Laparoscopic adrenalectomy for malignancy

Assessment of the diagnostic efficacy of radiological and functional evaluation of primary adrenal mass and its' surgical outcomes

INTRODUCTION

Objective of this study was to assess the diagnostic efficacy of the most commonly used radiological evaluation in form of contrast enhanced computed tomography of abdomen with adrenal protocol, basic functional evaluation and surgical outcomes of primary adrenal masses.

MATERIAL AND METHODS

We have retrospectively analysed the institutional records of 108, patients admitted from August 2017 to September 2023, who had underwent surgical intervention for their adrenal mass after thorough evaluation and stabilization.

RESULTS

Flank pain was the most common symptoms in 44 (40.74%) patients. Non-functional adrenal adenoma was found in 36 (33.33%) patients. Pheochromocytoma was the most the common functional adrenal mass found in 24 (22.22%) patients. CECT abdomen had suggested features of malignancy in 16(14.81%) patients. In final histopathological report 26(24.07%) patients had pheochromocytoma and 12 (11.11%) patients had adrenocortical carcinoma. CECT abdomen had sensitivity of 75%, specificity of 95.6%. Plasma free metanephrines and normetanephrine analysis had shown sensitivity of 90%, specificity of 92.86%, aldosterone to renin ratio had sensitivity of 92%, specificity of 100%. Sensitivity and specificity of the low-dose dexamethasone suppression test and plasma dehydroepiandrosterone was 100% in our study. Eighty patients (74.07%) were operated with laparoscopic adrenalectomy, 20 (18.52%) patients with open adrenalectomy. Eight patients (7.41%) were converted from laparoscopic to open. Laparoscopic approach had significantly lesser mean operating time, lesser blood loss, lesser hospitalization and lesser post-operative complications.

CONCLUSION

Radiological analysis and functional analysis has shown good sensitivity and high specificity. Laparoscopic approach has advantage of lesser operative time, lesser hospitalization and lesser post-operative complications.

Clinical characteristics and outcomes of adrenal hemorrhage

BACKGROUND

Although uncommon, adrenal hemorrhage has multiple etiologies. Because clinical characteristics, management, and outcomes of patients with adrenal hemorrhage are inadequately described, we examined the underlying etiology, need for intervention, evolution of imaging characteristics, and adequacy of subsequent evaluation.

METHODS

We performed a retrospective review of patients diagnosed with adrenal hemorrhage (radiologist-confirmed density consistent with hemorrhage on computed tomography) from 2005 to 2021 at a university-based institution. Demographic characteristics, hemorrhage etiology, and subsequent follow-up were analyzed.

RESULTS

Of 193 adrenal hemorrhage patients, the mean age was 49.2 ± 18.3 years, and 35% were female. Clinical presentations included trauma (47%), abdominal or flank pain (28%), incidental findings on imaging acquired for other reasons (12%), postoperative complication (8%), or shock (3%). Hemorrhage outside of the gland was present in 62% of patients. Unilateral hemorrhage was more frequent (93%) than bilateral (7%). A total of 12% of patients had nodules, but only 70% of these were identified on initial imaging, and only 43% had hormonal evaluation. Of 7 patients who had adrenalectomy or biopsy, pathology was either benign (57%) or nonadrenal malignancy (43%). No adrenocortical carcinomas were identified. Follow-up imaging was performed in 56% of patients and revealed decreased, stable, resolved, or increased adrenal hemorrhage size in 39%, 19%, 30%, and 12% of patients, respectively.

CONCLUSION

Adrenal hemorrhage is secondary to multiple etiologies, most commonly trauma. In the setting of adrenal hemorrhage, many adrenal nodules were not identified on initial imaging. Only a minority of patients with nodules underwent "complete" biochemical evaluation. Follow-up imaging may improve the identification of underlying nodules needing hormonal evaluation.

Blood-Based Next-Generation Sequencing in Adrenocortical Carcinoma

BACKGROUND

Adrenocortical carcinoma (ACC) is a rare and heterogeneous malignancy with poor prognosis. We aimed to evaluate the feasibility of next-generation sequencing (NGS) testing of circulating cell-free tumor DNA (ctDNA) in patients with ACC, to characterize the genomic landscape of alterations, and to identify potential clinically actionable mutations.

METHODS

Retrospective analysis of genomic data from 120 patients with ACC who had ctDNA testing between 12/2016 and 10/2021 using Guardant360 (Guardant Health, CA) was performed. ctDNA NGS analysis interrogated single nucleotide variants, fusions, indels, and copy number amplifications of up to 83 genes. The frequency of genomic alterations, landscape of co-occurring mutations, and pathogenic/likely pathogenic alterations with potential targeted therapies was identified. The prevalence of alterations identified in ctDNA was compared to those detected in tissue using a publicly available database (cBioPortal).

RESULTS

The median age of this cohort was 53 years (range 21-81), and 56% of patients were female. Ninety-six patients (80%) had ≥1 somatic alteration detected. TP53 (52%), EGFR (23%), CTNNB1 (18%), MET (18%), and ATM (14%) were found to be the most frequently altered genes in ACC samples. Pathogenic and/or likely pathogenic mutations in therapeutically relevant genes were observed in 56 patients (47%) and included EGFR, BRAF, MET, CDKN2A, CDK4/6, and ATM. The most frequent co-occurring mutations were EGFR + MET (9%), MET + CDK4 (7%), EGFR + CDK4 (7%), and BRAF + MET (7%). The frequencies of mutations detected in ctDNA were similar to those detected in tissue.

CONCLUSIONS

Utilizing blood-based NGS to characterize genomic alterations in advanced ACC is feasible in over 80% of patients. Almost half of the patients had actionable mutations with approved therapies in other cancers. This approach might inform the development of personalized treatment options or identify clinical trials available for this aggressive malignancy.

Can we differentiate neoplastic and non-neoplastic spontaneous adrenal bleeding? Imaging findings with radiopathologic correlation

Spontaneous adrenal bleeding is a rare clinical event with non-specific clinical features. Life-threatening bleeding in the adrenal glands may be promptly diagnosed with imaging. Computed tomography (CT) is generally the first imaging modality to be used in these patients. However, in the acute phase of bleeding, it may be difficult to detect the underlying mass from the large hematoma. In these patients, additional imaging studies such as magnetic resonance imaging or positron emission tomography/CT may be utilized to rule out a neoplastic mass as the source of bleeding. In patients where an underlying neoplastic mass could not be identified at the time of initial diagnosis, follow-up imaging may be helpful after the acute phase subsides.

