Laparoscopic Versus Open Adrenalectomy for Localized/Locally Advanced Primary Adrenocortical Carcinoma (ENSAT I-III) in Adults: Is Margin-Free (R0) Resection the Key Surgical Factor that Dictates Outcome ?- A Review of the Literature
Eustratia Mpaili, MD,1 Demetrios Moris, MD, PhD? Diamantis I. Tsilimigras, MD,” Dimitrios Oikonomou, MD,1 Timothy M. Pawlik, MD, MPH, PhD, Dimitrios Schizas, MD, PHD,1 Alexandros Papalampros, MD, PHD,1 Evangelos Felekouras, MD, PHD,1 and Dimitrios Dimitroulis, MD, PHD3
Abstract
Background: The aim of this study was to review the current literature on the role of laparoscopic adrenal- ectomy (LA) in the treatment of primary adrenocortical carcinoma (ACC; European Network for the Study of Adrenal Tumors [ENSAT] I-III) in adults.
Materials and Methods: Nonrandomized controlled trials published between January 1999 and February 2017 were identified by searching the Pubmed, EMBASE, Cochrane Library, and Google Scholar databases. Primary and secondary endpoints included surgical and pathological parameters (patients age, tumor size, ENSAT stage, type of surgical approach, and period of follow-up), surgical outcomes (operative time, estimated blood loss, length of hospital stay, conversion rate to laparotomy, RO resection, and surgical margin’s status), and onco- logical outcomes (rate of recurrence, disease-free survival [DFS], and overall survival [OS] rates).
Results: A total of 13 studies encompassing data on 1171 patients were included in the review. Compared with open approach, LA demonstrated lower tumor size, shorter operative time, lower intraoperative blood loss, shorter postoperative hospital stay, and equivalent local recurrence rates. No significant differences were observed between groups treated with an open or laparoscopic approach for the following criteria: RO surgical resection status, tumor overall recurrence, and postoperative DFS and OS rates.
Conclusions: LA appears to be equivalent to open method for localized/locally advanced primary ACC (ENSAT I-III) in terms of RO resection rate, overall recurrence, DFS, and OS, therefore suggesting that the extent of surgery with adequate tumor resection is the predominant endpoint, rather than the surgical approach itself. Multicenter randomized controlled trials with long follow-up time periods exploring the long-term oncological outcomes are required to determine the benefits of the laparoscopic over the open approach in adrenocortical carcinoma.
Keywords: adrenocortical cancer, laparoscopic versus open, adrenalectomy, R0 resection, margin status, oncological outcome
Introduction
A DRENOCORTICAL CARCINOMA (ACC) is a rare and ag- gressive endocrine malignancy, with an annual incidence of approximately 1-2/1,000,000 people worldwide accounting
for 0.05%-0.2% of all malignancies. The age distribution is bimodal with a first peak in childhood and a second higher peak in the fourth and fifth decade of life, with a slight female predominance.1,2 Although most ACCs are sporadic, numer- ous hereditary syndromes have been associated with this
1First Department of Surgery, Laikon General Hospital, University of Athens Medical School, Athens, Greece.
2Department of Surgery, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.
3Second Department of Propaedeutic Surgery, Laikon General Hospital, University of Athens Medical School, Athens, Greece.
type of cancer including Beckwith-Wideman syndrome, multiple endocrine neoplasia type 1, Li-Fraumeni, congenital adrenal hyperplasia, familial adenomatous polyposis, and Lynch syndrome.2
In 2004, the World Health Organization (WHO) and Union for International Cancer Control (UICC) introduced the first Tumor, Node, and Metastasis (TNM) staging system for ACC based on the traditional McFarlane classification, modified by Sullivan. This classification system has been recently challenged due to a failure to discriminate between the prognosis of patients classified as Stages II and III. Ra- ther, the newly introduced European Network for the Study of Adrenal Tumors (ENSAT) system has become more widely adopted by the ACC community due to its better stratification of patient outcomes. The ENSAT staging sys- tem defines ACC disease into four stages. Stage I (≤5 cm) and stage II (>5 cm) tumors are confined to the adrenal gland. Stage III tumors extend into surrounding tissue (e.g., para- adrenal adipose tissue or adjacent organs) or involve loco- regional lymph nodes. Stage IV is reserved for patients with distant metastasis, as lung (40%-80%), liver (40%-90%), and bone (5%-20%).5
Although prognosis is certainly dependent on an accurate diagnosis, survival of patients with ACC is mainly associated with both intraoperative findings, and surgical resection technique leading to an RO margin being one of the most important prognostic factors.6-9 When surgical excision is deemed complete, the 5-year survival ranges from 32% to 58%, but when incomplete, the median survival is generally <1 year (range, 2-16 months). Unfortunately, even after an apparent complete resection, local or distant relapse occurs in nearly 80% of patients.
