Adrenocortical carcinoma surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2] Mohammed Abdelwahed M.D[3]

Overview

Surgery is the mainstay of treatment for adrenocortical carcinoma. Appropriate preoperative evaluation and operative planning are really important to assure the best outcome. Lymph nodes should be removed as part of the en bloc resection. Recurrence in the peritoneum outside the tumor bed has the worst survival. Surgery is indicated in those patients with disease confined to one site or organ.

Surgery

Laparoscopic adrenalectomy (LA) Open adrenalectomy (OA)
  • American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons recommended OA as the procedure of choice.[7]
  • The peritoneal spread is 60% with significant earlier recurrence.
  • 30% of patients had positive margins.
  • Recurrence rate of 86% in the OA group.
  • Survival for patients with stage 2 was longer in those undergoing OA.

Surgical approach

1. Incision and exploration of the peritoneal cavity.

2. Evaluation of liver for metastasis.

3. Containment: a self-retaining retractor system with towels or laparotomy pads should be placed in such a way as to exclude the rest of the peritoneal cavity from the area of the tumor and other organs requiring resection.

4. Mobilization of organs adjacent to tumor.

5. En bloc resection. Preserve any tissue overlying the tumor.

6. Regional lymphadenectomy.

7. Provide intact en bloc specimen for pathologic review.

8. Mark field to facilitate postsurgical external beam radiation therapy.

9. Dictate operative report.

Recurrence of ACC

  • The number of organs involved by tumor at the time of the first metastasis is a predictor of survival.[8]
  • University of Michigan data shows the site of first metastasis can also be used to predict the survival.
  • Recurrence in the peritoneum outside the tumor bed has the worst survival.
  • Surgery is indicated in those patients with disease confined to one site or organ.
  • Waiting 3 months while treating with chemotherapy to assess for tumor responsiveness of progression. If progression is not rapid, surgery may proceed with greater benefit.[4]
  • The median survival of 74 months in those undergoing complete second resections and a median survival of 16 months in those undergoing incomplete second resection.[9]

Video shows laparoscopic retroperitoneal adrenalectomy

References

  1. Sabolch A, Feng M, Griffith K, Hammer G, Doherty G, Ben-Josef E (2011). "Adjuvant and definitive radiotherapy for adrenocortical carcinoma.". Int J Radiat Oncol Biol Phys. 80 (5): 1477–84. PMID 20675074. doi:10.1016/j.ijrobp.2010.04.030. 
  2. Gaujoux S, Brennan MF (2012). "Recommendation for standardized surgical management of primary adrenocortical carcinoma.". Surgery. 152 (1): 123–32. PMID 22306837. doi:10.1016/j.surg.2011.09.030. 
  3. Reibetanz J, Jurowich C, Erdogan I, Nies C, Rayes N, Dralle H; et al. (2012). "Impact of lymphadenectomy on the oncologic outcome of patients with adrenocortical carcinoma.". Ann Surg. 255 (2): 363–9. PMID 22143204. doi:10.1097/SLA.0b013e3182367ac3. 
  4. 4.0 4.1 Miller BS, Gauger PG, Hammer GD, Doherty GM (2012). "Resection of adrenocortical carcinoma is less complete and local recurrence occurs sooner and more often after laparoscopic adrenalectomy than after open adrenalectomy.". Surgery. 152 (6): 1150–7. PMID 23158185. doi:10.1016/j.surg.2012.08.024. 
  5. Gonzalez RJ, Shapiro S, Sarlis N, Vassilopoulou-Sellin R, Perrier ND, Evans DB; et al. (2005). "Laparoscopic resection of adrenal cortical carcinoma: a cautionary note.". Surgery. 138 (6): 1078–85; discussion 1085–6. PMID 16360394. doi:10.1016/j.surg.2005.09.012. 
  6. Grubbs EG, Callender GG, Xing Y, Perrier ND, Evans DB, Phan AT; et al. (2010). "Recurrence of adrenal cortical carcinoma following resection: surgery alone can achieve results equal to surgery plus mitotane.". Ann Surg Oncol. 17 (1): 263–70. PMID 19851811. doi:10.1245/s10434-009-0716-x. 
  7. Zeiger MA, Thompson GB, Duh QY, Hamrahian AH, Angelos P, Elaraj D; et al. (2009). "American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons Medical Guidelines for the Management of Adrenal Incidentalomas: executive summary of recommendations.". Endocr Pract. 15 (5): 450–3. PMID 19632968. doi:10.4158/EP.15.5.450. 
  8. Erdogan I, Deutschbein T, Jurowich C, Kroiss M, Ronchi C, Quinkler M; et al. (2013). "The role of surgery in the management of recurrent adrenocortical carcinoma.". J Clin Endocrinol Metab. 98 (1): 181–91. PMID 23150691. doi:10.1210/jc.2012-2559. 
  9. Assié G, Antoni G, Tissier F, Caillou B, Abiven G, Gicquel C; et al. (2007). "Prognostic parameters of metastatic adrenocortical carcinoma.". J Clin Endocrinol Metab. 92 (1): 148–54. PMID 17062775. doi:10.1210/jc.2006-0706. 



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