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Implications of Conversion during Attempted Minimally Invasive Adrenalectomy for Adrenocortical Carcinoma

  • Endocrine Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Although advocated by some, minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) is controversial. Moreover, the oncologic implications for patients requiring conversion to an open procedure during attempted MIA for ACC are not extensively reported.

Patients and Methods

The National Cancer Database was queried for patients undergoing resection for ACC. Overall survival (OS) for patients undergoing successful MIA was compared with those requiring conversion, and additionally evaluated with a multivariable Cox regression analysis including other factors associated with OS. After propensity matching, those experiencing conversion were further compared with patients who underwent planned open resection.

Results

Among 196 patients undergoing attempted MIA for ACC, 38 (19.4%) required conversion. Independent of 90-day postoperative mortality, conversion was associated with significantly reduced OS compared with successful MIA (median 27.9 months versus not reached, p = 0.002). Even for tumors confined to the adrenal, conversion was associated with worse median OS compared with successful MIA (median 34.2 months versus not reached, p = 0.003). After propensity matching for clinicopathologic covariates to establish well-balanced cohorts (N = 38 per group), patients requiring conversion during MIA had significantly worse OS than those having planned open resection (27.9 months versus 50.5 months, p = 0.020). On multivariable analysis for predictors of OS, conversion during MIA (HR 2.32, p = 0.003) was independently associated with mortality.

Conclusions

ACC is a rare tumor for which adequate oncologic resection is the only chance for cure. Given the relatively high rate of conversion and its associated inferior survival, open resection should be considered standard of care for known or suspected ACC.

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References

  1. Gagner M, Lacroix A, Bolte E. Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med. 1992;327(14):1033.

    CAS  PubMed  Google Scholar 

  2. Fassnacht M, Arlt W, Bancos I, et al. Management of adrenal incidentalomas: European Society of Endocrinology Clinical Practice Guideline in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol. 2016;175(2):G1–G34.

    CAS  PubMed  Google Scholar 

  3. Network NCC. Neuroendocrine and adrenal tumors (Version 1. 2019). https://www.nccn.org/professional/physician_gls/pdf/neuroendcocrine_blocks.pdf. Accessed 18 Apr 2019.

  4. Stefanidis D, Goldfarb M, Kercher KW, et al. SAGES guidelines for minimally invasive treatment of adrenal pathology. Surg Endosc. 2013;27(11):3960–80.

    PubMed  Google Scholar 

  5. Zeiger MA, Thompson GB, Duh QY, et al. The American Association of Clinical Endocrinologists and American Association of Endocrine Surgeons medical guidelines for the management of adrenal incidentalomas. Endocr Pract. 2009;15 Suppl 1:1–20.

    PubMed  Google Scholar 

  6. Gonzalez RJ, Shapiro S, Sarlis N, et al. Laparoscopic resection of adrenal cortical carcinoma: a cautionary note. Surgery. 2005;138(6):1078–85. (discussion 1085–1076).

    PubMed  Google Scholar 

  7. Cooper AB, Habra MA, Grubbs EG, et al. Does laparoscopic adrenalectomy jeopardize oncologic outcomes for patients with adrenocortical carcinoma? Surg Endosc. 2013;27(11):4026–32.

    PubMed  Google Scholar 

  8. Leboulleux S, Deandreis D, Al Ghuzlan A, et al. Adrenocortical carcinoma: is the surgical approach a risk factor of peritoneal carcinomatosis? Eur J Endocrinol. 2010;162(6):1147–53.

    CAS  PubMed  Google Scholar 

  9. Mir MC, Klink JC, Guillotreau J, et al. Comparative outcomes of laparoscopic and open adrenalectomy for adrenocortical carcinoma: single, high-volume center experience. Ann Surg Oncol. 2013;20(5):1456–61.

    PubMed  Google Scholar 

  10. Sgourakis G, Lanitis S, Kouloura A, et al. Laparoscopic versus open adrenalectomy for stage I/II adrenocortical carcinoma: meta-analysis of outcomes. J Invest Surg. 2015;28(3):145–52.

    PubMed  Google Scholar 

  11. Brix D, Allolio B, Fenske W, et al. Laparoscopic versus open adrenalectomy for adrenocortical carcinoma: surgical and oncologic outcome in 152 patients. Eur Urol. 2010;58(4):609–15.

    PubMed  Google Scholar 

  12. Lombardi CP, Raffaelli M, De Crea C, et al. Open versus endoscopic adrenalectomy in the treatment of localized (stage I/II) adrenocortical carcinoma: results of a multiinstitutional Italian survey. Surgery. 2012;152(6):1158–64.

