title: Surgical quality of minimally invasive adrenalectomy for adrenocortical carcinoma: a contemporary analysis using the National Cancer Database.
abstract: To compare quality outcomes between open (OA) and minimally invasive (MIA) adrenalectomy for adrenocortical carcinoma (ACC).
  
  
  
  In the National Cancer Database, we identified 481 patients with non-metastatic ACC who underwent adrenalectomy from 2010 to 2013. OA and MIA were compared on positive surgical margin (PSM) and lymph node dissection (LND) rates (primary outcomes), and lymph node yield, length of stay (LOS), readmission, and overall survival (secondary outcomes). Using the intention-to-treat principle, minimally-invasive-converted-to-open cases were considered MIA. Logistic regression analysis was used to identify predictors of PSMs and LND. Associations between approach and the outcomes were further assessed by stage and tumour size.
  
  
  
  Overall, 161 patients (33.5%) underwent MIA. MIA was used more commonly in older, comorbid patients; for smaller, localised tumours; and at lower-volume centres. In the intention-to-treat analysis, MIA independently predicted PSMs [odds ratio (OR) 2.0, 95% confidence interval (CI) 1.1-3.6; P = 0.03) and no LND (OR 0.1, 95% CI 0.03-0.6; P = 0.01). On subgroup analysis, the association between MIA and PSMs only held true for pT3 disease (48.7% vs 26.7%, P = 0.01). A higher PSM rate was seen for tumours of ≥10 cm managed with MIA vs OA, but this difference was not significant (28.2% vs 18.5%, P = 0.16). Likewise, the association between MIA and no LND was only observed for male patients, tumours ≥10 cm, and cN0 disease. After excluding minimally-invasive-converted-to-open cases, the difference in PSM was less pronounced and non-significant (OR 1.8, 95% CI 0.9-3.4; P = 0.08). MIA was associated with significantly shorter median LOS (3 vs 6 days, P < 0.01) and non-significantly decreased readmissions (4.4% vs 8.8%, P = 0.08) compared to OA without any difference in lymph node yield or overall survival.
  
  
  
  For organ-confined disease, MIA offers comparable surgical quality to OA, while expediting inpatient recovery. OA is associated with superior outcomes for locally advanced disease.
authors.affiliation: Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Matthew J
authors.identifier: 0000-0002-0324-8795
authors.initials: MJ
authors.lastname: Maurice
authors.affiliation: Urology Institute, University Hospitals Case Medical Center, Cleveland, OH, USA.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Bream
authors.affiliation: Urology Institute, University Hospitals Case Medical Center, Cleveland, OH, USA.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Kim
authors.affiliation: Urology Institute, University Hospitals Case Medical Center, Cleveland, OH, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Abouassaly
mesh_terms: D000306:Adrenal Cortex Neoplasms / Q000601:surgery*; D000315:Adrenalectomy / Q000379:methods*; D018268:Adrenocortical Carcinoma / Q000601:surgery*; D000328:Adult; D000368:Aged; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States
keywords: adrenocortical carcinoma; lymphadenectomy; minimally invasive surgical procedures; positive surgical margins