Minimally Invasive Surgery for Resectable Adrenocortical Carcinoma: A Nationwide Analysis

Introduction: The utilization of minimally invasive surgery (MIS) for adrenocortical carci-noma (ACC) remains controversial due to concerns regarding the quality of surgical resection and subsequent oncologic risks. Current guidelines recommend open resections for all cases of suspected ACC independent of size; however, there has been increased adoption of MIS for ACC over time. We sought to determine whether the rise in the utili-zation of MIS is associated with worse survival outcomes for ACC. Methods: The National Cancer Database was queried for patients with ACC who underwent surgical resection between 2010 and 2017. Patient selection, oncologic outcomes, and overall survival were compared among patients who received an MIS approach (laparo-scopic or robotic) versus an open approach. Results: A total of 1483 patients underwent ACC resection with 982 (66.2%) patients un-dergoing an open approach and 501 (33.8%) receiving an MIS operation. The overall utili-zation of MIS for ACC increased significantly after 2013 (37.7% versus 29.5%, P < 0.01). There was no difference in overall survival between MIS and open resections on univariable (log -rank P = 0.12) analysis. On multivariable analysis, survival was improved in MIS patients versus open resection (Hazard ratio: 0.83, 95% CI: [0.70-0.99]). Notably, survival remained comparable among patients who underwent resection for large ACCs (6-10 cm, log-rank P = 0.66) and giant ACCs (>10 cm, log-rank P = 0.24), irrespective of operative approach. Conclusions: Our findings suggest that in appropriately selected patients with ACC, MIS can be performed safely without a significant decrease in overall survival, independent of size. We recommend consideration of a minimally-invasive approach for adrenal masses despite size >6 cm. (c) 2022 Elsevier Inc. All rights reserved.