Laparoscopic adrenalectomy on adrenocortical carcinoma of the left adrenal gland in a 43-year-old man: first experience in Saiful Anwar General Hospital

Laparoscopic adrenalectomy on adrenocortical carcinoma of the left adrenal gland in a 43-year-old man: first experience in Saiful Anwar General Hospital

Kurnia Penta Seputra^1,&, Hamid Hunaif Dhofi Alluza¹

¹Department of Urology, Faculty of Medicine, Brawijaya University, Saiful Anwar General Hospital, Malang, East Java, Indonesia

^&Corresponding author
Kurnia Penta Seputra, Department of Urology, Faculty of Medicine, Brawijaya University, Saiful Anwar General Hospital, Malang, East Java, Indonesia

Introduction    

Adrenocortical carcinoma (ACC) is a highly malignant endocrine neoplasm and a very rare malignancy, in contrast to benign adrenal tumors which are common human neoplasias affecting 3% to 10% of the human population [1]. Data from the National Cancer Institute survey and the SEER (surveillance, epidemiology and end results) database estimate an incidence of 0.7-2.0 cases per million people per year. The incidence in adults is maximal in those aged around 40-50 years, but the tumor can appear at any age [2]. The clinical symptoms of ACC vary and relate to the secretion of affected adrenal hormones and/or symptoms related to the tumor itself [3]. Conn's syndrome, caused by aldosterone-producing ACC, is one of the rare signs and manifests as hypertension with profound hypokalemia [2]. Complete surgical excision is essential in the management of ACC and offers the best chance of cure, and control of symptoms [4]. Since its first description by Gagner et al in 1992, laparoscopic adrenalectomy has become increasingly used and now has become the technique of choice for most adrenal lesions because of decreased blood loss, lower morbidity, shorter hospital stays, faster recovery, and overall cost-effectiveness in comparison with the open approach [5]. Although laparoscopic surgery for adrenal carcinomas is still under debate, there are many reports at high-volume centers showing the equal effectiveness of laparoscopic adrenal resection for adrenal carcinomas [6]. This case report aimed to report our first experience treating ACC with a laparoscopic approach, and its outcome in Saiful Anwar General Hospital.

Patient and observation     

A 43-year-old man with suspected adrenal tumor with metabolic syndrome was referred by an internist. The chief complaint was palpitation in the previous 3 years. The patient also complained about general weakness for 3 years that had worsened in the previous 6 months. The patient reported with stage II hypertension (controlled with amlodipine, lisinopril, and spironolactone by the internist), hyperglycemia (controlled with gliquidone), and persistent hypokalemia (ranging from 2.8-3.4mmol/L in the care of the internist, controlled with KSR tablets). The patient's height was 162 cm, weight 76kg, and BMI 23.46kg/m². Physical examinations revealed that blood pressure was 140/90mmHg (with the patient still consuming amlodipine, lisinopril, and spironolactone) and heart rate was 84 bpm. There was no palpable mass in the left flank of the patient during physical examination. The ECG was within normal limits. Notable laboratory findings during the examination were hypokalemia (3.3mmol/L with the patient still consuming KSR tablets), normal blood glucose level (102mg/dL with the patient still consuming gliquidone), and slightly elevated renal function test (urea 32.1mg/dL; creatinine 1.37mg/dL). The morning (08.00) serum cortisol level was normal (230.90 nmol/L). An abdominal CT scan with contrast revealed a left suprarenal (paraaortic) nodular solid lesion, with suspicion of a suprarenal mass of 1.5 x 2 x 1.6cm, and no visible renal-vein or intra-abdominal metastases. Abdominal CT angiography showed that vascular formation was within normal limits. There was no visible metastasis in the thorax. The patient was diagnosed with a left suprarenal tumor with early suspicion of adrenocortical adenoma. Left laparoscopic adrenalectomy with a trans-peritoneal approach was chosen with the patient's compliance (Figure 1).

