LAPAROSCOPIC AND OPEN SURGERY IN LAPAROSCOPIC AND OPEN SURGERY IN ADRENAL MALIGNANCYADRENAL MALIGNANCY

G.N. ZOGRAFOSG.N. ZOGRAFOS

Third Department of Surgery, Athens General Third Department of Surgery, Athens General Hospital Hospital

EUROPEAN SURGICAL CONGRESS 2014 EUROPEAN SURGICAL CONGRESS 2014

Laparoscopic surgery has been established for benign

adrenal diseases without prospective randomized trials, opposed to open surgery

Ganger M Laparoscopic adrenalectomy in Cushing’s syndrome and pheochromocytoma. N Engl J Med 1992;327:1033.

MALIGNANT ADRENAL TUMORS

• Malignant tumors of the adrenal cortex

• Malignant pheochromocytoma

• Metastatic tumors from other origin

MALIGNANT TUMORS OF THE ADRENAL CORTEX

• Rare tumors ( 0.2% of all cases of cancer)

• Functioning in a percentage 60% ( Cushing syndrome, hyperandrogenism or mixed picture)

• Usually asymptomatic

• Abdominal pain, anorexia, weight loss in advanced disease

ADRENAL CORTICAL CARCINOMA

• Large tumors

• Local invasion common

• High percentage of local recurrence in several lap.series

• En-block resections necessitate open technique

ADRENAL CANCER WITH LOCAL INVASION

• En-block resection of tumor ( R0, R1) with involved organs necessitate open approach

• Right side nephrectomy / & hepatectomy

• Left side nephrectomy / & distal pancreatectomy+ splenectomy

SUSPICIOUS OR POTENTIALLY MALIGNANT TUMORS

Local invasion has to be excluded either preoperatively or intraoperatively

Tumor must be excised without disruption of the capsule

Cautious approach

Ζografos G.N et al Laparoscopic surgery for malignant adrenal tumors Journal Surgical Oncology 2009;13(2):196-202

POTENTIALLY MALIGNANT TUMOR LAPAROSCOPIC RIGHT RESECTION

LEFT ADRENOCORTICAL CARCINOMASTAGE ΙΙ, 10,5 cm

Laparoscopic resection

LAPAROSCOPIC SURGERY IN MALIGNANCY

• Is feasible

• Can be radical

• Port-site metastasis are avoidable

• Oncological principles essential

ONCOLOGICAL PRINCIPLES

• R0 excision

• Avoidance of tumor fragmentation & spillage

• Use of grippers attached to the trocars

• Evacuation of pneumoperitoneum through suction

• Use of specimen bag

• Irrigation of trocar sites

THE ROLE OF LAPAROSCOPIC SURGERY IN PRIMARY ADRENAL MALIGNANCY

Controversy due to rarity of the disease and lack of randomized trials

. Herrera F. Results of adrenal surgery. Data of a Spanish National Survey. Langenbecks Arch Surg. 2010 Sep;395(7):837-43.

Kim JH et al.J Urol. 2004 Mar;171(3):1223 Section of Laparoscopic and Minimally Invasive Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Laparoscopic radical adrenalectomy with adrenal vein tumor thrombectomy: technical considerations.

.

Related Articles,

Links

• 

Lee et al Surgery 2005;138:1078MD Anderson Cancer Center, Houston

Laparoscopic resection of adrenal cortical carcinoma: a cautionary note

Oncologic outcomes for patients with malignant primary and metastatic adrenal tumors after laparoscopic resection

Mean follow up (months)

Primary malignancies

Primary malignancies Recurrence

n(%)

Metastatic tumors

Metastatic tumors

Metastatic disease n(%)

Heniford et al.

Henry et al.

Hobart et al.

Valeri et al.

Kebebew et al.

MacGillivray et al.

Sarela et al.

Miccoli et al.

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9.9

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24.5

21

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3

7

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6

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0

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11

16

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•Brunt L.M, Brunt L.M, Surg Endosc. 2006 Mar;20(3):351-61Surg Endosc. 2006 Mar;20(3):351-61 •a Τοπική υποτροπή

AACE/AAES Guidelines 2009

Open adrenalectomy should be performed if ACC is suspected

( Grade C, BEL 3)

Endocrine Practice 2009; vol 15, suppl 1.

