Wilhelm S M, Prinz R A, Barbu A M, Onders R P, Solorzano C C
University Hospitals of Cleveland/Case Western Reserve University, Cleveland, Ohio, USA.
Surgery. 2006 Oct;140(4):553-9; discussion 559-60. doi: 10.1016/j.surg.2006.07.008. Epub 2006 Sep 7.
Laparoscopic adrenalectomy for small pheochromocytomas, although challenging, is widely accepted. However, its application to pheochromocytomas larger than 6 cm is questioned due to concerns of malignancy and case complexity. Our aim was to examine the impact of pheochromocytoma tumor size (>/=6 cm vs <6 cm) on operative approach and postoperative patient outcomes.
A retrospective review of adrenalectomies performed at 3 university hospitals over 1 decade was analyzed. All pheochromocytomas were identified and then divided based on size into large (>/=6 cm) and small (<6 cm) groups. We examined patient and tumor demographics, pathologic diagnosis, operative approach (laparoscopic vs open), postoperative complications, and biochemical cure rates. Data were analyzed using the Student t test and Fisher exact test with a P value <.05 considered significant.
From 1995 to 2005, 65 pheochromocytomas were resected. Of the total, 38% (n = 25) tumors were >/=6 cm and 62% (n = 40) were <6 cm. For the large tumors, 1 out of 25 (4%) was malignant, whereas no small tumors were malignant. There was no statistically significant increased risk of malignancy in tumors >/=6 cm in size (P = .31). Initial operative approach was based on surgeon preference. Of the adrenalectomies performed, 88% were laparoscopic, with 3 of 25 (12%) large tumors requiring conversion from laparoscopic to open for intraoperative bleeding. None of the small tumors required conversion. No major postoperative complications (eg, stroke or myocardial infarction) occurred in either group. Minor complications (eg, wound infections and hematomas) were noted in 16% of large tumors and 12.5% of small tumors (P = .45). A total of 96% (24 of 25) patients with large tumors and 100% with small tumors showed postoperative biochemical cure. Tumor recurrence was noted in 1 patient with a tumor <6 cm.
Pheochromocytomas >/=6 cm pose a challenge for laparoscopic resection, and concerns have been raised about the validity of this operative approach. This study demonstrates that there is no significant difference in the rate of malignancy for pheochromocytomas >/=6 cm versus <6 cm. There also were no significant differences identified in complication rates, postoperative biochemical cures, or tumor recurrence rates between these groups. Laparoscopic resection of pheochromocytomas can be safely accomplished regardless of size in centers with surgeons experienced in these procedures.
腹腔镜下肾上腺切除术治疗小的嗜铬细胞瘤，尽管具有挑战性，但已被广泛接受。然而，由于对恶性肿瘤及病例复杂性的担忧，其在直径大于6 cm的嗜铬细胞瘤中的应用受到质疑。我们的目的是研究嗜铬细胞瘤大小（≥6 cm与＜6 cm）对手术方式及术后患者预后的影响。
对3所大学医院10年间实施的肾上腺切除术进行回顾性分析。识别出所有嗜铬细胞瘤，然后根据大小分为大（≥6 cm）、小（＜6 cm）两组。我们研究了患者及肿瘤特征、病理诊断、手术方式（腹腔镜与开放手术）、术后并发症及生化治愈情况。采用Student t检验和Fisher精确检验进行数据分析，P值＜0.05认为具有统计学意义。
1995年至2005年，共切除65例嗜铬细胞瘤。其中，38%（n = 25）的肿瘤直径≥6 cm，62%（n = 40）直径＜6 cm。对于大肿瘤，25例中有1例（4%）为恶性，而小肿瘤均无恶性。直径≥6 cm的肿瘤发生恶性肿瘤的风险无统计学显著增加（P = 0.31）。初始手术方式基于外科医生的偏好。在实施的肾上腺切除术中，88%为腹腔镜手术，25例大肿瘤中有3例（12%）因术中出血需要从腹腔镜手术转为开放手术。小肿瘤均无需中转。两组均未发生重大术后并发症（如中风或心肌梗死）。大肿瘤组16%、小肿瘤组12.5%出现轻微并发症（如伤口感染和血肿）（P = 0.45）。大肿瘤患者中96%（24/25）、小肿瘤患者100%术后生化治愈。1例直径＜6 cm的肿瘤患者出现肿瘤复发。
直径≥6 cm的嗜铬细胞瘤对腹腔镜切除构成挑战，且有人对这种手术方式的有效性提出质疑。本研究表明，直径≥6 cm与＜6 cm的嗜铬细胞瘤在恶性率方面无显著差异。两组在并发症发生率、术后生化治愈率或肿瘤复发率方面也未发现显著差异。在有经验丰富的外科医生的中心，无论嗜铬细胞瘤大小，均可安全地完成腹腔镜切除。
