Annals of SURGICAL ONCOLOGY OFFICIAL JOURNAL OF THE SOCIETY OF SURGICAL ONCOLOGY
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ASO Author Reflections: Conversion During Attempted Minimally Invasive Adrenalectomy for Adrenocortical Carcinoma: A Cautionary Tale
Olivia M. DeLozier, MD, and Paxton V. Dickson, MD, FACS
Division of Surgical Oncology, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
PAST
Adrenocortical carcinoma (ACC) is an aggressive malignancy for which margin negative resection is critical for cure. Given reports of peritoneal seeding, margin pos- itivity, and decreased survival following minimally invasive adrenalectomy (MIA), open adrenalectomy (OA) is generally recommended for ACC.1,2 Conversely, some have reported equivalent outcomes between MIA and OA in select patients.3,4 There is appeal in a strategy of starting in a minimally invasive way, with a plan to convert to an open procedure if the operation proves difficult. However, the oncologic implications of conversion during attempted MIA for ACC are not extensively reported.
PRESENT
The aim of this study was to identify predictors of conversion and better define its oncologic implications during attempted MIA for ACC. Analysis of 196 patients from the National Cancer Database undergoing attempted MIA for ENSAT stages I-III ACC revealed that 38 (19.4%) required conversion. Predictors of conversion included larger tumor size and right-sided lesions. Exclu- sive of 90-day mortality, patients requiring conversion had significantly worse median overall survival compared with patients having successful MIA. On multivariable analysis among patients who underwent attempted MIA, conversion
was independently associated with an increased risk of death. A comparison of propensity-matched patients revealed that overall survival among those requiring con- version was nearly half that of patients who underwent planned open resection. Patients who required conversion tended to have higher rates of margin positive resection than those who underwent successful MIA and planned OA.5
FUTURE
A noted finding within the analysis was that a robotic approach was independently associated with a lower risk of conversion compared with a laparoscopic approach. However, the robotic approach was employed less fre- quently, limiting a more in-depth analysis. A better understanding of the appropriateness of MIA for ACC might be established in highly selected patients within a controlled, prospective trial utilizing experienced robotic adrenal surgeons. Any such study would need to examine quality metrics such as lymph node evaluation and resec- tion margins in addition to recurrence and survival.
REFERENCES
1. Network, N.C.C. Neuroendocrine and Adrenal Tumors (Version 1. 2019). 18 April 2019. https://www.nccn.org/professional/physicia n_gls/pdf/neuroendcocrine_blocks.pdf.
2. Zeiger MA, Thompson GB, Duh QY, et al. The American Association of Clinical Endocrinologists and American Associa- tion of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract. 2009;15(Suppl 1):1-20.
3. Autorino R, Bove P, De Sio M, et al. Open versus laparoscopic adrenalectomy for adrenocortical carcinoma: a meta-analysis of surgical and oncological outcomes. Ann Surg Oncol. 2016;23(4):1195-1202.
@ Society of Surgical Oncology 2020
First Received: 7 July 2020 Accepted: 8 July 2020
e-mail: pdickso1@uthsc.edu
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):609-615.
5. DeLozier OM, Stiles ZE, Deschner BW, et al. Implications of conversion during attempted minimally invasive adrenalectomy for adrenocortical carcinoma. Ann Surg Oncol. 2020. https://doi. org/10.1245/s10434-020-08824-9.
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