    PubMed  Google Scholar 

  13. Porpiglia F, Fiori C, Daffara F, et al. Retrospective evaluation of the outcome of open versus laparoscopic adrenalectomy for stage I and II adrenocortical cancer. Eur Urol. 2010;57(5):873–8.

    PubMed  Google Scholar 

  14. Bellantone R, Lombardi CP, Raffaelli M. What is the appropriate role of minimally invasive versus open surgery for small adrenocortical cancers? Curr Opin Oncol. 2015;27(1):44–9.

    PubMed  Google Scholar 

  15. 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):1195–202.

    PubMed  Google Scholar 

  16. Langenhuijsen J, Birtle A, Klatte T, Porpiglia F, Timsit MO. Surgical management of adrenocortical carcinoma: impact of laparoscopic approach, lymphadenectomy, and surgical volume on outcomes-a systematic review and meta-analysis of the current literature. Eur Urol Focus. 2016;1(3):241–50.

    PubMed  Google Scholar 

  17. Henry JF, Peix JL, Kraimps JL. Positional statement of the European Society of Endocrine Surgeons (ESES) on malignant adrenal tumors. Langenbecks Arch Surg. 2012;397(2):145–6.

    PubMed  Google Scholar 

  18. Sturgeon C, Shen WT, Clark OH, Duh QY, Kebebew E. Risk assessment in 457 adrenal cortical carcinomas: how much does tumor size predict the likelihood of malignancy? J Am Coll Surg. 2006;202(3):423–30.

    PubMed  Google Scholar 

  19. Saunders BD, Doherty GM. Laparoscopic adrenalectomy for malignant disease. Lancet Oncol. 2004;5(12):718–26.

    PubMed  Google Scholar 

  20. Lee CW, Salem AI, Schneider DF, et al. Minimally invasive resection of adrenocortical carcinoma: a multi-institutional study of 201 patients. J Gastrointest Surg. 2017;21(2):352–62.

    PubMed  Google Scholar 

  21. Huynh KT, Lee DY, Lau BJ, Flaherty DC, Lee J, Goldfarb M. Impact of laparoscopic adrenalectomy on overall survival in patients with nonmetastatic adrenocortical carcinoma. J Am Coll Surg. 2016;223(3):485–92.

    PubMed  Google Scholar 

  22. Winoker JS, Ahlborn DT, Omidele OO, Fernandez-Ranvier G, Derweesh IH, Mehrazin R. Minimally invasive adrenal surgery: Virtue or vice? Future Oncol. 2018;14(3):267–76.

    CAS  PubMed  Google Scholar 

  23. Lee JE, Berger DH, elNaggar AK, et al. Surgical management, DNA content, and patient survival in adrenal cortical carcinoma. Surgery. 1995;118(6):1090–98.

    CAS  PubMed  Google Scholar 

  24. Schulick RD, Brennan MF. Long-term survival after complete resection and repeat resection in patients with adrenocortical carcinoma. Ann Surg Oncol. 1999;6(8):719–26.

    CAS  PubMed  Google Scholar 

  25. Grubbs EG, Callender GG, Xing Y, et al. Recurrence of adrenal cortical carcinoma following resection: surgery alone can achieve results equal to surgery plus mitotane. Ann Surg Oncol. 2010;17(1):263–70.

    PubMed  Google Scholar 

  26. Bilimoria KY, Shen WT, Elaraj D, et al. Adrenocortical carcinoma in the United States: treatment utilization and prognostic factors. Cancer. 2008;113(11):3130–6.

    PubMed  Google Scholar 

  27. Fassnacht M, Johanssen S, Quinkler M, et al. Limited prognostic value of the 2004 International Union against cancer staging classification for adrenocortical carcinoma: proposal for a revised TNM classification. Cancer. 2009;115(2):243–50.

    PubMed  Google Scholar 

  28. Donatini G, Caiazzo R, Do Cao C, et al. Long-term survival after adrenalectomy for stage I/II adrenocortical carcinoma (ACC): a retrospective comparative cohort study of laparoscopic versus open approach. Ann Surg Oncol. 2014;21(1):284–91.

    PubMed  Google Scholar 

  29. Fossa A, Rosok BI, Kazaryan AM, et al. Laparoscopic versus open surgery in stage I-III adrenocortical carcinoma—a retrospective comparison of 32 patients. Acta Oncol. 2013;52(8):1771–7.

