Department of Digestive and Endocrine Surgery, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France.
Surgery. 2012 Jul;152(1):123-32. doi: 10.1016/j.surg.2011.09.030. Epub 2012 Feb 4.
Operative resection is the only potentially curative treatment for primary adrenocortical carcinoma (ACC), but standards of operative care are not defined with regards to the extent of local resection. We propose recommendations for operative management.
Anatomic and clinical literature review focusing on local management of ACC, including lymphadenectomy and resection of adjacent organs or large vessels.
First-order drainage nodes of the adrenal gland include the renal hilum lymph nodes, the celiac lymph nodes, and the para-aortic and paracaval lymph nodes, mainly above the renal pedicle and ipsilateral to the adrenal glands. Lymph node involvement occurs in about 20% of patients with ACC, and is an important prognostic factor, but lymphadenectomy is performed infrequently. The adrenal glands and kidneys are contained in the same anatomic space, but systematic en bloc nephrectomy has no proven benefits for survival. Direct invasion of the kidney or adjacent organs is rare, but major venous invasion with tumor thrombus is relatively common. Both are associated with decreased survival, but complete resection can lead to long-term survival.
Standardization of regional lymphadenectomy including first-order drainage nodes is proposed. Systematic nephrectomy is not necessary in the absence of gross local invasion, but locally involved organs or large veins should be resected en bloc, with tumor thrombus embolectomy, if R0 resection is possible. Operative standardization improves tumor staging, potentially decreases local recurrence, and may be associated with better survival. Evidence-based standards of operative care and prospective investigations within international collaborating groups are necessary.
手术切除是治疗原发性肾上腺皮质癌（ACC）唯一可能治愈的方法，但对于局部切除的范围，手术治疗标准尚未确定。我们提出了手术管理的建议。
对 ACC 的局部管理，包括淋巴结清扫术和邻近器官或大血管的切除术，进行解剖学和临床文献复习。
肾上腺的一级引流淋巴结包括肾门淋巴结、腹腔淋巴结和腹主动脉旁及腔静脉旁淋巴结，主要位于肾蒂上方和肾上腺同侧。约 20%的 ACC 患者存在淋巴结受累，这是一个重要的预后因素，但淋巴结清扫术很少进行。肾上腺和肾脏位于同一解剖空间内，但系统性整块肾切除术对生存没有明显益处。肾脏或邻近器官的直接侵犯很少见，但伴有肿瘤血栓的大静脉侵犯则相对常见。两者均与生存率降低相关，但完全切除可导致长期生存。
提出了包括一级引流淋巴结在内的区域淋巴结清扫的标准化建议。在没有明显局部侵犯的情况下，不需要进行系统性肾切除术，但应整块切除局部受累的器官或大静脉，并进行肿瘤血栓取栓术，如果可以达到 R0 切除。手术标准化可改善肿瘤分期，降低局部复发率，可能与更好的生存相关。有必要制定基于循证的手术护理标准，并在国际合作组内进行前瞻性研究。