The patient was positioned in modified flank position, angled back to around 30-40 degrees. The camera holder was to the left of the surgeon. The laparoscopy procedure was done using a three-trocar placement with the camera probe in the middle, as shown in Figure 2. The first step after trocar placement was to identify the spleen and splenic flexure, and the mobilization of the spleen proceeded by incising the peritoneum. Once the spleno-colic and lienorenal ligaments were divided, the spleen was easily mobilized medially, and adequate exposure of the adrenal gland was achieved. The adipose capsule of the kidney was incised until the adrenal gland or the upper pole of the kidney was visible. Once adequate exposure was attained, adrenal dissection started with ligation; subsequent dissection of the adrenal artery and adrenal vein was done using an energy-based hemostatic device. The specimen was then removed intact via a retrieval bag. The hemostatic evaluation was performed carefully, and the drainage tube was then placed. The total duration of the procedure was approximately 90 minutes. The specimen measured 7 x 8cm. The histopathology result revealed a clear cell ACC (Figure 3). The patient was discharged 3 days after surgery. He came back 1 month after surgery for laboratory examination. He no longer had any complaint of weakness or palpitation. Blood pressure and heart rate were normal, and the patient no longer took the anti-hypertension agents. Laboratory examination showed a remarkable improvement in potassium level (4.51 mmol/L) with the patient no longer taking the KSR tablets. Blood glucose and cortisol levels were also normal.

Discussion     

This patient, referred from an internist, came with classic Conn´s syndrome, manifested as hypertension and profound hypokalemia. The chief complaints of the patient, palpitation and general weakness, are very well caused by the hypokalemia. Systemic signs and symptoms, physical examination, and electrolyte evaluation showed very positive evidence of functional hyperaldosteronism. Diagnosis of primary hyperaldosteronism is made by observation of a raised aldosterone: renin ratio and confirmed by adrenal vein sampling or ACTH stimulation [7]; unfortunately, none of those are available in our hospital. The incidence rate of malignancy is small in all adrenal masses that are < 4cm. In series with tumors > 5cm, carcinoma may be found in as many as 7% of patients [4]. However, CT or MRI scanning may underestimate the size of an adrenal lesion [8], with a difference in the final pathologic adrenal size of up to 40% [9]. About 60% of these tumors are functioning and may secrete excess cortisol, androgens, estrogens, aldosterone, or a combination of those [4]. The size of tumors that produce excess levels of aldosterone should be carefully considered, as the median size of benign aldosteronomas and aldosterone-secreting ACC is considerably smaller than that of other types [7]. Imaging characteristics can give insight into the nature of the tumor, although the sensitivity and specificity profiles of each technique are far from perfect [7]. Finding a heterogeneous adrenal mass with contrast-enhanced CT, or intermediate or increased signal intensity on T2-weighted MRIs indicates probable malignancy of the adrenal mass. If these features are absent, the likelihood of a nonfunctioning adrenal mass under 6 cm being malignant is 1 in 10.000 [8]. Underestimation of the size of the adrenal tumor, in this case, was very much expected.

Currently, the only curative approach to ACC is complete tumor resection as it is virtually the only option to achieve cure [2]. The choice of the best surgical approach (open vs laparoscopic adrenalectomy) remains controversial. Laparoscopic adrenalectomy (LA) has become the gold standard for resection of benign adrenal masses, and it has been shown to result in significantly lower morbidity, less pain, shorter hospital stays, and decreased overall time to recovery when compared with open adrenalectomy (OA). Because effective adjuncts to surgery for the treatment of ACC are extremely limited, ensuring a complete, margin-negative tumor resection in the initial operation is critical [1]. In published studies, it is suggested that there is only one contraindication for LA, the involvement of the surrounding tissue or of adrenal and caval veins by a malignant adrenal lesion (invasive adrenal carcinoma) [10]; however, several studies also suggest that LA has more risk of developing local recurrence, as shown in Table 1 [4]. While studies on OA vs LA are still lacking and inconclusive, a prospective randomized study of the role of laparoscopic surgery in adrenal cancer is not feasible because of the rarity of primary and metastatic adrenal malignancies. LA should be performed only when it can achieve complete tumor resection with an intact adrenal capsule. If a complete resection cannot be performed safely, the operation should not be continued laparoscopically. Conversion to an open procedure should be an early decision, prior to tumor morcellation or fracture of the tumor capsule. Patients who have a local invasion, tumors that are too large, or who require organ resection require an open procedure [4].

Conclusion     

Our first experience of choosing a laparoscopic approach in treating ACC was feasible and showed an excellent postoperative outcome. While the choice of using LA remains controversial, it can be used for small ACC and should be performed only when it can achieve complete tumor resection with an intact adrenal capsule.