Contemporary management of adrenocortical carcinoma Eur Urology 2011;60:1055-1065

• L.A appropriate option for malignant tumors < 10 cm without evidence of invasive disease

• L.A for adrenal malignancy remains a high-risk procedure that requires meticulous preservation of tissue planes and avoidance of tumour violation

• Surgery for suspected ACC should be limited to centers with > 20 adrenalectomies per year

MALIGNANT PHEOCHROMOCYTOMA

• Pheochromocytoma: Rare catecholamine-secreting tumors (1-2 / 100.000 adults per year)

• 10% ( ?) malignant

• Classical symptoms: Paroxysmal hypertension, headaches, polyhydrosis, arrhythmias

MALIGNANT PHEOCHROMOCYTOMA

• Malignancy can not be established preoperatively

• Hypervascular, friable tumors. Technically demanding procedures, possible dissemination of the disease

• Tumors <10 cm laparoscopic approach but necessitate experience

• Large tumors >/= 10cm or organ invasion need open approach

Prinz RA Ann Surg Oncol 2007;14(10):3004-10

SOLITARY ADRENAL METASTASIS

Primary localization

• Lung ( the most common)• Bowel• Breast• Kidney• Melanoma• Lymphoma

• Usually asymptomatic

Related Articles, Links

• 

•Conlon KC et al Ann Surg Oncol. 2003;(10):1191•Department of Surgery, Memorial Sloan-Kettering Cancer

Center, New York, New York 10021, USA. 

•Metastasis to the adrenal gland: the emerging role of laparoscopic surgery.

•

SOLITARY ADRENAL METASTASIS

• Laparoscopic approach is usually safe and radical (αbsence of local invasion)

• Evidence in the literature

• Tumors < 10 cm

Right Adrenal metastasis 9 cm from contralateral renal cancer

G. Zografos et al . Laparoscopic adrenalectomy for large adrenal metastasis from contralateral renal cell carcinoma. J.S.L.S 2007;11(2):261-265Gittens PR et al. Semin Oncol 2008;35(2):172-6

European Society of Endocrine Surgeons Workshop, May 12-14, 2011 Lyon

Laparoscopic resection for solitary adrenal metastasis is feasible and safe for tumors confined to the adrenal gland

Η. Park Outcomes from 3144 adrenalectomies in the United States. Arch Surg 2009;144(11):1060-67

Lombardi CP Adrenocortical carcinoma: effect of hospital volume on patient outcome.Langenbecks Arch Surg. 2012 Feb;397(2):201-7.

Better results in high volume centers

Third Department of Surgery Athens General Hospital May 1997 – September 2013

Resection of Adrenal tumors

330 procedures on 316 patients (14 bilateral synchronous or metachronous adrenalectomy)

In 264 patients laparoscopic approach In 40 patients open approach Σε 26 conversion of laparoscopic procedure to open

G. Zografos, G. Papastratis. Laparoscopic surgery for adrenal tumors. A retrospective analysis Hormones 2006;5(1):52-56

G.N. Zografos, et al. Laparoscopic resection of pheochromocytoma with delayed vein ligation Surg Laparosc Endosc Percut Tech 2011;21(2):116

Athens General Hospital, Third Department of Surgery May 1997 – September 2013Resection of Adrenal tumors

102 Αdenomas(42 subclinical hormone activity)20 Potentially malignant tumors43 Cushing syndrome 7 Cushing disease51 Pheochromocytoma (5 paragagglioma, 4 ΜΕΝ ΙΙΑ)35 Malignant tumors3 Malignant pheochromocytoma1 Recurrent Malignant pheochromocytoma 7 Μetastatic Ca (3 lung.,colon 1., kidney 3)23 Primary adrenocortical carcinoma1 Angiosarcoma50 σ. Conn12 Myelolipoma11 Cysts, cystic neoplasms3 Ganglioneuroma , 1Hematoma, 2 scwhanoma, 1 Αngiolipoma

CONCLUSIONS

• Laparoscopic surgery in adrenocortical carcinomas and malignant pheochromocytomas > 10 cm is rarely safe & feasible due to the risk of tumor disruption and/or invasion of adjacent tissues or organs

• Laparoscopic resection of adrenal tumors < 10 cm suspicious for malignancy needs cautious approach and laparoscopic experience

• Local invasion necessitates open approach from the start or early conversion of the laparoscopic procedure to open surgery

• Metastatic adrenal tumors up to 10 cm is absolute indication for laparoscopic surgery