Reassessing the impact of tumor size on operative approach in adrenocortical carcinoma

Abstract

Background Adrenocortical carcinoma (ACC) is often a contraindication to minimally invasive adrenalectomy (MIA). We used an administrative data set to analyze postoperative outcomes. We hypothesized that small tumors would have better short‐ and long‐term outcomes, independent of the operative approach. Methods The National Cancer Database (2010–2016) identified patients with ACC who underwent adrenalectomy. Tumors were grouped: <5 cm (n = 125), 5–10 cm (n = 431), and >10 cm (n = 443). The primary and secondary outcomes were margin positivity and overall survival, respectively. Results Nine hundred and ninety‐nine patients were analyzed: 37% MIA and 63% open adrenalectomy (OA). As the size increased, the rate of attempted MIA decreased. Larger tumors were associated with conversion to open. Although tumors with local invasion and those which required conversion to open were associated with an increased likelihood of a positive margin, tumor size was not. Although “complete” MIA (vs. OA) and tumor size were not associated with differences in survival, conversion (HR = 1.83, p = .02), positive margins (HR = 1.54, p = .01), and local invasion (HR = 1.84, p < .001) were associated with poor survival. Conclusion Positive margins are associated with poor survival in ACC. Tumors ≥ 5 cm were associated with an increased conversion rate and subsequent increase in margin positivity. MIA may be considered for select patients with small tumors but adequate oncologic resection is critical.

Minimally invasive adrenalectomy for large pheochromocytoma: not recommendable yet? Results from a single institution case series

“…It is still a matter of debate whether LA for large adrenal tumors is safe and feasible. Several studies show that, especially in case of PCC, large adrenal lesions are associated with higher rates of conversion and blood loss, longer operative time, and hospital stay [10][11][12][15][16][17][18][19][20], while others failed to find a correlation between tumor size and perioperative outcomes [21][22][23]. Laparoscopic approach was not identified as a variable influencing perioperative outcomes in recent studies [36][37][38][39]; furthermore, Kiernan et al [40] reported how the open technique significantly increased intra-and postoperative hemodynamic instability.…”

“…Several risk factors for perioperative morbidity after LA have been identified [10][11][12][13][14][15], but only few studies have investigated specific predictors of morbidity after LA for PCC [16][17][18][19][20]. In particular, the role of PCC size, one of the most frequently reported predictor of perioperative complications, is controversial [21][22][23].…”

Laparoscopic surgery for adrenocortical carcinoma: Estimating the risk of margin‐positive resection

“…Notably, tumor size alone was not a risk factor for margin positive resection. Prior work by Hue et al similarly showed that, among MIS‐resected ACC, local invasion and conversion to OA were more powerful predictors of PM than tumor size 16 . These data challenge the notion that adrenal nodules beyond a certain diameter must be approached via OA resection.…”

Estimation of the tumor size at cure threshold among adult patients with adrenocortical carcinoma: A populational-based study

“…Similarly, Cord S et al suggested that tumor size is a useful way for predicting the likelihood of ACC [ 27 ]. Jonathan J et al implied that tumor size of ACC ≥ 5 cm increased the margin positivity rate and affected the prognosis of ACC patients [ 28 ].…”