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EJSO 34 (2008) 67-70
EJSO the Journal of Cancer Surgery
Laparoscopic surgery is safe for large adrenal lesions
P.S.H. Soon a,d, M.W. Yeh , L.W. Delbridge ª, C.P. Bambach ª, M.S. Sywak a, B.G. Robinson c,d, S.B. Sidhu a,d,*
ª University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
b UCLA Endocrine Surgery, University of California Los Angeles, Los Angeles CA, USA
” Department of Endocrinology, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia d Kolling 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 adrenalec- tomy 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 intraoper- ative features of malignancy.
@ 2007 Elsevier Ltd. All rights reserved.
Keywords: Laparoscopic adrenalectomy; Open adrenalectomy; Adrenal tumours
Introduction
Since its introduction in the 1990s, laparoscopic adrenal- ectomy has surpassed open adrenalectomy as the gold stan- dard for excision of benign adrenal lesions. Patients undergoing laparoscopic adrenalectomy benefit from reduc- tions in perioperative morbidity, analgesic requirement, length of hospitalization, and interval to normal dietary in- take, as well as improved cosmetic results when compared to patients undergoing open adrenalectomy.1-5
* 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.
E-mail address: stansidhu@nebsc.com.au (S.B. Sidhu).
Open adrenalectomy is recommended for excision of malignant primary adrenal lesions.6 8 Because the preva- lence of adrenocortical carcinoma varies directly with adre- nal 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 adrenal- ectomy 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 Re- search Ethics Committee. Patients were identified by search- ing 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 the- atre), histological size and histopathology. Laparoscopic ad- renalectomy 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 sta- tistical software package (College Station Texas, USA). Categorical data were analysed using Fisher’s exact test. Continuous data variables were compared using the un- paired t-test. Statistical significance was defined as a two- sided p-value <0.05.
Results
Patient groups
One hundred and forty tumours were removed laparos- copically; 7 underwent laparoscopy converted to open adre- nalectomy 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 indi- cations for surgery are summarized in Table 1.
Twenty-nine of the adrenal tumours resected in this study were ≥60 mm and of these, 16 were resected laparos- copically. Of the 144 adrenal tumours <60 mm, 131 under- went laparoscopic resection. The mean age and weight of the patients and the mean length of operation in the two groups were similar (Table 2).
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.
Complications
Complications developed in 6 patients in the group with tumours <60 mm. These were bleeding in 2, hypotension in 3 and pulmonary atelectasis in 1 patient. In the group with tumours ≥60 mm, 1 patient developed a postoperative
| 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 < 0.001) and for lap v conversion (p < 0.021).
b Operative time significantly less for lap v conversion (p < 0.002) and for open v conversion (p < 0.001).
fever from pulmonary atelectasis and 1 patient required blood transfusion for intraoperative bleeding.
Adrenocortical carcinomas in tumour group ≥60 mm
Of the group with tumours ≥60 mm, 8 patients had ad- renocortical 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 adrenalec- tomy, while 2 had a laparoscopic adrenalectomy and 1 had a laparoscopic converted to open procedure because of lo- cal tumour invasion. Of the patients undergoing open adre- nalectomy, 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 adre- nalectomy are alive without evidence of recurrence, al- though 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
| Laparoscopic adrenalectomy | Open adrenalectomy | ||
|---|---|---|---|
| <60 mm | ≥60 mm | ≥60 mm | |
| 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 <60 mm v laparoscopic adrenalectomy group with tu- mours ≥60 mm is 0.002, laparoscopic adrenalectomy group with tumours <60 mm v open adrenalectomy group with tumours ≥60 mm is 0.965 and for laparoscopic adrenalectomy group with tumours ≥60 mm v open adrenalectomy group with tumours ≥60 mm is 0.003.
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 adrenocorti- cal carcinomas should undergo an open adrenalectomy.6-8 Isolated case reports suggest that laparoscopic adrenalec- tomy for adrenocortical carcinomas may increase the risk of peritoneal dissemination and metastases.11-13 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 adre- nocortical carcinomas increases to 30% in tumours ≥60 mm in size, as was shown in this study and others,14, 14,15 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 adrenalec- tomy. The central controversial question is therefore how to manage adrenal tumours 60-100 mm in size, which are po- tentially malignant, as there is currently no preoperative test which can definitely exclude malignancy. Of the 29 patients with tumours ≥60 mm, eight had adrenocortical car- cinomas. The first 5 patients underwent 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 |
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 recur- rence. 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 con- version to an open procedure.
We found that the complication rate was similar for tu- mours ≥60 mm resected by laparoscopic or open adrenal- ectomy. The length of operation for large adrenal tumours resected laparoscopically, however, was longer than those undergoing open operation (p < 0.003).
In their 11-year experience with 462 adrenalectomies, Palazzo et al. performed laparoscopic adrenalectomy on 19 patients with adrenal tumours ≥60 mm with no preoper- ative or intraoperative evidence of malignancy.17 Eleven of these tumours were classified as either overtly or poten- tially 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 recur- rence detected 54 months after initial surgery. Similarly, Liao et al performed laparoscopic adrenalectomy on 4 ad- renocortical 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 ap- pears 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 lap- aroscopic adrenalectomy.
Conclusion
Our data show that patients with tumours 60-100 mm in size with no preoperative or intraoperative evidence of ma- lignancy can undergo successful laparoscopic adrenalec- tomy without recurrence in short term follow up. Our findings are concordant with the growing body of literature supporting laparoscopic adrenalectomy for potentially ma- lignant tumours ≥60 mm in diameter, without preoperative or intraoperative features of malignancy.
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