    PubMed  Google Scholar 

  30. Calcatera NA, Hsiung-Wang C, Suss NR, Winchester DJ, Moo-Young TA, Prinz RA. Minimally invasive adrenalectomy for adrenocortical carcinoma: five-year trends and predictors of conversion. World J Surg. 2018;42(2):473–81.

    PubMed  Google Scholar 

  31. NIH state-of-the-science statement on management of the clinically inapparent adrenal mass (“incidentaloma”). NIH Consens State Sci Statements. 2002;19(2):1–25.

  32. Abdel-Aziz TE, Rajeev P, Sadler G, Weaver A, Mihai R. Risk of adrenocortical carcinoma in adrenal tumours greater than 8 cm. World J Surg. 2015;39(5):1268–73.

    PubMed  Google Scholar 

  33. Mendiratta-Lala M, Avram A, Turcu AF, Dunnick NR. Adrenal imaging. Endocrinol Metab Clin North Am. 2017;46(3):741–59.

    PubMed  Google Scholar 

  34. Dickson PV, Kim L, Yen TWF, et al. Evaluation, staging, and surgical management for adrenocortical carcinoma: an update from the SSO endocrine and head and neck disease site working group. Ann Surg Oncol. 2018;25(12):3460–68.

    PubMed  Google Scholar 

  35. Pantalone KM, Gopan T, Remer EM, et al. Change in adrenal mass size as a predictor of a malignant tumor. Endocr Pract. 2010;16(4):577–87.

    PubMed  Google Scholar 

  36. Ng L, Libertino JM. Adrenocortical carcinoma: diagnosis, evaluation and treatment. J Urol. 2003;169(1):5–11.

    PubMed  Google Scholar 

  37. Ayala-Ramirez M, Jasim S, Feng L, et al. Adrenocortical carcinoma: clinical outcomes and prognosis of 330 patients at a tertiary care center. Eur J Endocrinol. 2013;169(6):891–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  38. Porpiglia F, Miller BS, Manfredi M, Fiori C, Doherty GM. A debate on laparoscopic versus open adrenalectomy for adrenocortical carcinoma. Horm Cancer. 2011;2(6):372–7.

    PubMed  Google Scholar 

  39. Gaujoux S, Jurowich C, Menegaux F, Mussack T, Porpiglia F, Dousset B. The importance of national cooperation and centralized surgery for adrenocortical surgery. Surgery. 2013;153(2):301.

    PubMed  Google Scholar 

  40. Hermsen IG, Kerkhofs TM, den Butter G, et al. Surgery in adrenocortical carcinoma: Importance of national cooperation and centralized surgery. Surgery. 2012;152(1):50–6.

    PubMed  Google Scholar 

  41. Kerkhofs TM, Verhoeven RH, Bonjer HJ, et al. Surgery for adrenocortical carcinoma in The Netherlands: analysis of the national cancer registry data. Eur J Endocrinol. 2013;169(1):83–9.

    CAS  PubMed  Google Scholar 

  42. Fassnacht M, Johanssen S, Fenske W, et al. Improved survival in patients with stage II adrenocortical carcinoma followed up prospectively by specialized centers. J Clin Endocrinol Metab. 2010;95(11):4925–32.

    CAS  PubMed  Google Scholar 

  43. Gratian L, Pura J, Dinan M, et al. Treatment patterns and outcomes for patients with adrenocortical carcinoma associated with hospital case volume in the United States. Ann Surg Oncol. 2014;21(11):3509–14.

    PubMed  PubMed Central  Google Scholar 

  44. Lombardi CP, Raffaelli M, Boniardi M, et al. Adrenocortical carcinoma: effect of hospital volume on patient outcome. Langenbecks Arch Surg. 2012;397(2):201–7.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Division of Surgical Oncology, University of Tennessee Health Science Center, Memphis, TN, USA

    Olivia M. Delozier MD, Zachary E. Stiles DO, Benjamin W. Deschner MD, Justin A. Drake MD, Jeremiah L. Deneve DO, Evan S. Glazer MD, PhD, Miriam W. Tsao MD, Danny Yakoub MD, PhD & Paxton V. Dickson MD, FACS

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  2. Zachary E. Stiles DO
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Delozier, O.M., Stiles, Z.E., Deschner, B.W. et al. Implications of Conversion during Attempted Minimally Invasive Adrenalectomy for Adrenocortical Carcinoma. Ann Surg Oncol 28, 492–501 (2021). https://doi.org/10.1245/s10434-020-08824-9

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