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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 93-95

Robotic-assisted radical adrenalectomy for large adrenocortical carcinoma


1 Department of Urology, Yenepoya Medical College, Yenepoya Deemed to be University, Mangalore, Karnataka, India
2 Yenepoya Research Centre, Yenepoya Deemed to be University, Mangalore, Karnataka, India

Date of Web Publication18-Nov-2019

Correspondence Address:
Dr. Muhammed A P. Manzoor
Yenepoya Research Centre, Yenepoya Deemed to be University, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ami.ami_71_18

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  Abstract 

Adrenocortical carcinoma (ACC) is a rare and highly aggressive malignancy with poor prognosis. Laparoscopic adrenalectomy has been a favorite surgical approach for the treatment of adrenal masses. The use of robotic-assisted surgery is the latest development for minimally invasive surgical management of adrenal masses. Here, we describe a rare case of ACC in a 51-year-old male patient who presented with pain in the lumbar region, and robot-assisted laparoscopic radical adrenalectomy was successfully performed transperitoneally with the assistance of the da Vinci robotic system. We also discuss the summary of clinical features of ACC. Robot-assisted laparoscopic adrenalectomy is safe, is easier with lesser blood loss, and is comfortable to the patient due to its low complication rates. The patient improved after tumor removal.

Keywords: Adrenocortical carcinoma, laparoscopic adrenalectomy, magnetic resonance imaging, robot-assisted laparoscopic radical adrenalectomy, sinusoidal network, suprarenal mass


How to cite this article:
Khan A, Singh VK, P. Manzoor MA, Mujeeburahiman M, Dsouza N. Robotic-assisted radical adrenalectomy for large adrenocortical carcinoma. Acta Med Int 2019;6:93-5

How to cite this URL:
Khan A, Singh VK, P. Manzoor MA, Mujeeburahiman M, Dsouza N. Robotic-assisted radical adrenalectomy for large adrenocortical carcinoma. Acta Med Int [serial online] 2019 [cited 2019 Dec 14];6:93-5. Available from: http://www.actamedicainternational.com/text.asp?2019/6/2/93/265376


  Introduction Top


Robotic assisted surgeries have at large improved the outcome of laparoscopic surgeries and cancer surgeries in particular. Three dimensional magnified view, seven degree of freedom of movements at the wrist of robotic instruments have made robotic surgeries easier and safer with less blood loss and peri-operative compilations. Adrenocortical carcinoma (ACC) is a rare and highly aggressive malignancy. Here we present a case of large ACC removed robotically without much blood loss or post operative morbidity.


  Case Report Top


A 51-year-old male patient was referred to the urology department with a history of pain in the left lumbar region for the past 2 months. The patient underwent a baseline assessment, including detailed medical history, complete blood count, ultrasonography of the abdomen, and 3T magnetic resonance imaging (MRI) of the abdomen and pelvis. All metabolic evaluations were normal including serum electrolytes and 24-h urine parameters. No familial history of cancer or endocrine disorders was noted. For MRI, after administration of paramagnetic contrast (gadolinium), axial, sagittal, and coronal T1-weighted images were studied. MRI study revealed a well-defined lobulated mixed signal intensity lesion measuring 10 cm × 5.7 cm × 8.3 cm in the left suprarenal region compressing and displacing the pancreatic tail anteriorly and left kidney inferiorly [Figure 1]a. Adjacent fat planes were well maintained. The lesion displayed hypointense signal intensity on T1-weighted images with hyperintense areas within (calcification/hemorrhage) and inhomogenously hyperintense signal intensity on T2-weighted images with hypointense areas.{Figure 1}

Surgical resection was successfully completed transperitoneally with the assistance of the da Vinci robotic system. The console time was 135 min, and the docking time was roughly 15 min. The total operation time was 150 min, and the intraoperative blood loss was 50 mL. No intraoperative or postoperative complications were observed. Pain score was calculated using numerical rating scale. The visual analog score was 2. The daily analgesic requirement was diclofenac (50 mg) for 2 days. The drain was removed on day 2. The patient was discharged on the 3rd postoperative day.

Gross examination of the suprarenal mass demonstrated a 10 cm × 5 cm × 5 cm tissue mass [Figure 1]b. The outer surface was lobular and covered by fat tissues. Cut surfaces revealed well-circumscribed nodular areas and pale white fibrotic and pale yellow areas. Microscopically, the mass showed an encapsulated tumor composed of cells arranged in sheets, trabeculae, cords, and nests [Figure 2]. Individual tumor cells were large and composed of pleomorphic nuclei, vesicular to powdery chromatins, and inconspicuous cytoplasm with distinct cell boarders. Few of the cells showed prominent nucleoli. Many bizarre cells, binucleate cells, and mitotic figures were also seen along with foci of necrosis. The sinusoidal invasion was noted in few areas. Areas of fibrosis were noted at the periphery of the tumor, especially in the sections where the tumor was grossly seen abutting the kidney. These areas also show focal aggregates of dense chronic lymphocytic inflammatory infiltrate seen, especially perivascularly and peri renal. At one focus, lymphoid follicle formation was also seen. Microscopically, no invasion into the kidney was noted. Morphological and histological features were suggestive of adrenocortical carcinoma (ACC) with oncocytic differentiation. The patient was followed up for 6 months with MRI of the pelvis, abdomen, and pelvis, which showed no signs of local recurrence and metastases.
Figure 2: (a) Microscopic image showing cells arranged in sheets, cords, and nests with a fine sinusoidal network. (b) Microscopic images showing encapsulated tumor with cells arranged with sheets and cords

