Adrenocortical carcinoma surgery: Difference between revisions

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Revision as of 15:36, 21 September 2017

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

Overview

Surgery is the mainstay of treatment for adrenocortical carcinoma.

Surgery

Surgery is the mainstay of treatment for adrenocortical carcinoma.
Surgery can also be performed even in the case of the invasion into large blood vessels, such as the renal vein or inferior vena cava.
A large percentage of patients are not surgical candidates.

Appropriate preoperative evaluation and operative planning are the most important to assure the best outcome.

Preoperative imaging should be obtained to evaluate the extent of the tumor.

Imaging should be done just before the surgery because ACC grow quickly and involvement of adjacent structures may change

Optimization of hormone excess in patients with functional masses especially those with Cushing’s syndrome

Patients widespread distant metastatic disease in multiple organs or those with multiple metastatic deposits in one organ system unable to be completely resected should not undergo adrenalectomy.

The primary tumor can instead be treated with external beam radiation for palliation along with other adjuncts to improve local symptoms and better control hormone excess,

if present (247).

Obstruction of the vena cava by tumor thrombus can lead to significant lower body edema, which leads to significant patient suffering. If tumor resection is not technically operable, vena cava stents can be placed, leading to temporary prevention of occlusion.

Debulking for control of hormone excess in the setting of known metastatic disease is also performed in some situations. The benefits of debulking must outweigh the risks of surgery in these patients who have poor wound healing and lengthy recovery periods due to preexisting debilitation

Lymph nodes ideally should be removed as part of the en bloc resection. The lymphadenectomy is performed based on the arterial supply of adrenal tumors. 248)
Risk of severe bleeding and benefits of massive removal of lymph nodes should be balanced by surgeons in every case. (249)

Published data comparing the efficacy of LA vs OA for ACC are limited.

Laparoscopic adrenalectomy (LA)	Open adrenalectomy (OA)
LA has shown lower morbidity, less pain, shorter hospital stays, and decreased overall time to recovery when compared with open adrenalectomy Application of laparoscopic instruments can result in the shedding of malignant cells. 246, 251 Local recurrence and peritoneal carcinomatosis were more common in the LA group. Shorter disease-free interval and but with a higher incidence of incomplete resections. Peritoneal carcinomatosis occurred in only 25% Recurrence rate of 86% in the OA group 16% of patients had positive margins.	American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons recommended OA as the procedure of choice (254). Peritoneal spread is 60%with significantly earlier recurrence. 30% of patients had positive margins. Recurrence rate is 100%. (251, 257). 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 (243, 265).
University of Michigan data show the site of first metastasis can also be used to predict survival
Recurrence in the peritoneum outside the tumor bed having the worst survival.
Surgery is indicated in those patients with disease confined to 1 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.
Median survival of 74 months in those undergoing complete second resections vs a median survival of 16 months in those undergoing incomplete second resection. (243, 245).

