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ASO Author Reflections: Minimally Invasive Versus Open Adrenalectomy in Patients with Adrenocortical Carcinoma: A Meta-analysis
Xu Hu, MD, and Xiang Li, MD
Department of Urology, West China Hospital, West China Medical School, Sichuan University, Chengdu, People’s Republic of China
PAST
Adrenocortical carcinoma (ACC) is a rare but aggres- sively malignant endocrine tumor. ACC can lead to the rapid development of locoregional invasion and distant metastasis, so the prognosis of ACC patients is poor. Local recurrence may be associated with inadequate pri- mary surgery, and there are few additional effective therapies for this disease. Therefore, complete resection of the tumor is the cornerstone and curative treatment modality for ACC patients.2 Open adrenalectomy (OA) with regional lymph node dissection (LND) is usually considered to be the best surgical treatment, because it can provide maximum exposure, thus reduce the possibility of tumor spillage, facilitate complete resection, and improve margin control.1,2 In addition, when necessary, it can allow for vascular control. However, open surgery is mostly associated with greater trauma, increased risk of postop- erative complications, and longer recovery time.
PRESENT
Laparoscopic adrenalectomy (LA) has been widely performed for benign adrenal tumors. Robotic-assisted adrenalectomy has also been introduced. Minimally inva- sive adrenalectomy (MIA), including LA and robotic- assisted adrenalectomy, is reported to be associated with less trauma, reduced pain, and decreased postoperative
complications.3 With the development of surgical tech- niques and the accumulation of evidence, some centers propose MIA as an alternative treatment for ACC patients. However, this remains controversial due to the oncological outcomes. For instance, a multi-institutional study of 201 patients demonstrated the surgical approach was not asso- ciated with survival and MIA could be performed for the patients with ACC ≤ 10 cm.3 Brix et al.4 enrolled 152 patients and also found LA and OA did not differ with regard to disease-specific survival and recurrence-free survival in patients with stage I-III ACC with a tumor ≤ 10 cm. However, Miller et al.5 included 156 ACC patients and observed OA is superior to LA regarding survival. In the present study, there was no significant difference in survival outcomes between MIA and OA, while MIA was associated with fewer postoperative com- plications and faster rehabilitation.6 MIA might be offered for selected ACC cases and performed by surgeons with appropriate laparoscopic expertise, ensuring improved survival for patients. However, MIA is not expressly rec- ommended for ACC.
FUTURE
There has been no randomized controlled study that compares MIA and OA in ACC patients. And most pub- lished studies had a short follow-up time and a small sample size. Hence, a further prospective randomized study with a large scale is obligatory. Also, longer follow-up is important to make long-term clinical outcomes available. The criteria to select a case for MIA remain unclear, and this needs to be explored further. Additionally, there are few effective treatments for advanced and recurrent dis- eases; thus, more relevant clinical trials should be performed. Hopefully, future studies will provide surgeons
@ Society of Surgical Oncology 2020
First Received: 24 March 2020
X. Li, MD e-mail: hx_uro@sina.com
with more useful information. Using such data, as well as current data, surgeons would be able to choose the optimal surgical approach conducted in an oncologically appro- priate manner to ensure improved survival.
DISCLOSURE The authors declare that they have no conflicts of interest to disclose.
REFERENCES
1. Ranvier GG, Inabnet WB 3rd. Surgical management of adreno- cortical carcinoma. Endocrinol Metab Clin N Am. 2015;44(2):435-52.
2. Fassnacht M, Dekkers OM, Else T, et al. European society of endocrinology clinical practice guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2018;179(4):G1-46.
3. Lee CW, Salem AI, Schneider DF, et al. Minimally invasive resection of adrenocortical carcinoma: a multi-institutional study of 201 patients. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2017;21(2):352-62.
4. Brix D, Allolio B, Fenske W, et al. Laparoscopic versus open adrenalectomy for adrenocortical carcinoma: surgical and onco- logic outcome in 152 patients. Eur Urol. 2010;58(4):609-15.
5. Miller BS, Gauger PG, Hammer GD, Doherty GM. Resection of adrenocortical carcinoma is less complete and local recurrence occurs sooner and more often after laparoscopic adrenalectomy than after open adrenalectomy. Surgery. 2012;152(6):1150-7.
6. Hu X, Yang WX, Shao YX, Dou WC, Xiong SC, Li X. Minimally invasive versus open adrenalectomy in patients with adrenocortical carcinoma: a meta-analysis. Ann Surg Oncol. 2020. https://doi.org/ 10.1245/s10434-020-08454-1.
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