

Mean age 51 50 54

Mean weight (kg) 79 81 79

Mean tumour size (mm) 27 74 101

Mean length of operation (min)a 152 198 140

Number of patients with data available 105 11 12

Number converted to open and reason 3 (bleeding, stuck to liver, high inaccessible adrenal vein) 4 (2 for bleeding, 2 for malignant lesion) Not applicable

Complication 9 (2 bleeding, 1 atelectasis, 1 hypertension, 2 fluid electrolyte problems, 3 other) 2 (bleeding, atelectasis) 0

a p-values for comparison of operative time for laparoscopic adrenalectomy group with tumours

 

For patients with tumours ?60 mm, length of operation data were available in 11 and 12 patients respectively who had laparoscopic and open adrenalectomies and is listed in Table 3.

 

Table 3.

 

Comparison of complication rate and length of operation for group with tumours ?60 mm undergoing laparoscopic and open adrenalectomy

Laparoscopic adrenalectomy Open adrenalectomy

Number of tumours 16 13

Mean age 50 54

Mean weight (kg) 81 79

Mean tumour size (mm) 74 101

Mean length of operation (min) 198 140

Number of patients with data available 11 12

Complications 2 (bleeding, atelectasis) 0

 

Complications

 

Complications developed in 6 patients in the group with tumours

Adrenocortical carcinomas in tumour group ?60 mm

 

Of the group with tumours ?60 mm, 8 patients had adrenocortical carcinomas, which ranged in size from 60 to 135 mm. An adrenocortical carcinoma was diagnosed if a patient had evidence of local invasion or metastases at the time of operation or if the Weiss score10 was greater than 2. Five of these patients underwent an open adrenalectomy, while 2 had a laparoscopic adrenalectomy and 1 had a laparoscopic converted to open procedure because of local tumour invasion. Of the patients undergoing open adrenalectomy, 4 died of their disease, while 1 is alive with recurrence 3 years later. The last 3 patients who underwent either laparoscopic or laparoscopic converted to open adrenalectomy are alive without evidence of recurrence, although follow up is only to 18 months. In addition, in the large tumour group, there were 7 phaeochromocytomas, 4 adenomas, 2 metastases and 7 other tumours.

 

Discussion

 

The purpose of this paper was to assess the safety of laparoscopic adrenalectomy in large adrenal tumours. Because of its many advantages over conventional open surgery, laparoscopic adrenalectomy has become the preferred approach for removal of benign adrenal tumours. However, it is generally agreed that patients with known adrenocortical carcinomas should undergo an open adrenalectomy.[6], [7] and [8] Isolated case reports suggest that laparoscopic adrenalectomy for adrenocortical carcinomas may increase the risk of peritoneal dissemination and metastases.[11], [12] and [13] Because the prevalence of adrenocortical carcinoma increases with increasing adrenal tumour size, the dilemma lies with the size threshold for offering laparoscopic adrenalectomy. Even though reports have shown that the incidence of adrenocortical carcinomas increases to 30% in tumours ?60 mm in size, as was shown in this study and others,[14] and [15] the majority of tumours ?60 mm are still benign. While there has been a report of laparoscopic resection of a 150 mm adrenal tumour,16 it is generally felt that tumours over 100 mm in size should be resected by open adrenalectomy. The central controversial question is therefore how to manage adrenal tumours 60?100 mm in size, which are potentially malignant, as there is currently no preoperative test which can definitely exclude malignancy. Of the 29 patients with tumours ?60 mm, eight had adrenocortical carcinomas. The first 5 patients underwent open adrenalectomy because of size over 10 cm or a strong preoperative suspicion of malignancy. We performed laparoscopic adrenalectomy on 2 patients who had no preoperative or intraoperative evidence of malignancy. Although follow up is only up to 18 months, both patients are well with no evidence of recurrence. One patient with a mean tumour noted to be 90 mm on preoperative CT scan underwent a laparoscopy and the tumour was noted to be locally invasive, resulting in conversion to an open procedure.