Complete surgical excision with microscopically negative margins is therefore the standard of care for localized/locally advanced disease (ENSAT I-III), leading to palliation of symptoms for patients with functional ACCs, and an in- creased disease-free and overall survival (OS).8,10 Routine regional lymphadenectomy should be considered for all pa- tients with ACC. In addition to surgical therapy, adjuvant treatment consisting of chemotherapeutic regimens with cy- totoxic agents such as single mitotane or combination therapy with streptozocin, etoposide/doxorubicin/cisplatin with or without radiotherapy for patients with high risk tumors such as an R1-R2 resection, in addition to stage III disease and IV metastatic disease. Even patients without these features should be considered for adjuvant therapy since many pa- tients will suffer from tumor recurrence even after seemingly complete removal of ACC.11,12
There is a consensus among the scientific community that radical adrenal surgery for localized/locally advanced primary ACC (ENSAT I-III) provides a chance for a long-term cure. However, throughout the past three decades there is an on- going debate regarding the best surgical approach in such patients. While evidence for invasive-metastatic disease (ENSAT IV) undoubtedly suggests open adrenalectomy (OA), some surgeons have successfully expanded the indications for laparoscopic adrenalectomy (LA) to large, nonfunctioning tumors with a malignant potential and to metastatic lesions given the constantly improved technological advances in the field and the rising technical experience with benign disease. In contrast, other clinicians argue that this approach is abso- lutely contraindicated.
The aim of this study was to review the current literature on the role of LA versus open technique in the surgical man- agement of primary ACC (ENSAT I-III) in adults. In addition, we sought to define the impact of R0 Resection on Recurrence Rate (RR), Disease-Free Survival (DFS), and OS and define its role as the appropriate surgical technique for ACC.
Materials and Methods
Search strategy and data sources
A PubMed, Embase, Cochrane Library, and Google Scholar database search was performed on literature published from January 1999 to February 2017. Only articles published in En- glish and studies with comparative analysis between open and laparoscopic approach were included in this study. The fol- lowing key terms were used to perform the research: “adreno- cortical cancer,” “laparoscopy” or laparoscopic,” “open,” “laparoscopic versus open,” “adrenalectomy,” “RO resec- tion,” “margin status,” and “oncological outcome.” Two in- dependent authors (E.M., D.M.) screened all results retrieved by the aforementioned search strategy. Reference lists of the eli- gible studies and reviews pertinent to our topic were manually assessed to identify potentially eligible articles.
Inclusion criteria
For inclusion in the review, a study had to fulfil the fol- lowing criteria: (1) original studies comparing OA with LA for ACC with at least five cases per each surgical approach in- cluded, (2) if multiple studies were reported by the same in- stitution with overlapping data, the most recent publication was included in the analysis, (3) all titles were screened for articles written in English language, and (4) the surgical pro- cedures were only performed on adult patients (>16 years).
Exclusion criteria
Articles were excluded if (1) they were abstracts, letters, or expert opinions; (2) they reported on adrenalectomy for be- nign lesions, metastatic ACC (ENSAT IV), or recurrence; (3) there was overlap between authors or centers in the published literature; and (4) there were case reports or less than five cases per each surgical approach included.
Data extraction and tabulation
The following parameters were extracted from each study: study demographics (first author, year of publication, study design, study period, country, number of patients included), surgical and pathological parameters (patients age, tumor size, ENSAT stage, type of surgical approach, period of follow-up), surgical outcomes (operative time, estimated blood loss [EBL], length of hospital stay, conversion rate to laparotomy, R0 resection, surgical margins status), and on- cological outcomes (rate of recurrence, DFS and OS rates).
Definitions and statistical analysis
The surgical approach was based on surgeon preference and expertise, and the referral pattern was the same for patients treated with either methodology. The open procedure was, for most of the cases, conducted via anterior subcostal or midline approach, although in few cases was held via posterior or flank approach. Laparoscopic procedure was conducted either via
LAPAROSCOPIC VERSUS OPEN ADRENALECTOMY
trans-peritoneal (lateral-anterior) or via retroperitoneal ap- proach (lateral-posterior).
