J. Hadaya1, S. Sakowitz1, N. Chervu1, S. Mallick1, B. Shuch2, P. Benharash1 1David Geffen School Of Medicine, University Of California At Los Angeles, Department Of Surgery, Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles, Department Of Urology, Los Angeles, CA, USA
Introduction: Although minimally invasive adrenalectomy has been widely adopted for benign adrenal neoplasms, data regarding its outcomes for adrenocortical carcinoma (AC) remains limited. The present study utilized a national cohort to evaluate the association between surgical approach and mortality following resection for AC.
Methods: The 2010-2020 National Cancer Database was queried for all adults undergoing adrenalectomy for stage I-III AC. Patients were stratified by intent-to-treat surgical approach: MIS, comprising robotic-assisted and laparoscopic, or open. Tumor size was categorized as <4cm, 4-6cm, or >6cm. The primary outcome was overall survival at one and five years. We secondarily considered lymph node harvest and residual surgical margins. Kaplan-Meier survival estimates and Cox proportional hazard models were fit to evaluate the association between surgical approach and mortality, while multivariable models were developed to assess lymph node harvest or margin status.
Results: Of 1,335 patients, 501 (37.5%) underwent MIS adrenalectomy. Patients undergoing MIS adrenalectomy were older (58 [47-68] vs 55 years [43-67], p=0.003) and more commonly of the highest income quartile (36% vs 29%, p=0.03), but similar in distribution of sex, insurance, and education, compared to open. The MIS group was less often treated at academic institutions (49% vs 59%, p<0.001) compared to the open group. The proportion of patients receiving MIS adrenalectomy was 55% for tumors <4cm, 69% for 4-6cm, but only 29% for >6cm. Following risk adjustment, relative to open resection, MIS was associated with similar hazard of one-year mortality for tumors <4cm (Hazard Ratio [HR] 0.94, 95% Confidence Interval [CI] 0.31-2.85) and 4-6cm (HR 0.49, 95% CI 0.11-2.20) (Figure, Panel A). However, mortality was greater for MIS adrenalectomy for tumors >6cm (HR 1.77, 95% CI 1.20-2.62) (Figure, Panel B). Similarly, MIS was linked with equivalent mortality to open at five years for neoplasms <4cm (HR 0.94, 95% CI 0.31-2.85) and 4-6cm (HR 0.99, 95% CI 0.54-1.81), but significantly increased mortality for tumors >6cm (HR 1.32, 95% CI 1.07-1.64). Patients undergoing MIS faced comparable likelihood of positive surgical margins irrespective of tumor size. However, MIS resection of tumors >6cm was associated with reduced nodal harvest by 1.3 (95% CI 0.2-2.3) lymph nodes, relative to open adrenalectomy, though there was no association for 4-6cm and <4cm.
Conclusion: Relative to open, MIS adrenalectomy appears to yield comparable one- and five-year survival for tumors ≤6cm, but inferior survival for tumors >6cm. These findings suggest that open surgery should be strongly considered for large adrenocortical tumors.