 

We found that the complication rate was similar for tumours ?60 mm resected by laparoscopic or open adrenalectomy. The length of operation for large adrenal tumours resected laparoscopically, however, was longer than those undergoing open operation (p

 

In their 11-year experience with 462 adrenalectomies, Palazzo et al. performed laparoscopic adrenalectomy on 19 patients with adrenal tumours ?60 mm with no preoperative or intraoperative evidence of malignancy.17 Eleven of these tumours were classified as either overtly or potentially malignant on histopathology. At a mean follow up of 34 months, two patients died from disease recurrence and one patient underwent re-operation for a local recurrence detected 54 months after initial surgery. Similarly, Liao et al performed laparoscopic adrenalectomy on 4 adrenocortical carcinomas ?50 mm with a local recurrence rate of 1 in 4, demonstrating that en bloc local resection is feasible with laparoscopic adrenalectomy.18 Thus, it appears to be safe to perform laparoscopic adrenalectomy in select patients with large adrenal tumours which do not demonstrate grossly malignant features on laparoscopic inspection.

 

Patients with a large and potentially malignant non-functional tumour with no evidence of local invasion or metastases on preoperative imaging should undergo a trial laparoscopic dissection. If there are signs of invasion on laparoscopy, which include regional lymphadenopathy, aberrant vasculature or tumour invasion into surrounding tissue, the procedure should then be converted to an open procedure. If, however, there is no evidence of malignancy intraoperatively, the surgeon may safely proceed with a laparoscopic adrenalectomy.

 

Conclusion

 

Our data show that patients with tumours 60?100 mm in size with no preoperative or intraoperative evidence of malignancy can undergo successful laparoscopic adrenalectomy without recurrence in short term follow up. Our findings are concordant with the growing body of literature supporting laparoscopic adrenalectomy for potentially malignant tumours ?60 mm in diameter, without preoperative or intraoperative features of malignancy.

 

References

 

1 M. Barreca, L. Presenti and C. Renzi et al., Expectations and outcomes when moving from open to laparoscopic adrenalectomy: multivariate analysis, World J Surg 27 (2003), pp. 223?228. View Record in Scopus | Cited By in Scopus (8)

 

2 D.C. MacGillivray, S.J. Shichman, F.A. Ferrer and C.D. Malchoff, A comparison of open vs laparoscopic adrenalectomy, Surg Endosc 10 (1996), pp. 987?990. View Record in Scopus | Cited By in Scopus (60)

 

3 R.A. Prinz, A comparison of laparoscopic and open adrenalectomies, Arch Surg 130 (1995), pp. 489?492 discussion 92?4.

 

4 R. Gonzalez, C.D. Smith and D.A. McClusky 3rd et al., Laparoscopic approach reduces likelihood of perioperative complications in patients undergoing adrenalectomy, Am Surg 70 (2004), pp. 668?674. View Record in Scopus | Cited By in Scopus (9)

 

5 S.H. Pillinger, C.P. Bambach and S. Sidhu, Laparoscopic adrenalectomy: a 6-year experience of 59 cases, ANZ J Surg 72 (2002), pp. 467?470. View Record in Scopus | Cited By in Scopus (11)

 

6 W.T. Shen, C. Sturgeon and Q.Y. Duh, From incidentaloma to adrenocortical carcinoma: the surgical management of adrenal tumors, J Surg Oncol 89 (2005), pp. 186?192. View Record in Scopus | Cited By in Scopus (13)

 

7 B. Allolio and M. Fassnacht, Adrenocortical carcinoma: clinical update, J Clin Endocrinol Metab (2006).

 

8 D. Kopf, P.E. Goretzki and H. Lehnert, Clinical management of malignant adrenal tumors, J Cancer Res Clin Oncol 127 (2001), pp. 143?155. View Record in Scopus | Cited By in Scopus (45)

 

9 NIH state-of-the-science statement on management of the clinically inapparent adrenal mass ("incidentaloma"), NIH Consens State Sci Statements 19 (2002), pp. 1?25.

