laparoscopic and open surgery in adrenal malignancy | Γιώργος Ζωγράφος -...
TRANSCRIPT
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.
8.3
—
9.9
—
39
24.5
21
15.4
1
3
7
0
6
1
0
0
0
0
0
—
3a(50)
1 (100)
—
—
10
3
1
6
13
2
11
16
2 (20)
0
0
3 (50)
4 (31)
1 (50)
0a
7 (44)
•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
Συστάσεις στη Χειρουργική του Θυρεοειδούς για την Δημιουργία Κατευθυντήριων Οδηγιών | Γιώργος
Λαπαροσκοπική Χειρουργική Επινεφριδιακών Νεοπλασμάτων | Γιώργος Ζωγραφος – Γιατρός Χειρουργός