Evaluation and management of adrenal neoplasms: endocrinologist and endocrine surgeon perspectives

The evaluation and management of adrenal disease is a complex endeavor that relies on an expert knowledge of human physiology and anatomy. Careful and proper patient assessment mandates a balanced approach which marries the disciplines of endocrinology, surgery, and radiology. Any of these three specialties may be on the front line in performing the initial workup when an adrenal neoplasm is discovered. With an ever-increasing volume of cross-sectional imaging, be it CT, MRI, or PET, large numbers of adrenal incidentalomas are being discovered. A close collaboration amongst specialties should strive to streamline the initial evaluation and minimize unnecessary testing and treatment.

The Characteristics and Trends in Adrenocortical Carcinoma: A United States Population Based Study

Background

Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis. Data on the incidence of ACC, however, are scarce and not recent. The purpose of this study was to characterize the tumor and the patients developing ACC over the last four decades using a large population based database.

Methods

We identified all cases of ACC diagnosed between 1973 - 2014 from the Surveillance, Epidemiology, and End Results-18 registry. Descriptive analyses were used for all extracted demographic, clinical, pathological, therapeutic and survival data, and were compared between the four time periods of 1973 to 1984, 1985 to 1994, 1995 to 2004 and 2005 to 2014 using Chi-square tests for categorical variables and one-way analysis of variance for continuous variables.

Results

There were a total of 2,014 cases of ACC between 1973 and 2014 with an age-adjusted incidence of 1.02 per million populations. The median age at diagnosis was 55 years with the majority of them being females and whites. The proportion of cases by different genders, races and age at diagnosis had not changed significantly over time. These malignancies were mostly the only primary malignancy, unilateral and of high grades at diagnosis. Surgical resection of the tumor remained the mainstay of treatment. However, there was a significant increase in the use of adjuvant radiotherapy, adjuvant chemotherapy and chemotherapy alone in recent times. The median survival time was 17 months, but continues to decrease in recent time periods.

Conclusions

ACC continues to be a rare malignancy in the United States. However, most cases continue to be diagnosed only in advanced stages and are associated with poor survival. These findings underline the need for specific diagnostics tools with new and more effective treatment options.

Laparoscopic Expertise Increases Hospital Volume of Adrenal Surgery

The laparoscopic approach is preferred for most adrenal tumors but technical challenges limit its use. We evaluated the effects of the availability of laparoscopic expertise on the volume of the adrenal surgery at a tertiary care hospital. Patients undergoing adrenalectomy 5 years before and 5 years after an advanced laparoscopic program was established were retrospectively reviewed. The average annual volume increased from 2 cases during the first period to 15 cases during the 5 years (1999-2003) after laparoscopic expertise became available. The average distance of travel to the hospital was significantly greater for the latter patients and significantly more patients were referred from outside of a 30-mile radius. Although the average statewide annual number of adrenalectomies has not significantly changed, the proportion of adrenalectomies performed at our institution rose. Offering a laparoscopic approach has altered physicians’ referral patterns and has significantly increased the volume of adrenal surgery at the institution.

[Adrenal tumors: principles of imaging and differential diagnostics]

CLINICAL/METHODICAL ISSUE

Adrenal masses are very common and are usually detected incidentally. Less frequently, imaging is performed for the localization of the underlying lesion in the case of endocrine disease. The differentiation between adenomas and non-adenomas is fundamental.

METHODICAL INNOVATIONS

Adenomas show a low density on unenhanced computed tomography (CT) and a rapid washout of contrast agents. In magnetic resonance imaging (MRI) adenomas are characterized by a low signal in opposed phase imaging as compared to in phase imaging.

PERFORMANCE

According to the literature a density of less than 10 HU in an adrenal mass has a specificity of 98% and a sensitivity of 71% for the presence of an adenoma and MRI is slightly more sensitive. Some adrenal lesions, e.g. cysts or myelolipomas can be diagnosed with high accuracy due to pathognomonic findings.

ACHIEVEMENTS

In the majority of cases the synopsis of imaging along with clinical and laboratory findings is necessary for a reliable diagnosis.

PRACTICAL RECOMMENDATIONS

For the evaluation of an adrenal mass the CT examination should begin with an unenhanced scan, if necessary followed by a washout examination. In the case of MRI in phase and opposed phase imaging are essential components of the examination.

LAPAROSCOPIC TECHNIQUE VERSUS OPEN TECHNIQUE IN SWINES ADRENALECTOMY

Among the main benefits of laparoscopic adrenalectomy (LA) compared to open adrenalectomy (OA) the rapid recovery of patients with decreased length of stay in hospital can be highlighted. The objective of this study was to compare the open adrenalectomy with laparoscopic adrenalectomy in swine. Thirty-two swine were operated. The animals had been divided into four groups (n = 8), one group was submitted to OA and the other to LA, together with its respective control group. Parameters were evaluated regarding operative time, body temperature, hematocrit, postoperative and intraoperative complications and time to deambulation. There was no meaningful difference between operative and deambulation times, even though the latter having been higher in the group submitted to OA. The most frequent intercurrences were in bowel, damage to adrenal vessels and renal hematoma. There were no significant blood losses, and observed hypothermia did not have any clinical impact. Laparoscopy in swine experimental adrenalectomy is a reliable technique that can serve as a reference for the surgical treatment of patients with adrenal diseases with surgical indications in other animal species.

Laparoendoscopic single site, laparoscopic or open surgery for adrenal tumors: Selecting the optimal approach

Numerous surgical modalities are available to treat adrenal lesions. Minimally-invasive approaches for adrenalectomy are indicated in most circumstances, and new evidence continues to be accumulated. In this context, current indications for open surgical adrenalectomy (OS-A), minimally-invasive adrenalectomy (MI-A), and laparoendoscopic single-site adrenalectomy (LESS-A) remain unclear. A comprehensive English-language literature review was performed using MEDLINE/PubMED to identify articles and guidelines pertinent to the surgical management of adrenal tumors. A comprehensive chart review was performed for three illustrative cases. Clinical recommendations were generated based on relevant literature and the expertise of the investigator group. MI-A offers advantages over OS-A in properly selected patients, who experience fewer complications, lower blood loss, and shorter hospital stays. Robot-assisted laparoscopic and retroperitoneoscopic adrenalectomy may offer advantages over transperitoneal surgery, and LESS-A may be an even less-invasive option that will require further evaluation. MI-A remains the surgical treatment of choice for most adrenal lesions. Tumor size and stage are the primary indications for selecting alternative treatment modalities. OS-A remains the gold standard for large tumors (> 10 cm) and suspected or known advanced stage malignancy. LESS-A appears to be an appropriate initial approach for small tumors (< 4-5 cm), including pheochromocytoma and isolated adrenal metastases.