 

10 L.M. Weiss, Comparative histologic study of 43 metastasizing and nonmetastasizing adrenocortical tumors, Am J Surg Pathol 8 (1984), pp. 163?169. View Record in Scopus | Cited By in Scopus (239)

 

11 B.D. Saunders and G.M. Doherty, Laparoscopic adrenalectomy for malignant disease, Lancet Oncol 5 (2004), pp. 718?726. Abstract | Full Text + Links | PDF (1660 K) | View Record in Scopus | Cited By in Scopus (9)

 

12 K. Iino, Y. Oki and H. Sasano, A case of adrenocortical carcinoma associated with recurrence after laparoscopic surgery, Clin Endocrinol (Oxf) 53 (2000), pp. 243?248. View Record in Scopus | Cited By in Scopus (16)

 

13 T. Ushiyama, K. Suzuki, S. Kageyama, K. Fujita, Y. Oki and T. Yoshimi, A case of Cushing's syndrome due to adrenocortical carcinoma with recurrence 19 months after laparoscopic adrenalectomy, J Urol 157 (1997), p. 2239. Abstract | Full Text + Links | PDF (386 K) | View Record in Scopus | Cited By in Scopus (35)

 

14 C. Sturgeon, W.T. Shen, O.H. Clark, Q.Y. Duh and E. Kebebew, Risk assessment in 457 adrenal cortical carcinomas: how much does tumor size predict the likelihood of malignancy?, J Am Coll Surg 202 (2006), pp. 423?430. Abstract | Full Text + Links | PDF (165 K)

 

15 L.M. Brunt and J.F. Moley, Adrenal incidentaloma, World J Surg 25 (2001), pp. 905?913. View Record in Scopus | Cited By in Scopus (55)

 

16 E. Kebebew, A.E. Siperstein and Q.Y. Duh, Laparoscopic adrenalectomy: the optimal surgical approach, J Laparoendosc Adv Surg Tech A 11 (2001), pp. 409?413. View Record in Scopus | Cited By in Scopus (30)

 

17 F.F. Palazzo, F. Sebag, M. Sierra, G. Ippolito, P. Souteyrand and J.F. Henry, Long-term outcome following laparoscopic adrenalectomy for large solid adrenal cortex tumors, World J Surg 30 (2006), pp. 893?898. View Record in Scopus | Cited By in Scopus (2)

 

18 C.H. Liao, S.C. Chueh, M.K. Lai, P.J. Hsiao and J. Chen, Laparoscopic adrenalectomy for potentially malignant adrenal tumors greater than 5 centimeters, J Clin Endocrinol Metab 91 (2006), pp. 3080?3083. View Record in Scopus | Cited By in Scopus (4)

 

 

Corresponding Author Contact Information

 

Corresponding author. University of Sydney Endocrine Surgical Unit, Department of Surgery, Royal North Shore Hospital, St Leonards, NSW 2065, Australia. Tel.: +61 2 94371731; fax: +61 2 94371732.

 

 

European Journal of Surgical Oncology (EJSO)

Volume 34, Issue 1, January 2008, Pages 67-70

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HI Mary . I see you are from Fair Fax Va . I am from Va .. but now live in Maryland .

I do not suffer from cushings , I had 2 incidentaloma tumors removed . I had one taken at NIH and the other at a local hospital in Va .

 

I am looking for a good Endocrinologist . Currently I see somone at Fair Oaks ..

 

Do you have any suggestions .

I am currently now having trouble with my TSH levels and my 4th adrenal crisis .

 

Any help would be appreciated .

 

Natalie

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  • Chief Cushie

Natalie, I saw a doctor at Fair Oaks - once - and left him!

 

I was finally diagnosed by an endo in the MacLean area. He was a good diagnostician and got me into NIH also but he has awful people skills.

 

I now go to see Dr Salvatori at Johns Holpkins in Baltimore. He's a pituitary specialist.

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