M. A. Adam1, S. A. Roman1, J. A. Sosa1,2 1Duke University Medical Center,Department Of Surgery,Durham, NC, USA 2Duke Clinical Research Institute,Durham, NC, USA
Introduction:
Controversy exists regarding the role of minimally invasive adrenalectomy (MIA) for adrenocortical carcinoma (ACC) due to concerns regarding adequacy of oncologic resection. Published data are limited by small sample size. This study examines patterns of use, completeness of resection, and survival associated with utilization of MIA vs. open adrenalectomy for ACC.
Methods:
Adult patients with ACC undergoing surgery were identified from the National Cancer Data Base (2010-2012). Multivariable regression and survival models were used to examine impact of surgical approach on margin status and survival while adjusting for tumor size, extra-adrenal extension, and extent of surgery.
Results:
506 ACC patients were included; 151 (30%) MIA, and 355 (70%) open surgery. Non-academic centers performed 47% of MIA and 38% of open cases. Open adrenalectomy was performed more often if there was a preoperative suspicion/diagnosis of ACC (82% vs. 18% for MIA, p<0.01). The proportion of unsuspected ACC cases undergoing MIA was 100% at community centers, 74% at community comprehensive centers, and 72% at academic centers (p=0.2). There were 18 cases converted from MIA to open surgery; 14 (78%) were unsuspected ACC. Compared to open adrenalectomy, patients undergoing MIA had smaller (13 vs. 7 cm) and more intra-adrenal tumors (46% vs. 60%), (all p<0.01). Hospital length of stay was shorter for MIA vs. open surgery (4 vs. 6 days, p<0.01), while overall rates of positive margins were similar (18% vs. 18%). After adjustment, length of stay remained shorter for MIA (-2 day, p<0.01); however, surgery at non-academic centers was associated with increased odds of positive margins (OR 1.94, p=0.03) compared to academic centers. Median follow-up was 22 months. After adjustment, overall survival was similar between MIA and open adrenalectomy (HR 1.10, p=0.65).
Conclusion:
MIA is being used for ACC in approximately a third of patients, with the majority of cases not suspected to be malignant preoperatively. While MIA is associated with a similar risk of positive margins and survival as open adrenalectomy, non-academic centers have a nearly double rate of incomplete resection. Our data emphasize the importance of preoperative evaluation and adequate referral for patients with large adrenal masses.