Therapeutic Interventions Surgery

Surgery is the main treatment for adrenocortial carcinoma and the only option with a potential for cure.

• Surgical resection, preferably complete resection, is the initial step in therapy. Surgical strategy should be planned based on preoperative imaging findings.

• Intraoperative and postoperative administration of steroids is necessary in patients with cortisol-secreting tumors to avoid addisonian crisis.

• A standard open approach is used for most large adrenal tumors. This gives excellent exposure, minimizes tumor spillage, and allows for vascular control of the inferior vena cava, aorta, and renal vessels. For very large tumors, a thoracoab-dominal approach provides better exposure. Laparoscopic adrenalectomy for large invasive adrenocortical carcinoma is difficult and risks inadequate resection and capsular rupture with seeding, causing local recurrence.

• Resection is possible in only two-thirds of patients.52 Invasion into adjacent organs is common and may require en bloc resection of the kidney, portions of the liver, and regional lymph nodes. Thus, preoperative evaluation of the function of the contraleral kidney is absolutely necessary should nephrectomy be required.

• Palliative resection may help to decrease hormone secretion.

• Adrenocortical carcinomas sometimes invade the liver, so segmentectomy or wedge resection may be necessary.

• Patients with recurrent or metastatic adrenocorti-cal carcinomas should undergo reoperation, if possible. Unfortunately, after an apparent curative resection, two-thirds of patients develop re-recurrence within 1 to 2 years.17'52'53 Reresection

Adrenal mass

? Metastases ? Functional

? Metastases ? Functional

Figure 10-2. Management of patients with adrenal incidentaloma.
Figure 10-3. Management of patients with adrenocortical carcinoma.

may palliate symptoms and prolong survival (56 months after resection versus 19 months with medical therapy only).17,54

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