Laparoscopic Adrenalectomy for malignancy by Shabani


									  Laparoscopic Adrenalectomy

Presented by: Hisham Shabani, MD
 Laparoscopic adrenalectomy has become
  the preferred surgical approach for the
  treatment of benign functioning and
  nonfunctioning adrenal disorders
 Less pain, shorter hospitalization and
  convalescence, less operative blood loss and
  need for transfusion, and fewer early and
  late incision complications
 Potentially malignant primary tumors and adrenal
  metastases, once considered contraindications to a
  laparoscopic approach, are now being removed
  laparoscopically in some centers
 In this article, we review the clinical features and
  risk factors for primary and metastatic malignant
  adrenal tumors, and the results of laparoscopic
  adrenalectomy for these lesions
    Primary adrenal neoplasms
 Incidentalomas
 The prevalence of adrenocortical carcinoma
  among incidentalomas is approximately 5%
 Our current approach is to resect adrenal
  incidentalomas larger than 3 cm in young patients
  with low operative risk, and 5 cm or larger in
  older patients with significant comorbidities
 Lesions initially too small to merit resection are
  removed if growth is observed during the follow-
  up period
   Malignancy should be suspected in association
    with the following findings:
   (1) large size
   (2) multiple elaborated hormones, or imaging
    studies demonstrating local or vascular invasion
   (3) adjacent lymphadenopathy
   (4) the presence of metastases
   Imaging studies demonstrating irregular tumor
    margins, heterogeneity, and hyperdensity have
    also been reported to be predictors of malignancy,
    but may also be seen in benign tumors
 Conn’s syndrome
 Primary hyperaldosteronism (Conn’s
  syndrome) due to a cortical adenoma is
  almost never malignant
 A laparoscopic approach has been shown to
  be a safe and effective method for the
  removal of these lesions
   Cushing’s syndrome
   Cortical adrenal adenomas are the most common,
    and account for 15% of cases
   These benign tumors are usually unilateral,
    smaller than 4 cm, and secrete cortisol
   Adrenocortical carcinomas (ACCs) may also be
    responsible for adrenocorticotropic hormone
    (ACTH)-independent Cushing’s syndrome
   They are also usually unilateral, but in contrast to
    adenomas, they are usually larger than 6 cm, and
    may hypersecrete more than one hormone
 Virilizing or feminizing tumors
 One third of these tumors are carcinomas
 Although adrenal neoplasms associated with
  excess sex steroid secretion are not necessarily
  malignant, there should be a high index of
  suspicion for ACC when this syndrome is
 A laparoscopic approach may be appropriate in
  syndromes of sex-steroid excess for lesions
  lacking imaging features suggestive of ACC
   Adrenocortical carcinoma
   Dismal prognosis
   Rare
   50% hormone active
   Adequate imaging is critical for the accurate
    staging of disease and operative planning
   ACCs are usually larger than 6 cm, are
    heterogenous, have irregular margins, are locally
    invasive, and are associated with nodal or liver
 Patients who have a rapid onset of Cushing’s
  syndrome or virilization, feminization (in adult
  men), or the secretion of multiple hormones have
  a higher risk of ACC
 Local disease at diagnosis and complete tumor
  resection are the two most important prognostic
  factors associated with an improved survival
 Recurrent and metastatic disease is common, even
  in patients who undergo complete resection
 Pheochromocytoma
 A diagnosis of malignant pheochromocytoma can
  only be made reliably by the findings of local
  invasion, or nodal or distant metastasis
 Malignant pheochromocytoma is more likely in
  extra-adrenal pheochromocytomas (30%–40%),
  tumors 6 cm or larger, dopamine-only secreting
  tumors, and in patients with postoperative
  persistent hypertension
 In the absence of local invasion or nodal or
  distant metastases on preoperative imaging,
  a laparoscopic approach should be
 The choice of surgical approach is
  dictated by tumor size, signs of local
  invasion, and surgeon experience
 Metastatic adrenal neoplasms
 There is growing evidence that suggests
  resection of isolated, metachronous adrenal
  metastases from various primary cancers
  may improve survival
 Nevertheless, resection of isolated adrenal
  metastases remains controversial, as is the
  role of laparoscopy for these lesions
     Risk assessment for
   malignant adrenal tumors