Complete (R0) surgical resection was the primary endpoint of this review, along with its association with the RR, DFS, and OS and was defined as no evidence of macro- or mi- croscopic residual disease on the basis of surgical reports, histopathologic analysis, and pre- and postoperative imaging. Recurrence was defined as (1) local, when involving the operative site or regional lymph nodes; (2) peritoneal, when evidence of abdominal carcinomatosis existed; or (3) distant. Disease recurrence was diagnosed on the basis of clinical, laboratory, and radiologic evidence without necessarily re- quiring histological confirmation of the recurrence.
DFS was defined as the period from surgery date and first time of recurrence or the date of last follow-up without re- currence. The OS was defined as the period between opera- tion date and the death of the patient or the date of the last follow-up if the patient was still alive. Continuous variables were described using mean (±standard deviation) or median (range).
Results
Selection of studies and study characteristics
The initial search for ACC yielded 3173 records. After initial screening based on title and abstract and removal of duplicates, 149 articles were considered and reviewed fo- cused on surgical approach selected. At the end of the process, 19 studies were reviewed in full text and 13 finally met the predefined eligibility criteria. Among studies in which there was overlapping data, only the study with the most recent information was included in the analysis. An overview of the studies, all published between 2005 and 2016, is provided in Table 1. A total of 1171 patients underwent adrenal surgery with a diagnosis of primary ACC, 910 (77%) underwent OA and 261 (23%) LA. Four of the studies were conducted in the
United States, one both in Israel and Canada, three in France, three in Italy, one in Germany, and one in Norway.
Clinicopathological characteristics
The general characteristics of the surgical groups are de- scribed in Table 2. The mean age of patients at the time of surgery was 46.9 years for the open approach group and 49.4 years for the laparoscopic group. Tumor stage was classified using the ENSAT (2008) classification system with histo- logical confirmation of surgical specimen in combination with preoperative biochemical work-up and imaging along with patients of all stages (I-IV) included in the various studies. Median tumor size was 10.78 cm for OA group and 6.75 cm for LA group.
Operative outcomes
The mean operative time was provided in only five studies (<50%) and ranged from 129 to 272.5 minutes for the open approach and between 133 and 297.5 minutes for the lapa- roscopic approach. One of the studies reported a longer op- erative time both in the OA and LA group.13 The EBL was reported in only four studies and ranged from 550 to 1700 mL in the OA group versus 200 to 1500 mL in the LA group. The conversion rate was documented in nine studies with a mean conversion rate of 11%. The length of hospital stay was re- ported in six studies, with mean hospital stay being 8.25 days in OA group and 4.7 days in the LA group (Table 3).
Surgical and oncological outcomes
Data related to surgical and oncological outcomes are re- ported in Table 4. The margin status leading to complete R0 surgical resection or not, was provided in all but 2 of 13 studies.14,15 Among 910 patients who had an OA for ACC, 896 patients had reported data on resection status and 649 (72%) patients had an (R0). Among the 261 patients who had
| Study (Ref.) | Study design | Country | Year of publication | Study period | No. of patients with ACC | Surgical approach (OA:LA), n (%) |
|---|---|---|---|---|---|---|
| Brix et al.33 | Retrospective case control | Germany | 2010 | 1996-2009 | 152 | 117 (77):35 (23) |
| Cooper et al.30 | Retrospective case control | Texas, United States | 2013 | 1993-2012 | 302 | 256 (85):46 (15) |
| Donatini et al.34 | Retrospective case control | France | 2013 | 1985-2011 | 34 | 21 (61):13 (39) |
| Fossa et al.20 | Retrospective case control | Norway | 2013 | 1998-2011 | 32 | 15 (47):17 (53) |
| Gonzalez et al.40 | Retrospective case control | Texas, United States | 2005 | 1991-2004 | 139 | 133 (95):6 (5) |
| Kirshtein et al.14 | Retrospective case control | Israel, Canada | 2008 | 1995-2005 | 12 | 7 (58):5 (42) |
| Leboulleux et al.29 | Retrospective case control | France | 2010 | 2003-2009 | 64 | 58 (90):6 (10) |
| Lodin et al.15 | Retrospective case control | Italy | 2007 | 1997-2005 | 12 | 7 (58):5 (42) |
| Lombardi et al.32 | Retrospective case control | Italy | 2012 | 2003-2010 | 156 | 126 (80):30 (20) |
| Miller et al.35 | Retrospective case control | Michigan, United States | 2012 | 2005-2011 | 156 | 110 (70):46 (30) |
| Mir et al.13 | Retrospective case control | Cleveland, United States | 2012 | 1993-2011 | 44 | 26 (59):18 (41) |
| Porpiglia et al.38 | Retrospective case control | Italy | 2010 | 2002-2008 | 43 | 25 (58):18 (42) |
| Vanbrugghe et al.37 | Retrospective case control | France | 2016 | 2002-2013 | 25 | 9 (36):16 (64) |
| Total= 13 | 1171 | 910 (77):261 (23) |
ACC, adrenocortical carcinoma; LA, laparoscopic adrenalectomy; OA, open adrenalectomy.