Laparoscopic adrenalectomy for the management of benign and malignant adrenal tumors

Laparoscopic adrenalectomy has become the preferred approach for removal of the adrenal gland. Many published studies support the use of laparoscopic adrenalectomy, with comparisons to open adrenalectomy suggesting many advantages to laparoscopy, including less postoperative pain, shorter hospital stay and earlier return to work. Adrenalectomy is usually required for the removal of adrenal tumors causing excess hormone production or because a malignant adrenal tumor cannot be excluded. Current controversies include the appropriateness of laparoscopic adrenalectomy for large or malignant tumors, the role of partial adrenalectomy and the management of some conditions with uncertain natural history (such as subclinical hypercortisolism). With the increased use of sensitive cross-sectional imaging, the detection of clinically inapparent adrenal masses is likely to continue to increase. Due to the fact that malignancy cannot be excluded with certainty in some patients with cortical adenomas, it is expected that the rate of laparoscopic adrenalectomy will continue to increase.

Laparoscopic adrenalectomy for cancer

Laparoscopic procedures are preferred by surgeons and patients alike because of decreased pain, reduced perioperative morbidity, and an earlier return to self-reliance. During the last decade, laparoscopic adrenalectomy has become the technique most commonly used for the removal of benign adrenal tumors. The indications for laparoscopy in malignant adrenal tumors remains controversial, because oncologic resections have not been reproducible compared with open techniques.

Risk of concomitant malignancy in hyperfunctioning adrenal incidentalomas

BACKGROUND

Adrenal masses are common incidental findings on radiologic imaging. The association between malignancy and hormonal hyperactivity found in incidentally discovered adrenal tumors, however, remains unclear.

METHODS

A retrospective analysis of prospectively collected data from patients who underwent adrenalectomy for incidentally discovered adrenal tumors at a single institution. Outcomes and operative data were compared by univariate analysis. Area under the curve was used to analyze the effect of tumor size in predicting malignancy.

RESULTS

There were 49 patients who initially presented with adrenal incidentalomas that underwent adrenalectomy. Most patients were Caucasian women with an average age of 51 ± 14 years. Of this group, 24 patients underwent resection for hyperfunctioning adrenal glands. There were no significant differences in malignancy rates between hyperfunctional and nonfunctional tumors (4.1% vs. 12.0%, P = 0.32). On final histopathology, there were four patients with adrenal malignancies: two adrenocortical carcinomas and two metastatic from renal carcinoma. Only one patient with a hyperfunctioning adrenal tumor had underlying malignancy. Overall, invasion of adjacent structures (P < 0.001), presence of lymphadenopathy (P = 0.02), metastasis (P = 0.03), irregular tumor margins (P = 0.01), heterogeneity (P = 0.05), and tumor size >6 cm (P = 0.04) on radiologic imaging were strongly associated with malignancy in adrenal incidentalomas.

CONCLUSIONS

The risk of concomitant malignancy and hormonal hyperactivity in adrenal incidentalomas is very low. Tumor size (>6 cm) and radiographic features remain the most important predictors of adrenal malignancy, regardless of tumor function.

Laparoscopic adrenalectomy for large tumours: Single team experience

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the procedure of choice to treat benign functioning and non-functioning adrenal tumours. With improving experience, large adrenal tumours (> 5 cm) are being successfully tackled by laparoscopy. This study aims to present our single unit experience of LA performed for large adrenal masses.

MATERIALS AND METHODS

Forty-six laparoscopic adrenalectomies performed for large adrenal lesions more than 5 cm during the period 2001 to 2010 were reviewed.

RESULTS

A total of 46 adrenalectomies were done in 42 patients. The mean tumour size was 7.03 cm (5-15 cm). Fourteen patients had tumour size more than 8 cm. The lesions were localised on the right side in 17 patients and on the left side in 21 patients with bilateral tumours in 4 patients. Functioning tumours were present in 32 of the 46 patients. The average blood loss was 112 ml (range 20-400 ml) with the mean operating time being 144 min (range 45 to 270 min). Five patients required conversion to open procedure. Three of the 46 patients (6.52%) on final histology had malignant tumours.

CONCLUSION

LA is safe and feasible for large adrenal lesions. Mere size should not be considered as a contraindication to laparoscopic approach in large adrenal masses. Graded approach, good preoperative assessment, team work and adherence to anatomical and surgical principles are the key to success.

Adrenalectomy improves outcomes of selected patients with metastatic carcinoma

BACKGROUND

Indications and survival benefit for adrenalectomy (ADX) in the setting of metastasis are not clearly defined. We aimed to determine which patients with primary malignancies may benefit from ADX performed for metastasis. Mayo Clinic institutional outcomes in patients with metastatic disease to the adrenal(s) treated by adrenalectomy were compared to stage-matched historical controls from the Surveillance Epidemiology and End Results (SEER) database.

METHODS

A retrospective review (1992-2010) was conducted to identify patients treated with ADX for metastatic cancer at Mayo Clinic, Rochester. Associations of clinical, surgical, and pathologic features with overall survival (OS) were evaluated using Cox proportional regression models. OS for those treated with ADX was compared with that for SEER database stage-matched patients who underwent primary resection without resection of distant disease using log-rank tests.

RESULTS

A total of 166 patients underwent ADX for metastatic primaries involving the kidney 60, lung 24, sarcoma 19, colon 15, pancreas 13, and other-35. Patients with sarcoma and kidney, lung, and pancreatic tumors who underwent ADX had better OS at 1, 2, and 3 years than did the SEER-matched controls. Respectively, the rates were for sarcoma (100, 93, 86% vs. 57, 36, 30%), kidney (86, 80, 72% vs. 55, 37, 27%), lung (91, 69, 52% vs. 52, 34, 25%), and pancreas (79, 56, 45% vs. 33, 20, 12%). Univariate analysis identified primary diagnosis <2 years before ADX, other distant site, pancreatic primary, palliative operation, and persistent disease as risk factors for death.

CONCLUSIONS

An aggressive surgical approach results in improved OS in patients with metastatic disease arising from soft tissues, kidney, lung, and pancreas. Other tumors may benefit, but larger study cohorts are needed for a meaningful comparison.

