Controversy About The Role Of Laparoscopy For Malignancy

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

The concern about laparoscopy for adrenal malignancy stems from seven individual case reports published in the last several years (Table 2) (26-32). These single case reports challenge the adequacy of adrenal resection for adrenal glands with a primary adrenal malignancy or solitary metastatic site. In each case report, the authors describe local recurrence or peritoneal carcinomatosis shortly after (4-14 months) routine laparo-scopic adrenalectomy. Two of the case reports consist of metastatic lung cancer to the adrenal gland. The other five case reports describe an initial adrenal mass thought to be benign after initial histopathologic analysis and only later diagnosed as malignancy when clinical recurrence was noted.

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.

These case reports raise two broad concerns about laparoscopic excision of malignant organs, namely, (i) port-site metastasis, and (ii) local recurrence/carcinomatosis. As regards port-site metastasis, Tsivian and Sidi reported the relatively rare occurrence in 11 cases (0.6%) in over 2000 urologic laparoscopic cases reviewed (34).

TABLE2 ■ Literature Review: Single Case Reports Questioning the Safety of Laparoscopic Adrenalectomy in the Setting of Malignancy

Tumor

Comment

Time to

Initial

Final

Author and

Age/

size

Laparoscopic

about

recurrence

Location of

specimen

reoperation

year (Ref.)

sex

Side

(cm)

History

approach

surgery

(mo)

recurrence

pathology

pathology

Ushiyama et al.,

50/F

L

5

Cushing's

N/A

Uncomplicated

14

Local recurrence,

Benign

ACC

1997 (26)

syndrome

case

carcinomatosis

adenoma

Suzuki et al.,

62/M

L

5.5

Lung cancer

N/A

Conversion to

8

"Multiple

Poorly

Poorly

1997 (27)

(adenocarcinoma)

open surgery with en-block removal of part of kidney

metastasis"

differentiated lung cancer

differentiated lung cancer

Hofle et al.,

43/F

L

3

Cushing's

N/A

Uncomplicated

4

Local

"Undetermined"

Could not

1998 (28)

syndrome

case

recurrence, carcinomatosis

malignant potential

confirm ACC as tumor was fragmented

Hamoir et al.,

25/F

R

12

Secondary

N/A

"Difficult and bloody"

6

Carcinomatosis

Benign

ACC

1998 (29)

amenorrhea

converted to

and virilization

open procedure

Deckers et al.,

74/M

R

2.7

Conn's

Trans

Partial adrenalectomy

10

Carcinomatosis

Benign

Same features

1999 (30)

syndrome

performed

as initial tumor, with increased cellularity and necrosis consistent with ACC

Foxius et al.,

74/M

R

2.7

Conn's

Trans

Uncomplicated

6

Local recurrence,

Benign

Identical to

1999 (31)

syndrome

case

carcinomatosis

initial tumor, deemed ACC based on clinical metastasis

Chen et al.,

55/F

L

2.5

Lung cancer

Trans

Intraoperatively,

5

Carcinomatosis

Non small cell

Non small cell

2002 (32)

(non small cell)

mass was noted

including port-

lung cancer

lung cancer

to have increased to

site recurrence

8 X6 cm. Specimen

was removed intact

in entrapment sack

Abbreviations: R, right; L, left; Trans, transperitoneal; ACC, adrenal cell carcinoma; N/A, not available.

Source: From Ref. 33.

The most significant risk factors in terms of port-site metastasis included the biological aggressive nature of the tumor, non-placement of the tumor in a specimen bag, violation of the tumor boundary, and ascites.

Port-site metastatic potential has been addressed in animal models as well. It is hypothesized that the escape of potential tumor filled pneumoperitoneum gas around loose fitted trocars may produce a "chimney effect" leading ultimately to port-site metastasis. Tseng et al. demonstrated the increased tumor growth rate in the rat model at port sites where there was a leak of pneumoperitoneum (478 mg of tumor) versus a control group (153 mg, p = 0.01) (35). However, such occurrence has not been clinically validated. Ikramuddin et al. used a saline trap to capture the effluent gas of 35 patients who underwent elective laparoscopic procedures (36). Although 15 patients had malignancies, only two were found to have malignant cells in the effluent. Both of these patients had carcinomatosis detected at the beginning of the case. As such, the authors concluded the unlikely nature of cell aerosolization as a significant contributor to port-site metastasis. The various animal models used thus far must be called into question (37). It may not be valid to extrapolate from such studies founded on the use of foreign malignancies remote from the usual primary site, which are introduced into the abdominal cavity.

With regard to carcinomatosis, two hypothetical concerns specific to the laparo-scopic approach have been expressed including the dispersion of the malignant cells by the peritoneal CO2 gas and the possibility of the immunosuppressive effects of pneu-moperitoneum (38).

There are a limited number of basic science manuscripts using animal models that specifically attempt to address these concerns. In one such study using a rat model, a suspension of adenocarcinoma cells was placed in the abdomen with or without insufflation and compared to a third group with laparotomy (39). The animals were sacrificed six days post-tumor implantation. The abdomen was divided in six quadrants and gross examination was performed to score tumor density in each quadrant. The group with CO2 insufflation had more disseminated cancer spread when compared to the gasless group or the laparotomy group. However, validation of these results has been mixed. Using a murine model, Allendorf et al. demonstrated an increased number (p = 0.04) and two times larger sized (p < 0.01) tumor carcinomatosis at peritoneal sites in the laparotomy group when compared to the insufflation group. The same authors have further defined the seeming protective effects of pneumoperitoneum in preventing carcinomatosis. They propose that a relative increased T-cell function associated with insufflation may lead to protection against cancer spread. This advantage may be lost with conventional laparotomy (40).

Nicotine Support Superstar

Nicotine Support Superstar

Stop Nicotine Addiction Is Not Easy, But You Can Do It. Discover How To Have The Best Chance Of Quitting Nicotine And Dramatically Improve Your Quality Of Your Life Today. Finally You Can Fully Equip Yourself With These Must know Blue Print To Stop Nicotine Addiction And Live An Exciting Life You Deserve!

Get My Free Ebook


Post a comment