| Study (Ref.) | Mean age (OA:LA), years | Tumor stage (ENSAT) | Tumor size (OA:LA), cm, median | Follow-up (OA:LA), months, median |
|---|---|---|---|---|
| Brix et al.33 | 52.3:50.7 | I-III | 8:6.2 | 32:64 |
| Cooper et al.30 | 46.5:45.8 | I-IV | 12:8 | 35.5:29.2 |
| Donatini et al.34 | 44:46 | I-II | 6.8:5.5 | 57:80 |
| Fossa et al.20 | 52:45 | I-III | 13:8 | 60:60 |
| Gonzalez et al.40 | 46 | I-IV | 13:6 | 28:21 |
| Kirshtein et al.14 | 40:56 | I-IV | 8:4 | NR |
| Leboulleux et al.29 | 54 | I-IV | 14:7.0 | 35 |
| Lodin et al.15 | 47.7:47.4 | I-IV | 8.7:5.8 | NR |
| Lombardi et al.32 | 46.6:52.2 | I-II | 9.04:7.73 | 40:50 |
| Miller et al.35 | 47:50 | I-III | 12.0:7.4 | 29.5:19 |
| Mir et al.13 | 48:53 | I-IV | 13:7 | 31:18 |
| Porpiglia et al.38 | 41.3:47 | I-II | 10.5:9.0 | 38:30 |
| Vanbrugghe et al.37 | 44.31:48.9 | I-III | 11.6:6.2 | 52.9:36.4 |
ENSAT, European Network for the Study of Adrenal Tumors; LA, laparoscopic adrenalectomy; NR, not reported; OA, open adrenalectomy.
an LA for ACC, 251 had reported data on resection status and 182 (72%) had a complete (R0) resection. Overall incidence of recurrence was provided in 11 studies and ranged from 24% to 100% for OA group versus 22% to 100% for the LA group. DFS was reported in 11 studies and ranged from 8.1 to 48.5 months in the open group versus 6.1 to 61.17 months in the laparoscopic group. OS was documented in nine studies and ranged from 36.5 to 103.1 months in the open group versus 27.5 to 108 months in the laparoscopic group.
Discussion
Adrenal surgery has a long history, with the first adrenal- ectomy described in 1889 by Thonton.1 The first successful adrenalectomy was carried out by Mayo and Roux for pheochromocytoma in 1927.2 For decades, multiple changes to adrenal surgery were developed eventually leading to the first LA described by Gagner et al. in 1992.16 The introduc- tion of a minimally invasive approach revolutionized adrenal surgery. Since then, LA has become the gold standard of care for the management of benign adrenal tumors.17 A number of
studies have demonstrated its advantages over laparotomy including reduced blood loss, decreased perioperative com- plications and postoperative pain, shorter recovery time and hospital stay, improved cosmetic result, and more efficient use of healthcare expenditure.” 14,18-20
LA is an established procedure and can be performed using a trans-peritoneal (anterior/lateral) or retroperitoneal (lateral/ dorsal) approach.21 While each approach has its relative ad- vantages and potential limitations, comparative studies had demonstrated no differences in terms of perioperative out- comes.22-24 The recent wide adoption of the robotic surgical system, especially among urologists, has found its way into adrenal surgery. In addition, single-port surgery has gained increased adoption as the latest addition to the minimal in- vasive techniques, as progress is made in skills, instruments, and technology.2 25,26
The basic principle of LA is to perform gentle and elegant dissection of the surrounding tissues away from the adrenal mass avoiding tumor rupture or excessive release of catechol- amines during aggressive manipulation.27 Another principle is the early control of the main adrenal vein to avoid an
| Study (Ref.) | Operative time (OA:LA), minutes | Estimated blood loss (OA:LA), mL | Conversion rate, % | Length of hospital stay (OA:LA), days |
|---|---|---|---|---|
| Brix et al.33 | NR | NR | 34 | NR |
| Cooper et al.30 | NR | NR | NR | NR |
| Donatini et al.34 | NR | NR | 0 | 9:7 |
| Fossa et al.20 | 230:150 | 1700:400 | 11 | 13:6 |
| Gonzalez et al.40 | NR | NR | 16 | NR |
| Kirshtein et al.14 | 170:153 | 550:200 | 7 | 7:2 |
| Leboulleux et al.29 | NR | NR | NR | NR |
| Lodin et al.15 | 161:133 | 1500:900 | 4 | 5.2:4 |
| Lombardi et al.32 | 129:135 | NR | 0 | 9.3:5.3 |
| Miller et al.35 | NR | NR | NR | NR |
| Mir et al.13 | 272.5:297.5 | 1100:1500 | 27 | 6:4 |
| Porpiglia et al.38 | NR | NR | NR | NR |
| Vanbrugghe et al.37 | NR | NR | 0 | NR |
LA, laparoscopic adrenalectomy; NR, not reported; OA, open adrenalectomy.
