Laparoscopic Resection of Adrenocortical Carcinoma
Adrenocortical carcinoma is a rare tumor with an annual incidence of between 0.5 and 2 cases per million. This contrasts with the incidence of adenomas of the adrenal gland. As many as 2% of all autopsies show adenomatous change in the adrenal gland (2).There is a bimodal occurrence by age, with one peak occuring at less than 5 years of age and a second peak, in the fourth and 5th decades. There is a slight female predominance in most series.
Adrenocortical tumors are classified as either functional or nonfunctional. Patients develop symptoms due to excess amounts of corticosteroid, androgen, estrogen, or mineralocorticoid. (2) We considered our patient’s tumor to be functioning.
Once an adrenocortical carcinoma is suspected, computer tomography (CT) is the radiology study of choice. Abdominal CT provides information about the tumor's resectability, the patient's renal function, and the presence of metastatic disease to the liver, lymph nodes, or other sites in the peritoneal cavity. Approximation and adherence of the tumor to the liver and kidney are common, but actual invasion occurs much less frequently. Magnetic resonance imaging (MRI) gives information similar to that of CT. Sometimes, planes between the tumor and adjacent organs are better delineated with MRI. (2)
The most effective treatment for adrenocortical carcinoma is complete resection. Surgery remains the only potentially curative treatment for this disease.
Since its first description in 1992, laparoscopic adrenalectomy (LA) has become widely used in the surgical management of virtually all adrenal pathologies. However, the treatment of adrenal malignancy with laparoscopy is still controversial, because so few patients have been reported.
Several studies comparing LA with open adrenalectomy showed that LA was associated with less postoperative discomfort, decreased hospital stay, less disability, and either a lower or similar rate of complications.
Currently in experienced hands the primary specific contraindication to laparoscopic adrenalectomy is a large adrenocortical carcinoma with local periadrenal invasion or venous thrombus. Although size is not a definite contraindication, laparoscopy may not be generally advisable for adrenal tumors larger than 10 to 12 cm. because of the increased incidence of cancer. Moreover, other limitations, e.g. bilateral lesions, previous surgery in the adrenal region or morbid obesity, are not considered a specific contraindication (3). Generally the indications and contraindications of laparoscopic adrenalectomy are currently dictated largely by the experience of the individual laparoscopic surgeon.
In published studies it is suggested that there is only one contraindication for LA, the involvement of the surrounding tissue or of adrenal and caval veins by a malignant adrenal lesion (invasive adrenal carcinoma), but there are few reports on LA for malignancy (4) .
Fransesco et al in evaluating the effectiveness and safety of LA, found the mean operative duration were long, because of technical difficulties, both for peri-adrenal tissue sclerotic reaction, the need for an accurate dissection to avoid violating the tumour capsule, and to respect the principles of oncological surgery (4).
Whether large but well encapsulated adrenal masses without evidence of local invasion should be removed laparoscopically remains questionable. Up to now the consensus has been to restrict the endoscopic approach to adrenal tumors measuring > 5 to 6 cm in diameter. (5) However, it has been recently demonstrated that in experienced hands the endoscopic resection of benign-appearing large adrenal masses up to 10 cm is technically feasible and safe. (6) For most surgeons the small working space provided by the retroperitoneal approach is not suitable for dissecting tumors > 5 to 6 cm in diameter. Therefore, the lateral trans-abdominal approach is the approach of choice.
The main risk run by the surgeon during laparoscopic dissection of a large tumor is capsular disruption. Once the tumor capsule has been violated, if the tumor is malignant there is a risk of intra-abdominal contamination. As with open surgery, large tumors should be excised en bloc.
Thus, LA appears to be a feasible option in patients with adrenal malignancy, but when peri-adrenal infiltration is suspected during LA, or the principles of oncological surgery can not be respected (i.e. tumour capsule violation), the procedure must be converted to open surgery. However, in experienced hands, LA can be proposed for large (>6 cm), potentially malignant adrenal tumors. (5)