 Tumor Size
 Imaging Features
 Historyof Malignancy
 Syndrome Association
 Functioning Tumors
               Tumor size

 The current literature suggests that 4 cm is a
  reasonable size threshold for the resection
  of most nonfunctioning cortical tumors
 Although all pheochromocytomas should be
  resected, the exact tumor size threshold that
  is associated with a high risk of a malignant
  tumor is less clear
               Tumor size
 Several reports have shown that imaging
  studies consistently underestimate the true
  size of adrenal neoplasms when compared
  with direct measurement at operation
 CT underestimates tumor size by 16% to
  47%, and appears to be less accurate in
  smaller tumors. MRI may also
  underestimate tumor size by up to 20%
                Tumor size
 Observe nonfunctioning adrenal tumors <3 cm.
  Resect those tumors >= 3 cm in young, healthy
  patients, or those with suspicious imaging
  features, and recommend resection of all
  incidentalomas > = 5 cm.
 Surgeons should not hesitate to convert to an open
  approach when they encounter signs of local
  invasion or any difficulty in dissection that may
  risk incomplete resection or tumor fracture.
           Imaging Features
   Indicators of malignant potential on CT or MRI
   Large tumor size ( >6 cm)
   Irregular tumor margin
   Heterogeneity, hemorrhage, necrosis
   Rapid tumor growth rate
   Adjacent lymphadenopathy
   Density >10 HU on non-contrast CT
          Imaging Features
 Metastases  and local invasion into adjacent
  organs or the vena cava are common
  radiographic features of ACC
 Central necrosis and calcifications are also
  common in ACC, the latter occurring in
  approximately 20% to 30% of cases
            Imaging Features
 Several reports suggest that malignant and
  metastatic lesions of the adrenal can be identified
  by PET scanning, but these studies require further
 Radiocholesterol scintigraphy, using 131I-6-beta-
  iodomethyl-norcholesterol (NP-59), has been used
  to determine if an adrenal cortical tumor is benign
    – Most ACCs have no uptake of NP-59
       History of Malignancy

 Many primary malignancies have the propensity to
  spread to the adrenal glands, including cancers of
  the colon, lung, stomach, breast, kidney,
  melanoma, and lymphoma
 The most common malignant tumor found
  postmortem in the adrenal gland is a metastasis
 Suspicion of an adrenal metastasis is an indication
  for FNA biopsy only when the information gained
  would change the clinical management
       Functioning Tumors

