Minimally invasive adrenalectomy for adrenocortical cancers: A systematic review

Introduction: Adrenocortical cancer (ACC) is a rare malignancy with poor prognosis. Due to the widespread use of imaging, greater proportion of cases are being discovered at an early stage, and it is possible to surgically excise these tumors by minimally invasive (MIS) approaches, including pure laparoscopy and robotic assistance. However, due to the fear of capsular breach, tumor spill, and incomplete removal, open surgery (OS) is still the preferred option for managing ACC. The aim of this review is to compare the two approaches and assess where MIS can be option for the surgical management of ACC. Methods: This review was performed as per the Preferred Reporting Items for Systematic Reviews statement. Studies comparing OS and MIS approaches for ACC were retrieved from the PubMed, Scopus, and Cochrane databases. The two approaches were compared for tumor characteristics and outcomes. Results: A total of 22 studies comparing MIS with OS were included in this review. Out of the total 4639 patients, 1411 underwent surgery by MIS and 3228 by OS. Patients operated by MIS had smaller tumors, lower operative time and blood loss with higher positive surgical margin rate, and higher rate of local recurrence. However, the overall survival was comparable between the two approaches. Conclusions: MIS can be used in localized Stage-I ACC but only at high-volume centers. Stage II ACC may be considered for MIS if there is no evidence of local invasion and the surgery can be performed without capsular perforation and conversion to OS.