Laparoscopic adrenalectomy: lessons learned from 306 cases

INTRODUCTION

Laparoscopic adrenalectomy has become the standard of care for the surgical treatment of benign adrenal pathology. We present the following case series documenting our experience in refinement of this approach.

PAIENTS AND METHODS

Analysis of patient records identified those in whom laparoscopic adrenalectomy was performed from January 1997 through February 2010. Study variables included indications, operative time, blood loss, length of hospital stay, histopathological evaluation, and complications.

RESULTS

Laparoscopic adrenalectomy was performed in 306 patients using the transperitoneal lateral approach. No major operative complications were noted, and postoperative complications included a pulmonary embolism and 2 cases of pneumonia. Conversion to the open approach was necessitated in two cases. The median operative time was 95±29 minutes (range, 45-145 minutes). Estimated blood loss was 60 mL (range, 30-150 mL). The mean size of the removed gland was 5.9±1.6 cm (range, 3-13 cm). The mean size of the tumor was 5±2 cm (range, 0.5-12 cm). The median hospitalization was 4±3.7 days (range, 2-22 days). Adrenal pathology included adenoma (n=164), pheochromocytoma (n=79), hyperplasia (n=35), metastatic carcinoma (n=22), cyst (n=9), myelolipoma (n=9), hemangioma (n=3), ganglioneuroma (n=3), and melanoma (n=2).

CONCLUSION

Laparoscopic adrenalectomy is a safe and feasible approach to adrenal pathology, providing the patients with all the benefits of minimally invasive surgery.

Adrenocortical carcinoma: which surgical approach?

INTRODUCTION

There are no randomised studies comparing open and laparoscopic approaches foradrenalectomy in patients with adrenal cortical carcinoma.

METHODS

There is evidence of postoperative benefit for the patients undergoing laparoscopic adrenalectomy compared to open adrenalectomy (level B).

RESULTS

Results from comparison of oncological outcomes in ACC between open and laparoscopic approaches are equivocal: increasedrisk of local recurrence and peritoneal carcinomatosis by the laparoscopic route (level D), and identical results between the two approaches in terms of survival, recurrence and peritoneal carcinomatosis (level C).

CONCLUSION

An open approach is recommended in case of local invasion, with a view to achieving an R0 resection (level D). Laparoscopic resection of ACC/potentially malignant tumours, which includes removal of surrounding periadrenal fat and results in an R0 resection without tumour capsule rupture, may be performed for preoperative and intraoperative stage 1-2 ACC and tumours with a diameter < 10 cm (level C).

Obesity is a predictor of morbidity in 1,629 patients who underwent adrenalectomy

BACKGROUND

We examined the impact of obesity on 30-day outcomes of adrenalectomy using a multi-institutional database.

METHODS

Patients who underwent adrenalectomy in 2005-2008 according to the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) data set were grouped by body mass index (BMI): normal weight (BMI=18.5-24.9 kg/m2), overweight (BMI=25.0-29.9 kg/m2), obese (BMI=30.0-34.9 kg/m2), and morbidly obese (BMI≥35 kg/m2). Outcomes of the higher BMI groups were compared to those of the normal BMI group using χ2, analysis of variance (ANOVA), and multivariate regression.

RESULTS

There were 1,629 patients in the study: 22% were normal weight, 31% overweight, 22.2% obese, and 24.7% morbidly obese. Compared to normal-weight patients, obese and morbidly obese patients had a 12.5 and 16.7% increase in operation times (129 vs. 145 and 150 min, respectively, p≤0.01) and sustained more wound complications (0.2 vs. 0.4 and 1.2%, p<0.001), including superficial and deep wound infections (p<0.001 and p<0.01, respectively). Morbid obesity independently predicted overall complications (odds ratio [OR] 2.9, 95% confidence interval [CI]: 1.7-5.7), wound complications (OR 6.1, 95% CI: 2.0-18.9), and septic complications (OR 3.1, 95% CI: 1.1-8.8). Obesity independently predicted longer total time in the operating room (p<0.006). There were no differences in rates of reoperation and length of hospital stay by BMI category.

CONCLUSION

Obesity is an independent risk factor that needs to be considered in surgical decisions regarding adrenalectomy. Morbidly obese adrenalectomy patients are particularly at risk for wound and septic complications.

Surgical management of adrenal tumors

Laparoscopic adrenalectomy has become the preferred method for removal of almost all adrenal tumors. An important component in selecting patients for this operation is a thorough understanding of the clinical presentation (mainly hypertension) and diagnostic workup for the full variety of functioning and nonfunctioning adrenal tumors including genetic evaluation when necessary (MEN2, VonHippel-Landau [VHL], type 1 neurofibromatosis [NF1], succinate dehydrogenase mutations [SDH], and MEN1). The indications and contraindications for a laparoscopic approach are discussed with regard to each tumor type. Relevant literature about partial and bilateral adrenalectomy is also summarized. Main areas of controversy are discussed including the size threshold to avoid risk of adrenal capsular effraction and the appropriateness of laparoscopic resection for suspected and known malignancy. This article presents recent data to help the surgeon make well-informed decisions and to optimize the operative approach for a wide variety of adrenal pathologies (secreting vs. non-secreting, benign vs. malignant tumors).

Laparoscopic adrenalectomy: Gaining experience by graded approach

INTRODUCTION

Laparoscopic adrenalectomy (LA) has become a gold standard in management of most of the adrenal disorders. Though report on the first laparoscopic adrenalectomy dates back to 1992, there is no series of LA reported from India. Starting Feb 2001, a graded approach to LA was undertaken in our center. Till March 2006, a total of 34 laparoscopic adrenalectomies were performed with success.

MATERIALS AND METHODS

The endocrinology department primarily evaluated all patients. Patients were divided into Group A - unilateral LA and Group B - bilateral LA (BLA). The indications in Group A were pheochromocytoma (n=7), Conn's syndrome (n=3), Cushing's adenoma (n=2), incidentaloma (n=2); and in Group B, Cushing's disease (CD) following failed trans-sphenoid pituitary surgery (n = 8); ectopic ACTH- producing Cushing's syndrome (n=1) and congenital adrenal hyperplasia (CAH) (n=1). The lateral transabdominal route was used.

RESULTS

The age group varied from 12-54 years, with mean age of 28.21 years. Average duration of surgery in Group A was 166.43 min (40-270 min) and 190 min (150-310 min) in Group B. Average blood loss was 136.93 cc (20-400 cc) in Group A and 92.5 cc (40-260 cc) in Group B. There was one conversion in each group. Mean duration of surgical stay was 1.8 days (1-3 days) in Group A and 2.6 days (2-4 days) in Group B. All the patients in both groups were cured of their illness. Three patients in Group B developed Nelson's syndrome. The mean follow up was of 24.16 months (4-61 months).

