SURGICAL TREATMENT OF POTENTIALLY PRIMARY MALIGNANT ADRENAL TUMORS: AN OPEN ARGUMENT

Abstract

Although the great majority of incidentalomas are adrenocortical adenomas, a number, depending on the size and radiological characteristics of the lesions, will turn out to be carcinomas. These tumors may present as suspicious on initial approach and potentially malignant or malignant, finally, on histology. Adrenocortical carcinoma is a rare and aggressive malignancy with evolving diagnostic and therapeutic approaches. Laparoscopic surgery has become the gold standard for surgery of benign adrenal tumors. Despite the great experience gained in laparoscopic adrenalectomy, controversy still remains in the management of adrenal tumors with high suspicion or evidence of malignancy. The aim of this review is to update current existing information regarding the diagnostic approach and surgical management of suspicious and potentially malignant primary adrenal tumors. The interpretation of radiologic characteristics is a cornerstone in pre-operative assessment of large adrenal masses, since open surgery remains the preferred procedure when malignancy is suspected in large tumors with possible local invasion. Despite the improvement of imaging techniques, they lack enough accuracy to exclude primary malignancy in tumors with size from 4 cm to 10 cm. Initial laparoscopic approach can be used in this group of patients but early conversion to open technique is mandatory if curative resection cannot be performed. Adrenal tumors > 10 cm with malignant potential should be treated by open approach from the start. Solitary adrenal metastasis from other primary malignancy is usually amenable to laparoscopic surgery. Patients with suspected adrenal cancer must be referred to tertiary centers that perform laparoscopic and open adrenal surgery with minimal morbidity and mortality.