Macroscopic Morphology Preoperative Imaging and Surgical Strategy

At the time of surgery, most adrenocortical carcinomas are large tumors, ranging from 5 to 28.5 cm in diameter (average, 12.4 cm) and from 33 to 3100 g in weight (average, 849 g) according to Javadpour.25 In our experience, the largest tumor weighed 4600 g (see Fig. 69-1A and B).

The capsule of these grayish white tumors can be thick or thin. When thin with large superficial veins, the capsule is susceptible to rupture and local seeding. When thick, the capsule sticks to adjacent organs, the liver or the kidney, which may be invaded. Such adhesions may lead to extensive surgery; thus, it is often wiser to search for a plane of cleavage under the liver or the kidney capsule. It is necessary to bear in mind that CT scans often overestimate the local invasion.

Macroscopic venous invasion is common and more often observed on the right side (20% of surgical cases), often encompassing the inferior vena cava. Surgeons should obviously be prepared for this situation. The neoplastic thrombus of an adrenocortical carcinoma invades the venous wall more frequently than a renal adenocarcinoma and can reach up to the right atrium. Assessment or exclusion of venous invasion may influence the surgical strategy, and in some cases it is necessary to use cardiopulmonary bypass. Therefore, careful evaluation of the inferior vena cava, suprahepatic veins, and the right atrium by MRI, Doppler flow studies, and right atrium echography is mandatory. The effectiveness of MRI has eliminated the need for inferior vena cava phlebography.

Involved regional nodes occur in 10% to 45% of cases and should be resected with the tumor. They do not impede the surgical strategy.26

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