CONCLUSION

LA though technically demanding, is feasible and safe. Graded approach to LA is the key to success.

Laparoscopic resection of large adrenal tumors

Results of this study suggest that laparoscopic adrenalectomy should be the treatment of choice for benign adrenal tumors. However, experience in advanced laparoscopic and open abdominal surgery is necessary in the management of large adrenal tumors.

Background:

Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. It still remains to be clarified whether the laparoscopic resection of large (≥8cm) or potentially malignant tumors is appropriate or not due to technical difficulties and concern about local recurrence. The aim of this study was to evaluate the short- and long-term outcome of 174 consecutive laparoscopic and open adrenalectomies performed in our surgical unit.

Methods:

Our data come from a retrospective analysis of 174 consecutive adrenalectomies performed on 166 patients from May 1997 to December 2008. Fifteen patients with tumors ≥8cm underwent laparoscopic adrenalectomy. Sixty-five patients were men and 101 were women, aged 16 years to 80 years. Nine patients underwent either synchronous or metachronous bilateral adrenalectomy. Tumor size ranged from 3.2cm to 27cm. The largest laparoscopically excised tumors were a ganglioneuroma with a mean diameter of 13cm and a myelolipoma of 14cm.

Results:

In 135 patients, a laparoscopic procedure was completed successfully, whereas in 14 patients the laparoscopic procedure was converted to open. Seventeen patients were treated with an open approach from the start. There were no conversions in the group of patients with tumors >8cm. Operative time for laparoscopic adrenalectomies ranged from 65 minutes to 240 minutes. In the large adrenal tumor group, operative time for laparoscopic resection ranged from 150 minutes to 240 minutes. The postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 day to 2 days (mean, 1.5) and from 5 days to 20 days for patients undergoing the open or converted procedure. The mean postoperative stay was 2 days for the group with large tumors resected by laparoscopy.

Conclusion:

Laparoscopic resection of large (≥8cm) adrenal tumors is feasible and safe. Short- and long-term results did not differ in the 2 groups.

Spontaneous rupture of a functioning adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with poor prognosis, and it can be classified as either a functional or nonfunctional tumor. Affected patients usually present with abdominal pain or with symptoms related to the mass effect or hormonal activity of the tumor. Several cases of spontaneously ruptured nonfunctional adrenocortical carcinoma have been reported, but no case of a spontaneous rupture of functioning adrenocortical carcinoma has been described. We report a functioning adrenocortical carcinoma that spontaneously ruptured during a work-up.

Laparoscopic adrenalectomy: where do we stand now?

Laparoscopic adrenalectomy (LA) has become the procedure of choice for the surgical removal of the vast majority of small sized adrenal tumors (<or= 6 cm), because of its significant and multiple advantages: reduced hospital stay and wound morbidity, decreased transfusion requirements, postoperative pain and complications. The role of LA in patients with large adrenal lesions or potential malignancy remains controversial. The aim of this article is to review the current and up-to-date surgical approaches for LA, which include: 1) transabdominal anterior or flank approach and 2) retroperitoneal technique with the patient in either lateral or prone position. Specific advantages and disadvantages are referred to for each of them. The choice of each of these techniques is determined particularly by the preference and the experience of the surgeon, but other objective criteria must be taken into consideration, such as the size of the adrenal and history of previous abdominal surgeries.

[Abdominal preoperation. No contraindication for laparoscopic transabdominal adrenalectomy]

Benign adrenal gland tumors smaller than 6 cm are nowadays the indication for minimally invasive surgery. Until now there has been no significant difference between retroperitoneoscopic and transabdominal adrenalectomy. Intestinal adhesions could be a contraindication against transabdominal laparoscopic adrenalectomy, and therefore the retroperitoneoscopic approach could be an advantage in these cases. A prospective study concerning this question has not been published yet. Our clinical investigation here includes 114 adrenalectomies during the last 5 years. We show that in any case of abdominal preoperation, laparoscopic adrenalectomy can be performed by transabdominal approach and without conversion to open surgery. Discussed are the different indications for laparoscopic adrenalectomy, operating time, conversion rate to open surgery, and amount and type of abdominal preoperation. We compared patients with and without abdominal preoperations.

Surgery for Cushing's syndrome: an historical review and recent ten-year experience

BACKGROUND

Cushing's syndrome (CS), due to multiple etiologies, is a disorder associated with the ravages of cortisol excess. The purpose of this review article is to provide a historical synopsis of surgery for CS, review a recent 10-year period of operative management at a tertiary care facility, and to outline a practical approach to diagnosis and management.

MATERIALS AND METHODS

From 1996 to 2005, 298 patients underwent 322 operative procedures for CS at Mayo Clinic, Rochester, Minnesota. A retrospective chart review was carried out. Data was gathered regarding demographics, preoperative assessment, procedures performed, and outcomes. Data are presented as counts and percentages. Five-year survival rates were calculated where applicable by the Kaplan-Meier method. Statistical analysis was carried out with SAS, version 9 (SAS Institute, Inc., Cary, NC).

RESULTS

Two-hundred thirty-one patients (78%) had ACTH-dependent CS and 67 patients (22%) had ACTH-independent CS. One-hundred ninety-six patients (66%) had pituitary-dependent CS and 35 patients (12%) had ectopic ACTH syndrome. Fifty-four patients (18%) had cortisol-secreting adenomas, 10 patients (3%) had cortisol-producing adrenocortical carcinomas, and 1% had other causes. Cure rates for first time pituitary operations (transsphenoidal, sublabial, and endonasal) were 80% and 55% for reoperations. Most benign adrenal processes could be managed laparoscopically. Five-year survival rates (all causes) were 90%, 51%, and 23% for adrenocortical adenomas, ectopic ACTH syndrome, and adrenocortical carcinomas, respectively.

CONCLUSIONS

Surgery for CS is highly successful for pituitary-dependent CS and most ACTH-independent adrenal causes. Bilateral total adrenalectomy can also provide effective palliation from the ravages of hypercortisolism in patients with ectopic ACTH syndrome and for those who have failed transsphenoidal surgery. Unfortunately, to date, adrenocortical carcinomas are rarely cured. Future successes with this disease will likely depend on a better understanding of tumor biology, more effective adjuvant therapies and earlier detection. Clearly, IPSS, advances in cross-sectional imaging, along with developments in transsphenoidal and laparoscopic surgery, have had the greatest impact on today's management of the complex patient with CS.