 Approximately 50% of ACC are
  functioning at diagnosis
 The risk of malignancy in functioning
  adrenal cortical neoplasms is variable
 Aldosteronomas are almost always benign
 Catecholamine levels do not distinguish
  benign from malignant pheochromocytomas
       Functioning Tumors
 Cortisol, sex-steroid, or mineralocorticoid
  secreting tumors are more likely than
  aldosteronomas to be malignant, and the
  risk appears to be higher in larger tumors
  and tumors secreting multiple hormones
 The rapid onset of hormonal hypersecretion
  in cortical lesions is more common in ACC
      Syndrome Association
 Malignant pheochromocytomas and ACCs may
  occur sporadically, or as a component of several
  endocrine syndromes
 ACC has been associated with multiple endocrine
  neoplasia type 1 (MEN 1), Beckwith-Widemann
  syndrome, and Li-Fraumeni syndrome
 Pheochromocytomas in patients with familial
  syndromes are more likely to be benign and
  bilateral or multifocal, unless there is a family
  history of malignant pheochromocytoma
       Syndrome Association
 Familial syndromes associated with the
  development of pheochromocytomas include
  MEN 2A and 2B and some neuroectodermal
  syndromes: von Recklinghausen’s
  neurofibromatosis (NF1), von Hippel- Lindau
  syndrome (VHL), Sturge-Weber syndrome, and
  tuberous sclerosis
 Carney’s triad is associated with multifocal extra-
  adrenal pheochromocytomas
    Is fine-needle aspiration
 Disadvantages of this procedure are a high
  false-negative rate and the potential for
  complications, including seeding of the
  needle tract, hemorrhage, or fatal
  hemodynamic instability if the tumor is a
 For these reasons FNA is not recommended
     Is fine-needle aspiration
 Furthermore, the FNA result rarely alters clinical
  decision-making regarding the need for
 FNA may be useful in patients with a history of
  prior malignancy who are found to have a very
  small adrenal lesion that would otherwise be
 FNA may also be indicated when tumors of
  adjacent tissues (eg, retroperitoneal lymphoma or
  sarcoma) are possible diagnoses
     Results of laparoscopic
    adrenalectomy for cancer
 Malignant pheochromocytoma
 There is a lack of data on the long-term
  follow up of patients who have undergone
  laparoscopic adrenalectomy for malignant
 In the prelaparoscopic era, recurrence was
  observed in 6% to 8% of patients
 Following open resection, patients with
  malignant pheochromocytoma have a
  variable disease-free survival
 Recurrence has been reported as late as 24
  years following apparent curative resection
 For this reason, it may be impossible to
  detect a difference in recurrence with
  laparoscopic adrenalectomy
   In addition, a randomized prospective trial
    comparing the two methods is not feasible
    considering the rarity of malignant
    pheochromocytoma, the difficulty in
    accurately diagnosing malignancy
    preoperatively, and the distinct advantages
    of the laparoscopic technique
 Malignant primary cortical tumors (adrenocortical
 Laparoscopic adrenalectomy is controversial for
  potentially malignant adrenal cortical tumors
 The risk of locoregional recurrence, tumor
  dissemination, and port-site metastasis resulting
  from laparoscopic adrenalectomy is unclear,
  because of the limited data in the literature and the
  variable frequencies of these events
 Henry et al reported a series of laparoscopic
  adrenalectomies for tumors larger than 6 cm that
  included six cases of ACC. Half were
  nonfunctioning. At a mean follow up of 34 months
  (range 8–83 months) there was one patient who
  recurred with liver metastases and died. The other
  five patients were disease-free at follow up
 In contrast, Porpiglia and colleagues observed no
  locoregional recurrences or port-site metastases in
  four patients with ACCs who had laparoscopic
 Kebebew experience with laparoscopic
  adrenalectomies for suspected and unsuspected
  malignant adrenal neoplasms, six patients had
  ACCs. In four patients these tumors presented as
  incidentalomas, and in two patients as Cushing’s
  syndrome. One lesion was suspected to be
  malignant preoperatively, and the patient
  underwent open resection following diagnostic
 The mean tumor size in these six patients was 6.6
 In the five patients who underwent laparoscopic
  adrenalectomy, three patients had locoregional
  recurrences and none had port-site metastases,
  with a mean follow up time of 3.3 years
 Although laparoscopic adrenalectomy in their
  series was associated with a high recurrence rate,
  the reported recurrence rate for ACC following
  open resection is approximately 67%
   Most series of open adrenalectomy for ACC
    published before 2000 report a 5-year
    actuarial survival of about 45% (range
    32%–58%) for patients who undergo
    complete resection and a median survival of
    less than 1 year (range 2–16 months) for
    patients who undergo incomplete resection
 There are insufficient data to conclude that the
  results of laparoscopic adrenalectomy for ACC are
  equivalent to those of open adrenalectomy.
 Furthermore, in most reports of laparoscopic
