Palazzo F Fausto, Sebag Frederic, Sierra Mauricio, Ippolito Giuseppe, Souteyrand Philippe, Henry Jean-François
Department of Endocrine Surgery, La Timone University Hospital, Boulevard Jean Moulin, 13385, Marseille, CEDEX 4, France.
World J Surg. 2006 May;30(5):893-8. doi: 10.1007/s00268-005-0288-2.
Laparoscopic adrenalectomy (LA) is the procedure of choice for small benign adrenal tumors. In the absence of local invasion or metastases, the preoperative diagnosis of an adrenocortical carcinoma (ACC) is difficult, often leaving size as the principal predictor of malignancy. Large tumors are resectable laparoscopically, but the long-term outcome and therefore appropriateness of LA for cortical tumors > 6 cm is not known.
We reviewed the LA experience in our institution since its introduction in June 1994. Patients who underwent LA for solid cortical tumors > or = 60 mm in diameter without preoperative or intraoperative evidence of malignancy were reviewed. Follow-up data, including clinical examination, biochemical analysis, and repeat scans, were reviewed for evidence of local or systemic recurrent disease.
Between 1994 and 2004 a total of 462 adrenalectomies were performed, 391 of which were done laparoscopically. Among them, 19 were solid cortical tumors > or = 60 mm in diameter with no overt malignant preoperative or intraoperative characteristics: 9 nonsecreting tumors, 8 Cushing's syndrome tumors (including 2 virilizing variants), 1 virilizing tumor, and 1 aldosteronoma. The mean age of the patients was 49.9 years (range 22-77 years), and the mean tumor size was 69.0 mm (range 60-80 mm). Histology confirmed a cortical adenoma in eight patients, malignant tumors in three, and indeterminate tumors in eight. The mean follow-up was 34 months (range 4-108 months). Two patients died of systemic recurrent disease (liver metastases) at 10 and 19 months, respectively, following surgery; two other patients died 12 and 21 months, respectively following surgery owing to unrelated cardiovascular and cerebrovascular pathology. One patient underwent surgery for local recurrence 54 months after primary surgery; the remaining 14 patients are well with no clinical or radiologic evidence of recurrent disease.
Laparoscopic adrenalectomy for large solid cortical tumors without pre- or intraoperative evidence of malignancy is not contraindicated, and it is unlikely to have a deleterious effect on long-term outcome. Each case should be considered individually. We provide an algorithm for the approach to adrenocortical tumors > or = 6 cm.
腹腔镜肾上腺切除术（LA）是治疗小型良性肾上腺肿瘤的首选术式。在无局部侵犯或转移的情况下，肾上腺皮质癌（ACC）的术前诊断较为困难，肿瘤大小常成为恶性肿瘤的主要预测指标。大型肿瘤可通过腹腔镜切除，但LA治疗直径>6cm的皮质肿瘤的长期疗效以及该术式的适用性尚不清楚。
我们回顾了自1994年6月引入LA以来我院的相关经验。对因直径≥60mm的实性皮质肿瘤接受LA且术前或术中无恶性证据的患者进行了回顾性分析。复查随访数据，包括临床检查、生化分析及重复扫描结果，以寻找局部或全身复发疾病的证据。
1994年至2004年间共进行了462例肾上腺切除术，其中391例为腹腔镜手术。其中，19例为直径≥60mm的实性皮质肿瘤，术前或术中无明显恶性特征：9例无功能性肿瘤，8例库欣综合征肿瘤（包括2例男性化变异型），1例男性化肿瘤，1例醛固酮瘤。患者的平均年龄为49.9岁（范围22 - 77岁），平均肿瘤大小为69.0mm（范围60 - 80mm）。组织学检查证实8例为皮质腺瘤，3例为恶性肿瘤，8例为不确定肿瘤。平均随访时间为34个月（范围4 - 108个月）。两名患者分别在术后10个月和19个月死于全身复发疾病（肝转移）；另外两名患者分别在术后12个月和21个月因无关的心血管和脑血管病变死亡。一名患者在初次手术后54个月因局部复发接受手术；其余14例患者情况良好，无临床或影像学复发疾病证据。
对于术前或术中无恶性证据的大型实性皮质肿瘤，腹腔镜肾上腺切除术并非禁忌，且不太可能对长期疗效产生有害影响。应个案考虑每个病例。我们提供了一种针对直径≥6cm的肾上腺皮质肿瘤的处理方法。