| Study (Ref.) | R0 resection (OA:LA), n (%) | Overall recurrence rate (OA:LA), n (%) | Local recurrence rate (OA:LA), n (%) | Disease-free survival (OA:LA), months, median (%) | Overall survival (OA:LA), months, median (%) |
|---|---|---|---|---|---|
| Brix et al.33 | 64:24 (55:69) | 81:27 (69:77) | (38:50) | 21.5-24.2 | NR |
| Cooper et al. 30 | 134:25 (52:71) | 87.3:58.7:76.1ª | NRª | 9.5:19.5:10.9ª | 46:109.8:53.5ª |
| Donatini et al.34 | 21:13 (100:100) | 5:4 (24:31) | 2:1 (9:7) | 47:46 | (81:85) |
| Fossa et al.20 | 12:12 (80:70) | 15:12 (100:70) | 1:1 (6:5) | 8.1:15.2 | 36.5:103.6 |
| Gonzalez et al. 40 | 133:6 (100:100) | 115:6 (86:100) | 51:3 (38:50) | 13:NR | 43:NR |
| Kirshtein et al.14 | NR | NR | NR | NR | (5) |
| Leboulleux et al.29 | 37:5 (63:83) | (27:67)b | (72:34) | 20b | (38:5) |
| Lodin et al.15 | NR | NR | NR | Up to 58 | NR |
| Lombardi et al.32 | 126:30 (100:100) | 48:8 (38:26) | 14:4 (11:13) | 48:72 (38.3:58.2) | 60:108 (48:67) |
| Miller et al.35 | 72:26 (65:56) | (40:85.7) | NR | Stage II= 30.5:11.7, Stage III = 13.1:6.1 | Stage II = 103.1:50.9, Stage III: 43.7:27.5 (54:58) |
| Mir et al.13 | 16:11 (61:61) | (27:22)c | 12:10 (46:55) | 13.8:9.7 (60:39) | |
| Porpiglia et al.38 | 25:18 (100:100) | 16:9 (64:50) | 6:6 (24:33) | 18:23 | NR |
| Vanbrugghe et al.37 | 9:12 (100:75) | 4:6 (44.4:37.5) | 0:2 (0:12.5) | 40.45:61.17 (55.6:62.5) | 70.1:67.3 |
ªThree groups OA index:OA outside:LA.
bPeritoneal carcinomatosis.
“Adjustment for stage resulted in statistically significant differences.
LA, laparoscopic adrenalectomy; NR, not reported; OA, open adrenalectomy.
