经腹膜后途径与经腹腔途径腹腔镜肾上腺切除术治疗肾上腺皮质癌的疗效和安全性对比研究

The efficacy and safety comparison of transperitoneal laparoscopic adrenalectomy and retroperitoneal laparoscopic adrenalectomy for adrenocortical carcinoma

目的探讨经腹膜后途径腹腔镜肾上腺切除术(RLA)与经腹腔途径腹腔镜肾上腺切除术(TLA)治疗局限性肾上腺皮质癌(ACC)的疗效和安全性。方法回顾性分析2009年1月至2018年12月于四川大学华西医院接受腹腔镜肾上腺切除术的22例ACC患者的临床资料。男7例,女15例;中位年龄46(37,54)岁。22例临床分期为Ⅰ~Ⅱ期。按照手术路径不同分为RLA组和TLA组。RLA组和TLA组各11例,RLA组与TLA组年龄[44(35,54)岁与46(41,55)岁,P=0.793]、性别(男/女:3/8与4/7,P=1.00)、肿瘤有内分泌功能者比例(3/11与4/11,P=1.00)、肿瘤位置(左/右:6/6与7/4,P=1.00)、合并基础疾病比例(4/11与3/11,P=1.00)方面差异均无统计学意义。RLA组较TLA组肿瘤最大径更小[3.0(2.5,8.4)cm与7.7(5.2,8.4)cm,P=0.001],Ⅰ期患者所占比例更多[90.9%(10/11)与18.2%(2/11),P=0.002]。比较两组患者围手术期指标及肿瘤学预后结局;采用Kaplan-Meier法计算总生存率和无病生存率。结果RLA组较TLA组手术时间[90(70,100)min与110(90,120)min,P=0.005]和术后拔除引流管时间[2(2,3)d与3(2,6)d,P=0.002]更短,差异有统计学意义。TLA组中1例因术中肿瘤破裂转为开放手术。TLA组1例术后发生切口感染;两组均未出现围手术期死亡病例。术后病理检查均确诊为ACC,两组Ki-67指数差异无统计学意义[10%(3%,35%)与10%(9%,25%),P=0.484]。两组患者中位随访时间分别为48(26,98)个月和31(18,49)个月(P=0.237)。RLA组与TLA组患者术后局部复发转移率[36.4%(4/11)与63.6%(7/11)]差异无统计学意义(P=0.395)。生存分析结果显示RLA组和TLA组患者5年无病生存率分别为33.6%和73.2%,差异无统计学意义(P=0.118);术后5年总生存率分别为58.3%和45.5%,差异无统计学意义(P=0.485)。结论对于局限性(Ⅰ/Ⅱ期)ACC患者,RLA和TLA均安全可行,具有类似的肿瘤学控制效果;此外,RLA具有手术时间和术后引流管拔除时间更短的优势。本研究纳入病例数较少,研究结论需要多中心、大样本研究进一步验证。

Objective To compare the efficacy and safety of retroperitoneal laparoscopic adrenalectomy(RLA)and transperitoneal laparoscopic adrenalectomy(TLA)in the treatment of localized adrenocortical carcinoma(ACC).Methods The data of 22 patients with stageⅠ/ⅡACC underwent laparoscopic adrenalectomy in our institution from January 2009 to December 2018 were retrospectively analyzed.According to the different surgical approaches,these patients were divided into RLA and TLA groups.Eleven patients underwent RLA and 11 patients underwent TLA.There were no significant differences between the RLA group and the TLA group in terms of age at first diagnosis[44(35,54)vs.46(41,55)years,P=0.793],sex(male/female:3/8 vs.4/7,P=1.00),secreting tumor ratio(3/11 vs.4/11,P=1.00),tumor location(left/right:6/6 vs.7/4,P=1.00),with hypertension or diabetes mellitus(4/11 vs.3/11,P=1.00).However,RLA has significantly smaller tumor size[3.0(2.5,8.4)cm vs.7.7(5.2,8.4)cm,P=0.001],and more stageⅠpatients[90.9%(10/11)vs.18.2%(2/11),P=0.002],compared with those in TLA group.The perioperative indicators and oncology prognosis outcomes were collected and compared between the two groups.The Kaplan-Meier method was performed to calculate the overall survival(OS)and disease-free survival(DFS).Results Compared with TLA,RLA had shorter operation time[90(70,100)vs.110(90,120)min,P=0.005]and postoperative drainage tube removal time[2(2,3)vs.3(2,6)day,P=0.002),and the difference was statistically significant.In the TLA group,one patient was converted to open operation due to intraoperative tumor capsule rupture.For postoperative complications,one patient in the TLA group suffered with wound infection.There were no perioperative deaths in either group.All postoperative pathological examinations confirmed ACC,and there was no significant difference in Ki-67 index between the two groups[10%(3%,35%)vs.10%(9%,25%),P=0.484].The median follow-up was similar in the two groups[48(26,98)vs.31(18,49)months,P=0.237].The local recurrence and metastasis rates were 36.4%for RLA group and 63.6%for TLA group(P=0.395).Survival analysis showed no statistically significant difference in DFS[5-year DFS rate:33.6%vs.73.2%,P=0.118]between the two groups.The 5-year OS rates for RLA group versus TLA group were 58.3%vs.45.5%(P=0.485).Conclusions For localized(stageⅠ/Ⅱ)ACC,both RLA and TLA seem safe and feasible,based on the similar long-term oncological prognosis.However,compared with TLA,RLA has the advantage of shorter operation time and postoperative drainage tube removal time.Due to the small number of cases included in this study,further multi-center,large-sample studies are required to demonstrate clear benefit of one surgical approach in the future.