References

Template:WikiDoc Sources

@@ Line 25: / Line 25: @@
 Debulking for control of hormone excess in the setting of known metastatic disease is also performed in some situations. The benefits of debulking must outweigh the risks of surgery in these patients who have poor wound healing and lengthy recovery periods due to preexisting debilitation
+* Lymph nodes ideally should be removed as part of the en bloc resection. The lymphadenectomy is performed based on the arterial supply of adrenal tumors. 248)
+* Risk of severe bleeding and benefits of massive removal of lymph nodes should be balanced by surgeons in every case. (249)
+Published data comparing the efficacy of LA vs OA for ACC are limited.
+{| class="wikitable"
+!Laparoscopic adrenalectomy (LA)
+!Open adrenalectomy (OA)
+|-
+|
+* LA has shown lower morbidity, less pain, shorter hospital stays, and decreased overall time to recovery when compared with open adrenalectomy
+* Application of laparoscopic instruments can result in the shedding of malignant cells. 246, 251
+* Local recurrence and peritoneal carcinomatosis were more common in the LA group.
+* Shorter disease-free interval and but with a higher incidence of incomplete resections.
+* Peritoneal carcinomatosis occurred in only 25%
+* Recurrence rate of 86% in the OA group
+* 16% of patients had positive margins.
+|
+* American Association of Clinical Endocrinologists and the American Association of Endocrine Surgeons recommended OA as the procedure of choice (254).
+* Peritoneal spread is 60%with significantly earlier recurrence.
-'''''1.  Surgical approach'''''
+* 30% of patients had positive margins.
-'''''Adrenalectomy'''''
+* Recurrence rate is 100%. (251, 257).
+* Survival for patients with stage 2 was longer in those undergoing OA
+|}
+==== '''''Surgical approach''''' ====
 . Incision and exploration of the peritoneal cavity.
@@ Line 52: / Line 73: @@
 . Dictate operative report
-'''''2.  Lymph node dissection'''''
+==== '''''Recurrence of ACC''''' ====
+* The number of organs involved by tumor at the time of the first metastasis is a predictor of survival (243, 265).
-The role of lymph node sampling or formal regional
+* University of Michigan data show the site of first metastasis can also be used to predict survival
+* Recurrence in the peritoneum outside the tumor bed having the worst survival.
-lymph node dissection in the treatment of ACC remains
+* Surgery is indicated in those patients with disease confined to 1 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.
-unknown (248). the lymphadenectomy is performed based on following the arterial supply of adrenal tumors
+* Median survival of 74 months in those undergoing complete second resections vs a median survival of 16 months in those undergoing incomplete second resection. (243, 245).
-Because lymph nodes ideally should be removed as part of
-the en bloc resection, surgeons need to individually balance
-the increased risk due to extended surgery (eg, bleeding)
-with the presumed benefit of radical lymph node dissection.
-regional lymph node dissection improved tumor
-staging ability and led to a more favorable oncological
-outcome in patients with otherwise localized ACC. (249)
-'''''3. Open vs laparoscopic surgery'''''
-LA has
-become the gold standard for resection of benign adrenal
-masses, and it has been shown to result in significantly
-lower morbidity, less pain, shorter hospital stays, and decreased
-overall time to recovery when compared with
-open adrenalectomy (OA).
-Application of laparoscopic instruments to the tumor
-can result in shedding of malignant cells that is undetectable
-to the operating surgeon.
-Minimizing direct contact with the tumor
-surface is important so as not to abrade cells from the
-tumor surface or enter the tumor capsule.
-Some surgeons compromise by initiating adrenalectomies
-laparoscopically to assess for evidence of intraperitoneal
-metastasis or invasion of the adrenal gland into
-other organs (246, 251).
-Published data comparing the efficacy of LA vs OA for
-ACC are limited.
-At least 7 studies have been published since 2010 that
-specifically address the topic of LA vs OA for ACC.
-Two studies published by the M.D. Anderson Cancer Center
-reported a recurrence rate of 86% in the OA group (154
-patients) and 100% in the LA group (6 patients) (251,
-). Recent recommendations
-by the American Association of Clinical Endocrinologists
-and the American Association of Endocrine
-Surgeons advocate OA by an experienced surgeon as the
-procedure of choice (254).  Conversely, the European Society
-of Endocrine Surgeons and European Society for
-Medical Oncology suggest LA could be performed for
-stage 1 and 2 ACC tumors less than 8 or 10 cm if an R0
-resection is performed and surrounding periadrenal tissue
-removed (255, 256).
-Local recurrence and peritoneal carcinomatosis was
-more common in the LA group. In a study by Leboulleux
-et al (258), peritoneal carcinomatosis occurred in only
-% of patients treated by OA, as opposed to 60% of
-patients who underwent LA.
-In contrast, other studies reported evidence that LA
-may be comparable to OA in patients with stage 1 and 2
-ACC based on no significant difference in recurrence-free
-survival (259, 260).
-Surgical studies should focus on local and peritoneal
-recurrence as indicators of quality of surgical resection,
-because type of operative approach likely has a much
-smaller role in the development of distant metastases. A
-retrospective study from the University of Michigan reviewed
-ACC patients, 17 of whom underwent LA, and
-% of the operations were performed at outside facilities,
-and no laparoscopic operations for ACC were performed
-at the University of Michigan, potentially introducing
-a referral bias (262). Although overall recurrence
-rates were similar and despite on average smaller tumors
-in the LA group (7.0 cm) compared with the OA group
-(12.3 cm), the LA group had a significantly earlier recurrence
-(9.2 vs 19.2 months). Furthermore, there were more
-R1 or R2 resections or notation of intraoperative tumor
-spill (50% vs 18%). These data suggest that although LA
-may be technically feasible (even for large tumors) (263,
-), the use of LA in ACC leads to a shorter disease-free
-interval and a higher incidence of incomplete resections.
-These results were confirmed in an extended follow-up
-study of 110 patients undergoing OA and 46 undergoing
-LA. After LA,30%had positive margins or intraoperative
-tumor spill compared with 16% of OA patients despite
-larger tumors and more stage 3 tumors. Overall survival
-for patients with stage 2 ACC was longer in those undergoing
-OA, and time to visible tumor bed recurrence or
-peritoneal recurrence in stage 2 patients was shorter in LA
-patients.
-In summary, existing data are inconclusive and more
-studies are needed to better judge the equivalence of LA to
-OA. In accordance with the experience gained at the authors’
-institution, a conservative approach using an open
-approach is recommended for all adrenocortical lesions
-that cannot be classified as benign before surgery.
-'''''4. Surgery for recurrent disease'''''
-Extent of disease and tempo of disease progression
-guide the decision for reoperation in the setting of recurrence.
-The number of organs involved by tumor at the time
-of the first metastasis is a predictor of survival (243, 265).
-In addition, University of Michigan data show the site of
-first metastasis can also be used to predict survival,
-with those having tumor recurrence in the peritoneum outside
-the tumor bed having the worst survival.
-Surgery is indicated in those patients with disease confined to 1 site or organ.
-Beyond that, decisions regarding resection must be individualized. The type of initial operative resection is important to the decision-making process for reoperation.
-Patients with tumor bed recurrence who have undergone
-LA are much more likely to have disease too small to be
-detected by imaging elsewhere in the peritoneal cavity
-compared with those having undergone OA based on our
-experience.
-median survival of 74 months (5-year survival, 57%) in those undergoing complete second resections vs a median survival of 16 months (5-year survival, 0%) in those undergoing incomplete second resection. tumor grade nor additional nonsurgical treatment
-Tumor grade influences the decision for reoperation
-because it correlates with survival (243, 245).
-In those with low-grade tumors, tempo of disease progression can be slower and lead to longer survival with resection of sites of recurrence or metastasis.
-those patients with high-grade tumors, other sites of disease often appear quickly.
-wait 3 months while treating with chemotherapy to assess for tumor responsiveness and/or tempo of progression. If progression is not rapid, surgery may proceed with greater benefit, whereas those with evidence of
 ==References==