Bilateral primary adrenal non-Hodgkin's lymphoma and primary adrenocortical carcinoma--review of the literature preoperative differentiation of adrenal tumors

Most of the adrenal tumors that are incidentally detected are benign adenomas. The incidence of malignant adrenal tumors including adrenocortical carcinoma (ACC) and primary adrenal lymphoma (PAL) is rather low. As many patients with ACC and PAL are diagnosed at an advanced stage of disease, the overall survival time of both entities remains poor. The therapeutic strategies for both entities differ. Thus an early differentiation between ACC and PAL is necessary. Unfortunately hitherto preoperative diagnosis of potentially malignant adrenal masses is still a main problem in the treatment of adrenal tumors. We present the case of a 57-year-old male patient with ACC and the case of an 87-year-old male patient with PAL and provide a systematic comparison of the clinical and pathological features of both entities. In both cases clinical and radiological features resulted in an initially false diagnosis. Primary surgical therapy was performed in both patients. The patient with PAL died five months after initial surgery. The patient with ACC showed tumor progression with local and systemic recurrence despite adjuvant therapy with mitotane and additional surgical therapy. Prognosis of patients with ACC and PAL seems to be dependant on the ability to start accurate treatment without any time delay. We propose some guidelines for diagnosis and surgical management of adrenal tumors.

Laparoscopic adrenalectomy for adrenal malignancy: a preliminary report comparing the short-term outcomes with open adrenalectomy

BACKGROUND

The laparoscopic approach to adrenal malignancy remains a topic of debate.

METHODS

A retrospective analysis of patients who had an open or laparoscopic adrenalectomy for malignancy at a tertiary care center from 1995 to 2005 were included in this study.

RESULTS

Twenty-six cases were identified: 19 women and 7 men with a median age of 48 years (range, 20-81) underwent 12 open (8 adrenocortical carcinoma [ACC] and 4 metastases) and 14 laparoscopic adrenalectomies (5 ACC, 8 metastases, and 1 lymphoma). Conversion to open surgery was required in 1 laparoscopic case (7%). Cases with obvious invasion to adjacent organs were not approached laparoscopically. There was no difference in age, sex, American Society of Anesthesiologists status or diagnosis between the two groups, but patients in the laparoscopic group had a higher body mass index. Two patients required splenectomies for splenic tears in the open group. There was no difference in operative time between the two groups, but estimated blood loss (200 vs. 550 mL; P = 0.01) and hospital stay (2 vs. 7 days; P = 0.005) were less in the laparoscopic group. The size of tumors removed by open surgery was larger than by laparoscopy (8 vs. 4 cm; P = 0.003). No locoregional recurrences are reported so far in the laparoscopic group.

CONCLUSIONS

Laparoscopic adrenalectomy is both feasible and safe for some malignant tumors of the adrenal gland in experienced hands. However, it cannot be applied to all cases. Careful selection, preoperative staging, and respect for oncologic principles are important considerations in choosing laparoscopic surgery for primary and secondary adrenal malignancy. Short-term outcomes are better when the laparoscopic approach is possible. Confirmation and long-term results with further studies are required.

Predictive factors for open conversion of laparoscopic adrenalectomy: a 13-year review of 456 cases

BACKGROUND AND PURPOSE

Laparoscopic adrenalectomy has largely replaced open adrenalectomy for the treatment of adrenal tumor. However, certain cases still require conversion to open procedures. Identifying the risk of conversion remains difficult. This study identified risk factors that may predict conversion from a laparoscopic to an open procedure.

PATIENTS AND METHODS

From January 1993 to September 2006, a total of 456 laparoscopic adrenalectomies were performed at two urologic centers. A retrospective analysis of parameters, including tumor size, patient age, American Society of Anesthesiology classification, body mass index (BMI), sex, laparoscopic approach, previous abdominal surgery, laterality, type of tumor, laparoscopist experience, and surgeon, was performed. Multivariate logistic regression was used to identify those variables predicting conversion.

RESULTS

A total of 25 (5.5%) laparoscopic adrenalectomies required conversion. Significant predictors of conversion according to univariate analysis were tumor size > or =5 cm, BMI > or =24 kg/m(2), and pheochromocytoma. Multivariate analysis showed that the significant independent predictive factors for conversion were tumor size > or =5 cm (8.884 greater odds ratio [OR] of conversion; 95% confidence interval 3.543, 22.277; P < 0.001), BMI > or = 24 kg/m(2) (OR 3.632; 95% confidence interval 1.367, 9.648; P = 0.010), and pheochromocytoma (OR 3.068; 95% confidence interval 1.175, 8.007; P = 0.022).

CONCLUSIONS

Knowledge of tumor size, BMI, and tumor type can help in counseling patients undergoing laparoscopic adrenalectomy with regard to the probability of conversion. The size of the tumor was found to be the most important predictor.

Laparoscopic adrenalectomies: A nationwide single-surgeon experience

BACKGROUND

Laparoscopic adrenalectomy (LA) was first performed in Iceland in 1997. Since then, all procedures for presumed benign lesions of the adrenals have been performed laparoscopically in a single center. Compared with conventional adrenalectomy, LA appears to achieve superior results in terms of recovery, hospital stay, and morbidity. This study aimed to evaluate the results of LA in Iceland.

METHODS

The hospital records of all patients who underwent LA in Iceland from 1997 through 2005 were reviewed. The preoperative diagnosis was documented, as well as the pathologic diagnosis, operative details, complications, and length of hospital stay.

RESULTS

In 49 operations, 53 adrenal glands were removed from 48 patients (37 women and 11 men). The mean patient age was 53.6 years (range, 24.4-78.8 years). The left adrenal was removed from 29 patients, the right adrenal from 14 patients, and both adrenals from 5 patients. The most common indications and diagnoses included 17 nonsecreting tumors (12 adenomas, 3 hyperplasias, 1 complex adrenal cyst, and 1 hemangioma), 12 aldosteronomas (10 aldosteronomas and 2 nodular hyperplasias), and 10 pheochromocytomas (9 confirmed, 1 adrenal hyperplasia). Other indications and diagnoses were less common. The mean operative time was 168 min (range, 87-370 min) for unilateral operations and 412 min (range, 345-480 min) for bilateral operations. The mean blood loss was 117 ml (range, 0-650 ml) for unilateral operations and 200 ml (range, 0-350 ml) for bilateral operations. The complications were mild pancreatitis (n = 1), urinary tract infection (n = 1), atelectasis (n = 1), mild congestive heart failure (n = 2), and transient corneal abrasion (n = 1). No conversion to open procedure was needed. The mean tumor size was 3.5 cm (range, 1.5-6.2 cm), and the mean postoperative hospital stay was 2.6 days (range, 1-6 days).

