title: Adrenocortical carcinoma surgery-surgical extent and approach.
abstract: OBJECTIVE
  Adequate tumour resection is the gold standard of care for adrenocortical carcinoma (ACC). However, the optimal surgical strategy remains debatable. In our opinion, the extent of surgery (adequate tumour resection) is the primary concern, rather than the surgical approach (laparoscopic or open). We propose that both surgical approaches have a role in the management of ACC provided the extent of resection is selected based on patient and tumour characteristics and accurate pre-operative investigations.
  
  
  METHODS
  A review of 25 curative intent resections for ACC between 2002 and 2013 was done. Group A (16 patients-64 %) included all patients who underwent planned radical adrenalectomy without any other resection and group B (9 patients-36 %) included all patients who underwent a planned extensive resection based on pre-operative investigations.
  
  
  RESULTS
  Of 471 adrenalectomies, 25 were performed for ACC with curative intent. Tumours were significantly larger in group B with mean size of 119.6 versus 62.4 mm in group A (p = 0.002). Tumours in group B also had higher WEISS scores (mean score 7 vs 5.2, p = 0.033) and almost always required multi-organ resection. The recurrence rate was 37.5 % (n = 6) for group A and 44.4 % for group B (n = 4), p = 1.00. Poor prognosis was associated with significantly higher WEISS scores (p = 0.016) and a trend towards more advanced ENSAT disease stage (p = 0.06). Estimated overall survival was 74.17 months (group A 67.3 vs group B 70.1, p = 0.244).
  
  
  CONCLUSIONS
  Accurate pre-operative staging is critical to select a tailored surgical strategy. Multi-organ resection remains the preferred approach for large and potentially invasive ACC. Some patients presenting with smaller ACC may benefit from a more extensive resection.
authors.affiliation: Department of Endocrine Surgery, La Conception University Hospital, 176, boulevard Baille, 13006, Marseille, France. charlesvb@wanadoo.fr.
authors.forename: C
authors.initials: C
authors.lastname: Vanbrugghe
authors.affiliation: Department of Endocrine Surgery, La Conception University Hospital, 176, boulevard Baille, 13006, Marseille, France.
authors.forename: A J
authors.initials: AJ
authors.lastname: Lowery
authors.affiliation: Department of Endocrine Surgery, La Conception University Hospital, 176, boulevard Baille, 13006, Marseille, France.
authors.forename: C
authors.initials: C
authors.lastname: Golffier
authors.affiliation: Department of Nuclear Medicine, La Timone University Hospital, 264, rue Saint-Pierre, 13005, Marseille, France.
authors.forename: D
authors.initials: D
authors.lastname: Taieb
authors.affiliation: Department of Endocrine Surgery, La Conception University Hospital, 176, boulevard Baille, 13006, Marseille, France.
authors.forename: F
authors.initials: F
authors.lastname: Sebag
mesh_terms: D000306:Adrenal Cortex Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000315:Adrenalectomy; D018268:Adrenocortical Carcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D009367:Neoplasm Staging; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult
keywords: Adrenocortical carcinoma; Laparoscopic approach; Multi-organ resection; Radical adrenalectomies