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  Discussion Top


ACC is a rare and highly aggressive type of tumor arising from the adrenal cortex and affecting 1–2 cases per million populations.[1] The clinical presentations of ACC are heterogeneous with a poor prognosis. The incidence of ACC is higher in females. However, only limited cases have been reported in males.[2],[3],[4],[5] Early diagnosis and treatment are of vital importance for patients with ACC.

Advances in the use of imaging modalities such as computed tomography (CT) and MRI play a crucial role in the detection and diagnosis of adrenal tumors. MRI has a better resolution to determine soft tissues than CT and is thereby superior in the diagnosis of venous invasion. In our case, MRI revealed a well-defined lobulated mixed signal intensity lesion of 10 cm × 5.7 cm × 8.3 cm in the left suprarenal region.

Surgical treatment is recommended for ACC which provides possibility of cure for patients with ACC. Laparoscopic adrenalectomy is the gold standard method for management of adrenal masses. With robot-assisted approach, laparoscopic adrenalectomy for ACC was performed earlier.[6],[7] Our patient underwent robot-assisted left laparoscopic adrenalectomy, and tumor was completely excised and histopathological examination confirmed the diagnosis of ACC.

In our case, the tumor was comparatively larger in size with the earlier robot-assisted report.[6] For large-sized tumors, laparoscopic adrenalectomy can be performed using robot-assisted approach. This has potential advantages such as lesser blood loss, shorter hospital stay, less pain during the hospital stay, and less perioperative complications.[8],[9] In addition, elimination of tremor, scaling of instrument movements, and surgeon control of the laparoscope are of much important in the robotic approach.[6] Moreover, the three-dimensional optics, magnified view with excellent resolution and depth perception, and filtering out tremors are some advantages over traditional laparoscopic surgery.[10]


  Conclusion Top


Robot-assisted laparoscopic adrenalectomy surgery is a safe and potential approach for the management of large suprarenal gland. Robot-assisted surgeries have potential advantages, such as lesser blood loss, less pain during the hospital stay, and less perioperative complications.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bellantone R, Ferrante A, Boscherini M, Lombardi CP, Crucitti P, Crucitti F, et al. Role of reoperation in recurrence of adrenal cortical carcinoma: Results from 188 cases collected in the Italian national registry for adrenal cortical carcinoma. Surgery 1997;122:1212-8.  Back to cited text no. 1
    
2.
Sasaki K, Desimone M, Rao HR, Huang GJ, Seethala RR. Adrenocortical carcinosarcoma: A case report and review of the literature. Diagn Pathol 2010;5:51.  Back to cited text no. 2
    
3.
Sturm N, Moulai N, Laverrière MH, Chabre O, Descotes JL, Brambilla E. Primary adrenocortical sarcomatoid carcinoma: Case report and review of literature. Virchows Arch 2008;452:215-9.  Back to cited text no. 3
    
4.
Thway K, Olmos D, Shah C, Flora R, Shipley J, Fisher C. Oncocytic adrenal cortical carcinosarcoma with pleomorphic rhabdomyosarcomatous metastases. Am J Surg Pathol 2012;36:470-7.  Back to cited text no. 4
    
5.
Kao CS, Grignon DJ, Ulbright TM, Idrees MT. A case report of adrenocortical carcinosarcoma with oncocytic and primitive neuroectodermal-like features. Hum Pathol 2013;44:1947-55.  Back to cited text no. 5
    
6.
Zafar SS, Abaza R. Robot-assisted laparoscopic adrenalectomy for adrenocortical carcinoma: Initial report and review of the literature. J Endourol 2008;22:985-9.  Back to cited text no. 6
    
7.
Brunaud L, Bresler L, Ayav A, Zarnegar R, Raphoz AL, Levan T, et al. Robotic-assisted adrenalectomy: What advantages compared to lateral transperitoneal laparoscopic adrenalectomy? Am J Surg 2008;195:433-8.  Back to cited text no. 7
    
8.
Azhar RA, Gill IS, Aron M. Robotic nephron-sparing surgery for renal tumors: Current status. Indian J Urol 2014;30:275-82.  Back to cited text no. 8
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9.
Singh VK, Khan A, Manzoor MA, Mujeeburahiman M. Robot assisted nephron-sparing surgery for renal leiomyoma. J Clin Diagn Res 2019;13:1-2.  Back to cited text no. 9
    
10.
Pahwa M, Pahwa AR, Batra R, Abraham RR, Chawla A, Kathuria S, et al. Robotic assisted laparoscopic adrenalectomy: Initial experience from a tertiary care centre in India. J Minim Access Surg 2015;11:83-6.  Back to cited text no. 10
    


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