CONCLUSION

The results of laparoscopic adrenalectomies in Iceland for benign lesions of the adrenals are comparable with published results from large referral centers.

Is laparoscopic adrenalectomy safe and effective for adrenal masses larger than 7 cm?

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the gold standard treatment for small (less than 6 cm) adrenal masses. However, the role of LA for large-volume (more than 6 cm) masses has not been well defined. Our aim was to evaluate, retrospectively, the outcome of LA for adrenal lesions larger than 7 cm.

PATIENTS AND METHODS

18 consecutive laparoscopic adrenalectomies were performed from 1996 to 2005 on patients with adrenal lesions larger than 7 cm.

RESULTS

The mean tumor size was 8.3 cm (range 7-13 cm), the mean operative time was 137 min, the mean blood loss was 182 mL (range 100-550 mL), the rate of intraoperative complications was 16%, and in three cases we switched from laparoscopic procedure to open surgery.

CONCLUSIONS

LA for adrenal masses larger than 7 cm is a safe and feasible technique, offering successful outcome in terms of intraoperative and postoperative morbidity, hospital stay and cosmesis for patients; it seems to replicate open surgical oncological principles demonstrating similar outcomes as survival rate and recurrence rate, when adrenal cortical carcinoma were treated. The main contraindication for this approach is the evidence, radiologically and intraoperatively, of local infiltration of periadrenal tissue.

Incidentally discovered tumors of the endocrine glands

Clinically inapparent masses, or ‘incidentalomas’ of the endocrine glands are increasingly common owing to continued advancements in medical imaging. Incidentalomas of the adrenal glandS have received substantial attention in the literature, whereas lesions of the thyroid and endocrine pancreas, though frequently encountered in the clinic, have received relatively little attention. We review the detection and subsequent management of incidentalomas of the thyroid, adrenal and pancreas, with specific attention paid to the mode of detection and risk stratification of lesions.

[Adrenal incidentalomas]

Adrenal incidentalomas are clinically inapparent masses detected incidentally with imaging studies conducted for other reasons. They are relatively common and require structured diagnostic workup. In many cases surveillance is warranted. The diagnostic workflow has to reveal whether the mass is hormonally functioning and/or if there is evidence of malignancy. If the tumor is functionally silent and not larger than 4 cm, surveillance is warranted. Functioning tumors and masses larger than 6 cm have to be resected. Fine-needle aspiration biopsy is indicated in very rare cases, but pheochromocytoma has to be ruled out first.

Diagnosis and management of adrenal cortical carcinoma

Adrenal cortical carcinoma is a relatively uncommon malignancy that represents a significant clinical challenge for the development of optimal treatment strategies. Historically, successful treatment has relied upon rapid identification of the lesion, accurate staging with diagnostic imaging, and complete surgical extirpation. Although the framework of a successful treatment paradigm still relies on these steps, advances in diagnostic imaging have led to increased accuracy in diagnosis, and advances in laparoscopic surgical technique have served to reduce morbidity for patients facing treatment. This review focuses on a discussion of advances in modalities for the diagnosis and treatment of adrenal cortical carcinoma amenable to curative therapy. Patients that present with metastatic or locally advanced disease generally are treated with mitotane-based chemotherapy with or without the addition of cytotoxic drugs. Contemporary results of this treatment approach are presented in this review as well as a discussion of further directions for the treatment of patients with advanced disease.

Laparoscopic surgery and corticoadrenalomas

BACKGROUND

Nowadays, laparoscopic adrenalectomy is the "gold standard" procedure for the treatment of benign lesions. However, the situation is not so clearcut when the issue is laparoscopic excision of malignant adrenal tumors. We present our results of laparoscopic adrenalectomy for treating malignant tumors over the past decade.

METHODS

Between October 1995 and June 2004, 131 consecutive laparoscopic adrenalectomies were performed on 120 patients (11 synchronous bilateral procedures). All patients underwent a standardized investigation protocol during their workup for surgery.

RESULTS

There were only two conversions to laparotomy (1.6%). Complications that occurred during the procedure were limited to six patients (5%). Postoperative 30-days mortality was nil. Postoperative complications occurred in five patients (4.7%) during the first 30 days of recovery. The median hospital stay for all patients was 2.5 days (range = 2-10 days). Twelve patients (9%) had a malignant tumor: nine corticoadrenalomas, one pleomorphic sarcoma, one metastatic deposit from a previously excised colonic cancer, and one malignant pheochromocytoma. At mean followup of 34 months, mean survival time was 42.3 months for corticoadrenalomas that had undergone laparoscopy versus 29.7 months for those who had had a laparotomy. Five of the nine patients are alive and well at a mean of 37 months following surgery. One patient developed pulmonary metastases one year postsurgery; they were responsive to mitotane. Five years later, the same patient had a reoperation for an intra-abdominal retrogastric recurrence of her tumor and continues to do well. Another patient developed pulmonary metastases 22 months following adrenalectomy. Two patients died of metastatic intra-abdominal disease 20 and 7 months postsurgery.

CONCLUSION

When laparoscopic surgery is to used for cancer treatment, caution is the rule to maintain the primary objective of securing a survival rate at least as high as that for open surgery, without increased risk of recurrence. Considering the results presented within this study, it seems that the laparoscopic removal of a corticoadrenaloma should not worsen the prognosis, provided the surgeon respects the primary rules of oncologic resectional surgery. Any surgical conditions that would preclude the strict application of these criteria are contraindications to a laparoscopic procedure.

Recurrent adrenocortical carcinoma after laparoscopic resection

BACKGROUND

A 53-year-old man presented with left-sided flank pains to the Gastroenterology department of our clinic in September 2004. A left adrenal mass of 6.5 cm by 7.5 cm was detected by a CT scan. The patient showed no evidence of Cushing's syndrome, and had normal blood pressure and potassium levels. Endocrine tests ruled out excess levels of aldosterone or catecholamines. The patient underwent laparoscopic surgery to remove the tumor mass; histologic work-up revealed an adrenocortical carcinoma. A fluorodeoxyglucose (FDG)-PET scan 1 month, and a CT scan 8 months postoperatively showed no pathologic findings. The patient, however, again presented with left-sided flank pain to our Endocrinology department in August 2005.

