Use of Endoscopic Surgery
This position supports by reports of a high frequency of locoregional relapses, recurrences in the area of trocar insertion, as well as peritoneal carcinomatosis during endoscopic removal of malignant tumors of the adrenal glands. This explains by the impossibility of resection of the tumor as a single block with the surrounding tissue using endoscopic access in compliance with the rules of ablastics. As a result, a high frequency of non-radical removal of the primary focus, damage to the adrenal capsule with implantation metastasis of tumor cells along the peritoneum and at the trocar sites.
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Reported a possible negative effect of pneumoperitoneum and the existence of a “chimney” effect that promotes implantation metastasis of tumor cells in the peritoneum and in places where trocars places during desufflation of gas from the abdominal cavity.
At the same time, many authors noted that most adrenal tumors larger than 5 cm are benign. According to P. Copeland, there is only one case of adrenocortical cancer per 60 adrenalectomies performed for tumors with a diameter of more than 6 cm. At the same time, according to 13.5% of removed adrenocortical carcinomas were less than 5 cm in diameter. Thus, it was concludes that although the size of the tumor correlates to a certain extent with the likelihood of its malignant nature, it is not an absolute predictor of it.
Recommendations for Endoscopic Interventions
If a recommendation based on the fear of a malignant process follows and open interventions performs on all patients with tumors larger than 5 cm in diameter, then many patients with benign formations will receive obviously less perfect medical care.
Further expansion of the field of application of endoscopic interventions required the justification of their oncological adequacy.
More than 10 years ago, a differentiated approach to various types of malignant tumors of the adrenal glands took shape. They can represents by adrenocortical cancer, malignant pheochromocytoma, lymphoma, neuroblastoma, angiosarcoma, undifferentiated carcinoma, and tumor metastases of other localizations. In the adult population, adrenocortical cancer, malignant pheochromocytoma, and metastases of tumors of other localizations are more common.
Approaches of Treatment
There is a certain consensus in the approaches to the choice of the method of surgical treatment of pheochromocytoma. Due to the difficulties of preoperative determination of the tumor potential, all pheochromocytomas, which, according to the preoperative examination, do not have invasive growth, are subject to endoscopic intervention. If during the revision the invasion of the surrounding structures is determined, there are difficulties in dissection due to perifocal infiltration, the risk of damage to the capsule is high, and access conversion recommends. According to a number of authors, this approach is also possible in the case of tumors larger than 10 cm in diameter.
Surgical interventions for metastatic lesions of the adrenal glands began to undertake more than 30 years ago. Accumulation of experience demonstrating the possibility of improving survival rates in patients with adrenal metastases has led to a progressive increase in the number of such operations.
Initial doubts about the oncological adequacy of laparoscopic surgeries dispels by publications that demonstrated no differences in terms of survival, local recurrence rate, and peritoneal carcinomatosis, tumor recurrence in the surgical access zone in groups of patients operated laparoscopically and conventionally. From the very beginning, attitudes towards laparoscopic adrenalectomies for metastatic adrenal tumors were more positive than those for primary tumors are.
Minimally Invasive Interventions
These lead to a higher rate of implementation of minimally invasive interventions in this group, to the modern almost unanimous acceptance of them. This explains by the fact that, most often, isolated metastases at the time of diagnosis are small, they not characterizes by invasion into surrounding tissues and perifocal infiltration, and the malignant potential of such tumors is less pronounced than that of adrenocortical cancer.
The most controversial issue is the oncological adequacy of minimally invasive interventions in the surgical treatment of adrenocortical cancer. Adrenocortical cancer has an extremely high malignant potential and therefore stands apart from other malignant adrenal neoplasias. This determines the features of diagnostic and therapeutic approaches, also does not allow extrapolating the results of laparoscopic interventions for other malignant neoplasms to this group of patients.
Results of Treatment
The results of treatment of patients with adrenocortical cancer recognizes as unsatisfactory, with no significant improvement over the past decades. The overall five-year survival rate is, according to different authors, from 15 to 60%. Even more depressing are the data, according to which the recurrence rate reaches 85%, and the five-year relapse-free survival does not exceed 40%.
This is due to the biological potential of the tumor, which characterizes by extreme aggressiveness. Tumors characterized by early metastasis and rapid invasive growth. According to some data, no more than 30% of patients with adrenocortical cancer at the time of diagnosis of the disease have an early stage of the process.
Surgery is a key component of treatment. Only radical removal of the tumor allows one to hope for a cure. According to R0, resections are associated with a recurrence rate of 23%, while in the group of patients with R1 resections; the recurrence rate reaches 51%. R0 resection is an independent positive predictor of patient survival. The lack of local control over the disease after the first operation cannot compensates for by repeated interventions, radiation or chemotherapy. Nevertheless, the immediate and long-term results of surgical treatment of patients with adrenocortical cancer cannot called satisfactory. According to some reports, the proportion of R0 resections does not exceed 72%. Naturally, there is a high rate of local recurrence, which can reach 46%.
Conclusion
The regular integration of minimally invasive surgery into such a complex area is difficult, and its role in the treatment of patients with adrenocortical cancer has not yet been determined. The first studies showed disappointing results, reinforcing concerns about a higher incidence of positive resection margins, damage to the adrenal capsule, peritoneal carcinomatosis, and metastases in the area of operative approaches.
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