Adrenalectomy For Adrenocortical Carcinoma

Adrenocortical carcinoma is a rare disease with estimated 75 to 115 new cases a year in the United States (21). The staging system commonly used for adrenocortical carcinoma is shown in Table 1 (22). In this staging system, stages I and II include tumors localized to the adrenal gland, while stages, III and IV include tumors with local or distant spread, respectively. In a review of 602 patients from seven institutions, Ng and Libertino (23) found five-year survival based on stage as: stage I, 30% to 45%; stage II, 12.5% to 57%; stage III, 5% to 18%; and stage IV, 0%. Median survival was shorter in patients with unresectable tumors (3-9 months) as compared to those with complete surgical resection (13-28 months).

Stage appears to be one of the best prognostic indicators of survival. Specifically, those with localized disease (stage I or II) tend to have the best outcome after surgical resection (24,25).

The primary therapy for adrenocortical carcinoma is surgical en bloc removal of the tumor. However, even with complete resection, local recurrence is seen in 35% to 85% of reported cases (23).

TABLE 1 ■ Staging System for Adrenocortical Carcinoma

Tumor characteristics, disease extent:

T1 Tumor <5 cm, no capsule invasion

T2 Tumor >5 cm, no capsule invasion

T3 Tumor with invasion into periadrenal fat

T4 Tumor invading adjacent organs

N0 Negative lymph nodes

N1 Positive regional lymph nodes

M0 No metastases

Ml Distant metastases

Staging categories:

Source: From Ref. 22.

Although the role of laparoscopy for benign adrenal disease is currently defined, laparoscopic excision of malignant renal tumors of the adrenal gland remains controversial.

It is believed that laparoscopy may have been responsible for intraperitoneal tumor spread or local recurrence. However, definitive proof for this concern is not provided. More importantly, the innate aggressive nature of these cancers and the techniques involved in their removal are not addressed.

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