INVESTIGATIONS

In our department, laboratory work-up for endocrine activity was performed, as well as CT scans of the adrenal region, and FDG-PET scans in order to determine the extension of disease. Histologic work-up of the removed tumor tissue was performed.

DIAGNOSIS

Recurrent adrenocortical carcinoma after laparoscopic adrenalectomy.

MANAGEMENT

In our department, 10 months after initial laparoscopic surgery, local tumor recurrence was treated by repeated extensive surgery, tumor-bed radiation therapy, and mitotane treatment. A year later, a large lymph-node metastasis was surgically removed from the lower abdomen and mitotane treatment was again started postoperatively. The patient is now scheduled for polychemotherapy because of progressive metastatic disease revealed by follow-up CT and FDG-PET scanning in June 2006.

Isolated adrenal metastasis: the role of laparoscopic surgery

BACKGROUND

Solitary adrenal metastases (AM) are rare and their management unclear. Surgery, especially laparoscopic adrenalectomy (LA), is debatable in the management of AM. This retrospective study analysed the feasibility and the results of LA for AM.

METHODS

From 1997 to 2003, 16 patients underwent LA for isolated AM. Completeness of resection, postoperative morbidity and follow-up (FU) were recorded.

RESULTS

There were 10 synchronous AM and 6 metachronous AM. Primary tumours included lung cancer (n = 9), melanoma (n = 3), mesothelioma (n = 1), rhabdomyosarcoma (n = 1), colonic adenocarcinoma (n = 1) and renal cell carcinoma (n = 1). Five patients required conversion to an open procedure. Minor complications occurred in three patients. Pathology confirmed the diagnosis of AM. Mean tumour size was 60 (range: 15-110) mm. Nine patients (56%) had complete resections, 3 had positive margins and 4 had incomplete macroscopic resections. Mean observed FU was 25 (range: 1-68) months. Median overall calculated survival was 23 months. Overall 5-year survival was 33% (Kaplan-Meyer). At the end of study, 8 patients were alive with a mean FU of 35 months (3 without evidence of disease). No patient presented with local relapse or port-site metastasis. We did not identify any predictive factors. All patients with incomplete macroscopic resection died within 24 months.

CONCLUSIONS

LA can achieve an acceptable 5-year survival, comparable to open surgery but with better postoperative comfort. It should be considered for AM with the intention of complete resection. It offers the patient the possibility of tumour resection with the benefit of a laparoscopic approach.

Extent of disease at presentation and outcome for adrenocortical carcinoma: have we made progress?

BACKGROUND

Adrenocortical carcinoma (ACC), a rare and aggressive malignancy, accounts for up to 14% of adrenal incidentalomas. The only chance of cure for ACC is diagnosis at an early stage; therefore, a main indication for adrenalectomy in patients with adrenal incidentaloma has been the potential risk of ACC. Recent studies suggest that this has led to earlier stage of ACC at diagnosis, more curative operations, and better survival.

METHODS

We analyzed data on ACC from The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. Four equal time quartiles (1973-1979, 1980-1986, 1987-1993, and 1994-2000) were compared for changes in demographics, pathology, treatment, and cause-specific mortality.

RESULTS

The average age was 51.2 years (range: 1-97), and 45.9% of patients were men. The average tumor size was 12 cm (range: 2-36 cm), and only 4.2% were < or = 6 cm. Most (88%) patients had surgical resection of their tumor, and external beam radiotherapy was used in only 12% of patients. Between the time quartiles compared (as well as annually), there was no significant difference at presentation in age at diagnosis, sex, race/ethnicity, tumor size, tumor grade, the frequency of distant metastasis, and overall TNM stage. Low tumor grade, lower stage of ACC, later time quartile, and surgical resection were associated with a lower cause-specific mortality by univariate analysis (P < or = 0.002) and by multivariate analysis (P < or = 0.031).

CONCLUSIONS

Although adrenal incidentalomas have become a common indication for adrenalectomy, this has not resulted in patients with ACC being diagnosed earlier or treated at a lower stage of disease at the national level. The most important predictors of survival in these patients are tumor grade, tumor stage, and surgical resection.

Role of laparoscopy in the management of adrenal malignancies

BACKGROUND AND OBJECTIVES

The role of laparoscopic approach for the treatment of malignant adrenal diseases is still controversial. The aim of this study was to verify the results of laparoscopic adrenalectomy (LA) in the management of adrenal malignancies.

METHODS

The medical records of all the patients who underwent laparoscopic procedures for adrenal diseases and in whom malignancy was demonstrated at final histology were reviewed.

RESULTS

Nine patients were included (three malignant pheochromocytomas, four adrenocortical carcinomas, and two adrenal metastases). At a mean follow-up of 23.0 months, all but two patients were alive. One patient died for metastatic disease and the other one for unrelated causes. One patient operated on for an adrenocortical carcinoma developed a pelvic recurrence. One patient operated on for a malignant pheochromocytoma developed multiple intra-abdominal recurrences. No other case of recurrence was observed.

CONCLUSIONS

The results of this study demonstrate that LA can have a role also in case of adrenal malignancies. Conversion to open surgery is mandatory in case of local invasion and when the dissection cannot be as accurate as in conventional operations. A preliminary laparoscopic exploration can be planned in case of suspected malignant lesions to confirm the diagnosis and to evaluate their operability.

Adrenocortical carcinoma

PURPOSE OF REVIEW

Adrenocortical carcinoma is a rare malignancy, accounting for 0.02% of all annual cancers reported. Given the generally advanced stage at diagnosis, the overall 5-year survival remains poor, varying between 20 and 45%. While older studies purported an improved outcome for functional tumors in adult patients, this has not been borne out in more recent studies. In the pediatric population, though, virilizing tumors carry a better survival than non-functional or cortisol-secreting tumors.

RECENT FINDINGS

Recent studies focusing on the tumorigenesis of adrenocortical carcinoma have focused on onco-developmental genes present in the fetal adrenal cortex, as well as local adrenal paracrine and autocrine effects of cellular peptides.

SUMMARY

Pre-operative diagnostic advances in positron emission scanning are emerging as promising modalities for confirmation of malignancy of indeterminate adrenal masses. No significant advances in the treatment of adrenocortical carcinoma have been developed. Surgery remains the mainstay for primary and recurrent disease, including select patients with isolated liver metastases. Mitotane has remained the preferred adjuvant treatment agent, showing modest effect in patients with unresectable, residual or metastatic disease. Multi-institutional registries and trials need to be established, with multidisciplinary efforts focused on the development of new therapeutic strategies.