  adrenalectomy for ACC, a cancer diagnosis was
  not established or suspected preoperatively
 Because the ACCs in these reports were localized
  tumors, possibly representing less aggressive
  disease, results may not reflect the true survival
  and risk of locoregional recurrence or port-site
 Metastatic tumors
 Most studies demonstrate a median survival of
  between 20 and 30 months following adrenal
  metastasectomy, as compared with an expected 6
  to 8 months without adrenalectomy
 Nevertheless, resection of isolated adrenal
  metastases remains controversial, as is the role of
  laparoscopic adrenalectomy
   In a series of 37 open adrenalectomies for
    adrenal metastasis from various primary
    tumors, Kim et al [55] observed that
    complete tumor resection conferred a
    survival advantage in patients diagnosed
    after a disease-free interval (DFI) of greater
    than 6 months. The median survival was 21
    months, and the 5-year survival was 24%.
   Sarela et al updated this series with an additional
    41 patients and compared open with laparoscopic
    adrenalectomy (30 open and 11 laparoscopic).
   lung cancer was the most common primary,
    followed by renal cell cancer
   Overall median survival was 28 months, and the
    5-year actuarial survival was 29%
   They found no difference in positive resection
    margin or survival between open and laparoscopic
   No incisional or port-site recurrences
   Found that DFI greater than 6 months was the
    only significant predictor of improved survival
 They recently reviewed their experience in 17
  patients with adrenal metastasis who underwent
  laparoscopic adrenalectomy
 The most frequent primaries were non-small cell
  lung cancer (41%), and renal cell cancer (18%)
 All surgical margins were negative
 At a mean follow-up of 3.3 years, there were no
  locoregional and trocar site recurrences, but there
  were four distant recurrences
   These data show that the laparoscopic approach
    for suspected adrenal metastasis may be both
    diagnostic and therapeutic, and can be used to
    achieve complete tumor resection
   For adrenal metastasis, the indications for
    laparoscopic adrenalectomy may be:
   (1) curative intent for solitary adrenal metastasis
   (2) palliative intent for large symptomatic lesions
   (3) diagnostic
   Most studies show no difference in survival
    or resection margin status between
    laparoscopic and open adrenalectomy
     Caveats to selecting the
    approach to adrenalectomy
 An initial complete resection represents the
  best opportunity to cure patients, and even
  small primary adrenal tumors may be
 Laparoscopic adrenalectomy should be
  cautiously performed, with the goals of
  achieving complete tumor resection without
  disruption of the adrenal capsule
 Laparoscopy should be the initial step in the
  surgical approach to localized primary adrenal
 Laparoscopic techniques can be used to establish
  if the tumor has features suggestive of
  malignancy, such as intraabdominal metastases,
  local invasion, obliterated peri-adrenal tissue
  planes, or regional lymphadenopathy
   Such an approach offers laparoscopic
    adrenalectomy to the majority of patients
    who have a benign primary adrenal tumor,
    while allowing selective conversion to an
    open approach for those with a high
    likelihood of malignancy
   Laparoscopic adrenalectomy is more
    difficult and requires a more experienced
    surgeon when there is a history of prior
    upper abdominal surgery or when tumors
    are larger than 8 or 10 cm
 Most studies show that the results of laparoscopic
  adrenalectomy for cancer are similar to those of
  open adrenalectomy, without the morbidity of an
  open approach
 Although concerns have been raised regarding the
  risks of peritoneal carcinomatosis, local
  recurrence, and port-site metastases following
  laparoscopic adrenalectomy, most larger cohort
  series have not observed an increased frequency of
  these events
 A laparoscopic approach is contraindicated
  for known malignant primary adrenal
  tumors, or those tumors with local or
  vascular invasion
 A laparoscopic approach can be used for
  most incidentalomas, because the risk of a
  primary malignant adrenal tumor is low
 A primary malignant adrenal tumor is more
  likely if the following findings are present:
 (1) large size
 (2) hypersecretion of multiple hormones,
  and imaging studies demonstrating local or
  vascular invasion
 (3) adjacent lymphadenopathy
 (4) the presence of metastases
   Imaging features such as irregular margins,
    heterogeneity, and attenuation coefficients
    >10 HU on noncontrast CT have also been
    cited to be more common in malignancy,
    but may also be seen in benign lesions
   Laparoscopic resection is appropriate in
    selected patients with solitary metastases to
    the adrenal gland from cancers of the lung,
    kidney, colon, breast, and melanoma, and
    the indications for laparoscopic
    metastasectomy should be the same as for
    an open approach

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