Laparoscopy For Malignant Adrenal Lesions

To date, there have only been a limited number of series dealing with adrenalectomy for malignancy (Table 3) (33,41-47). These series, from experienced laparoscopic surgeons from around the world, present small numbers of patients with relatively short follow-up. Nonetheless, certain inferences regarding the safety of laparoscopy for malignant lesions may be drawn. As stated previously, carcinomatosis and port-site metastasis are major concerns leading to reservations about laparoscopy for adrenal malignancies. In this group of 98 patients, only one case of carcinomatosis (one case in the authors' series) was documented. In addition, no cases of port-site metastases were noted in any of the series.

Our review of 31 patients (33 procedures) with malignant adrenal lesions is the largest published experience to date (33). The cohort comprised metastatic cancer (n = 26) and primary adrenal malignancy (n = 7). Mean adrenal tumor size was 5 cm (range, 1-10 cm). Mean operative time was three hours with estimated blood loss 258 cc and a mean hospital stay of 2.1 days. Of the 33 procedures, one was electively converted to open surgery. There was no operative mortality. The metastatic group consisted most commonly of RCC (n = 13), colonic malignancy (n = 6), and lung cancer (n = 5). With a median follow-up of 26 months, 17 (55%) were alive, of whom 15 (48%) had no evidence of disease. Five-year actuarial survival was 40%. Seven (23%) patients had local recurrence with no cases of port-site metastasis. Local recurrence was associated with an inferior survival when compared to no local recurrence (p = 0.016). Survival did not correlate to a patient's age, gender, tumor size, tumor side, or surgical approach. Unlike prior reports where a disease-free interval of more than six months was associated with overall improved survival (46,48), similar analysis of data in our series did not reveal a survival benefit.

The reader may note the variance in outcome when comparing Table 2 (case reports) to Table 3 (contemporary series supporting laparoscopy for adrenal malignancy). This

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.

A carcinomatosis, two hypothetical concerns specific to the laparoscopic approach have been expressed including the dispersion of the malignant cells by the peritoneal CO2 gas and the possibility of the immunosuppressive effects of pneumoperitoneum.

TABLE 3 ■ Literature Review: Series of Laparoscopic Adrenalectomy for Cancer a

Study (Ref.)

No. of patients

Follow-up (mo)

Comments

Heniford et al., 1999 (41)

11

8.3 (mean)

10 of 11 patients (91%) disease free

Valeri et al., 2001 (42)

6

8.6 (mean)

3 of 6 patients (50%) disease free

Henry et al., 2002 (43)

6

27.5 median

All patients with ACC, 5 of 6 patients (93%) disease free

Kebebew et al., 2002 (44)

18

39.6 (mean)

9/13 (69%) patients with metastatic disease to the adrenal gland disease free;

2/5 patients with primary ACC (40%) disease free

Lombardi et al.,2003 (45)

9

17 (mean)

9 of 11 patients (82%) disease free; 1 died of unrelated cause

Sarela et al.,2003 (46)

11

21 (median)

~60% survival. Comparison of 11 laparoscopic adrenalectomy with 20 open

radical adrenalectomies. No difference noted in terms of overall survival

Feliciotti et al.,2003 (47)

6

19.5 (mean) for 2 patients

4 of 6 patients (67%) disease free

died; 7 (mean) for

4 patients alive

Moinzadeh and Gill

31

26 (median)

13 of 31 patients (42%) disease free

aOnly series with 5 or more cases are included. Abbreviation: ACC, adrenal cell carcinoma. Source: From Ref. 33.

discrepancy may be attributed to several factors. Solitary metastases of the adrenal gland cover a broad range of primary malignancies. Each specified cancer may have its own unique natural history and innate aggressiveness. With an adrenal metastasis, all the cancers in question have demonstrated the ability to metastasize; therefore, placing them in a more aggressive category. An overall limited survival with loco-regional recurrence should, therefore, not be surprising. The overall survival outcomes in Table 3 appear to compare favorably to the open series of adrenalectomy for malignancy presented earlier in this chapter.

With regard to adrenocortical carcinoma, the overall five-year survival after open surgery has been reported to be 25% (49). Furthermore, in a series of 179 patients having undergone open adrenalectomies, Bellantone et al. documented 52 patients (37%) with local recurrence (50). These data appear to compare favorably to available laparoscopic series, albeit small numbers of cases with the latter. Henry et al. (43) presented five of six patients with ACC having undergone laparoscopic excision with no evidence of disease at a median follow-up of 27.5 months. In our series, of the six patients with adrenocor-tical carcinoma, three (50%) were alive at a median follow-up of 21 months. Two patients had no evidence of disease, and one was undergoing chemotherapy.

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