intraoperative hypertensive crisis secondary to catecholamine release. A complete laparoscopic resection (R0) and the use of an entrapment sac for specimen extraction, in addition to wound protection have further made the laparoscopic ap- proach a reliable technique for malignant tumors.2 Nevertheless, the laparoscopic approach has been widely embraced from the clinical community for the management of large, nonfunctioning tumors with high potential for malig- nancy and metastatic lesions.30,31 28,29
Several studies have demonstrated the feasibility, safety, and potential benefits of laparoscopic surgery in the treatment of adrenocortical cancer provided that the surgeon has ade- quate experience and a low threshold for conversion when the local conditions demand it.20,32-34 However, some results are conflicting. 29-31,35
Therefore, in this study, we reviewed the current literature with the aim of summarizing the role of laparoscopic radical adrenalectomy in adrenocortical cancer. The median operative time and the EBL were both lower in LA compared with the open method in most comparative studies. The outcome of lower operative time can be probably explained by the shorter incisional surface and the smaller tumor size in the laparoscopic approach. The reasons for the reduced blood loss in the lapa- roscopic group include less traumatic surface, better visuali- zation and more precise and delicate dissection with the laparoscopic instruments.36 Nevertheless, <50% of the studies provided data with regards to these two variables, thus signif- icant biases may be possible with these observations. Further- more, the duration of hospital stay as an additional important outcome variable, affecting patient satisfaction and cost anal- ysis, was reported in 50% of the studies and was also shorter with laparoscopic approach compared with the standard open technique.
The primary objective of this study was to define data re- garding R0 surgical resection and assess results such as overall the RR, DFS, and OS. Out of 896 patients on undergoing OA for ACC with reported data concerning resection status, a total of 649 were offered a complete (R0) resection (72%). In an amount of 251 patients on undergoing LA for ACC with re- ported data concerning resection status, a total of 182 were offered a complete (R0) resection (72%). Hence, the present review strongly suggests that there is no significant difference between OA and LA approach concerning the achievement of R0 resection throughout the literature. Furthermore, the overall analysis of the RR, DFS, and OS in the present review dis- played no major differences between the OA and LA group, therefore suggesting the safety and efficacy of a laparoscopic versus an open technique.2 20,34,37
Analyzing overall recurrence, DFS, and OS, there is an unambiguous effect of the R0 resection and margin status on these variables (Table 4). Series with high grade of achieve- ment of RO resection are considerably accompanied by lower RR and simultaneously higher DFS and OS rates32,34,37,38 and vice versa. 33 Studies with similar results regarding R0 resec- tion between the two groups, also demonstrate similar results regarding RR, DFS, and OS.13,32,34,37,38 These observations suggest that since R0 resection is achieved, there is no major difference between the OA and LA approach with regards to the outcomes (RR, DFS, and OS) associated with each of the methods.
Some of the studies nevertheless had equivocal results29,35 with higher RR and lower DFS and OS for the LA group,
even though the R0 resection status appeared to be higher or equal with the OA group. This may be related to the low median period of follow-up in these two studies or the inclu- sion of larger and probably of higher malignant potential of tumors resulting in increased overall morbidity and mortality.
It has been advocated in the literature that the pneumo- peritoneum may favor the transit of malignant cells intra- peritoneally and free intraabdominal cancer cell implantation at the wound site or in the abdominal cavity. Aerosolization of tumor cells is therefore considered possible but implies previous tumor disruption during the dissection.29,39 With regards to our observations concerning local/peritoneal re- currence, six out of thirteen studies identified higher rates of recurrence for the laparoscopic group with a decreasing tendency in the more recent studies.33,35,37,38,40,41 This pos- sibly implies that the continuously increasing knowledge on this issue plus the progressive improvement of surgical skills and learning curves can confine this phenomenon, even though it does not appear to affect substantially the overall RR, DFS, and OS reported in the literature.
This study has several limitations. All the included trials were observational with a relatively low total number of patients and their results cannot be generalized to that extent of randomized controlled trials. Moreover, there was het- erogeneity between the two groups since patients character- istics were not always possible to match. In addition, there were few studies with partially reported data regarding on- cological outcomes. Finally, between individual studies, the follow-up time varied significantly.
Conclusions
ACC is a highly malignant tumor of the adrenal cortex necessitating complete surgical excision with microscopi- cally negative margins. LA appears to be equivalent to open method for localized/locally advanced primary ACC (EN- SAT I-III) in terms of RO resection rate, overall recurrence, DFS, and OS, therefore suggesting that the extent of surgery with adequate tumor resection is the predominant endpoint, rather than the surgical approach itself. Multicenter ran- domized controlled trials with long follow- up time periods exploring the long-term oncological outcomes are required to determine the benefits of the laparoscopic over the open ap- proach in ACC.
Disclosure Statement
No competing financial interests exist.
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Address correspondence to: Demetrios Moris, MD, PhD Department of Surgery The Ohio State University Wexner Medical Center Columbus, OH 43210
E-mail: dimmoris@yahoo.com
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