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Morelli V, Palmieri S. Adrenal incidentaloma: differential diagnosis and management strategies. MINERVA ENDOCRINOL 2018; 44:4-18. [PMID: 29808642 DOI: 10.23736/s0391-1977.18.02868-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Adrenal incidentaloma is a frequent clinical finding. Once an adrenal mass is detected, is mandatory to determine whether the lesion is malignant or benign and whether it is hormonally active or non-functioning, to estabilish an adequate treatement or follow-up. The European Society of Endocrinology and ENSAT Guideline recently provided the best recommendation based on the available literature. However, due to the retrospective design of the majority of the studies, the small number of patients included and the inadequate follow-up, some issues are still unresolved. In particular, there is a general consensus about the need of adrenalectomy in the presence of unilateral adrenal mass and clinically relevant hormone excess or radiological findings suspected for malignancy. On the other side, how to manage adrenal masses with indeterminate characteristics or subtle cortisol secretion, and how long the radiological and functional follow-up of benign adrenal mass should last in non-operated patients, are still open questions. Therefore, high-quality research for establish the adequate management of these patients and randomized clinical trials are needed to avoid unnecessary investigations and invasive procedures and ensure a clinically effective work-up.
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Affiliation(s)
- Valentina Morelli
- Unit of Endocrinology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy -
| | - Serena Palmieri
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Abstract
RATIONALE Malignant pheochromocytoma is a rare disease and surgical resection is the only curative treatment. PATIENT CONCERNS An 81-year-old man of Chinese ethnicity was found to have a giant retroperitoneal tumor. DIAGNOSES B-scan ultrasonography and CT scan presented a mass above the left kidney, measuring 13.5 × 10 .6 × 9.8 cm. Subsequent analysis of 24-h urinary catecholamines and vanillylmandelic acid, as well as of blood catecholamines and blood cortisol, showed no elevated levels. INTERVENTIONS The patient was treated with surgery. OUTCOMES The result from immunohistochemical staining confirmed the presence of malignant pheochromocytoma. After three months follow-up, the blood pressure and serum potassium were all within normal limits, no post-operative complications, no tumor recurrence and metastasis were found. LESSONS This is the oldest patient known to have histologic documentation of this disease. Giant malignant pheochromocytomas are rare entities requiring clinical suspicion coupled with strategic diagnostic evaluation to confirm the diagnosis, personalized therapeutic treatment is required, particularly among elderly population.
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Affiliation(s)
| | - Erlin Sun
- Tianjin Institute of Urology, The 2nd Hospital of Tianjin Medical University
| | - Bingxin Lu
- Department of Urology, Tianjin Nankai Hospital, Tianjin, China
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53
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Koperski Ł, Kotlarek M, Świerniak M, Kolanowska M, Kubiak A, Górnicka B, Jażdżewski K, Wójcicka A. Next-generation sequencing reveals microRNA markers of adrenocortical tumors malignancy. Oncotarget 2018; 8:49191-49200. [PMID: 28423361 PMCID: PMC5564760 DOI: 10.18632/oncotarget.16788] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 03/16/2017] [Indexed: 11/25/2022] Open
Abstract
Background Adrenocortical carcinoma is a rare finding among common adrenocortical tumors, but it is highly aggressive and requires early detection and treatment. Still, the differential diagnosis between benign and malignant lesions is difficult even for experienced pathologists and there is a significant need for novel diagnostic methods. In this study we aimed to reveal a complete set of microRNAs expressed in the adrenal gland and to identify easily detectable, stable and objective biomarkers of adrenocortical malignancy. Methods We employed next-generation sequencing to analyze microRNA profiles in a unique set of 51 samples, assigned to either a learning dataset including 7 adrenocortical carcinomas (ACCs), 8 adrenocortical adenomas (AAs) and 8 control samples (NAs), or a validation dataset including 8 ACCs, 10 AAs and 10 NAs. The results were validated in real-time Q-PCR. Results We detected 411 miRNAs expressed in 1763 length isoforms in the examined samples. Fifteen miRNAs differentiate between malignant (ACC) and non-malignant (AA + NA) tissue in the test set of independent samples. Expression levels of 6 microRNAs, miR-503-5p, miR-483-3p, miR-450a-5p, miR-210, miR-483-5p, miR-421, predict sample status (malignancy/non-malignancy) with at least 95% accuracy in both datasets. The best single-gene malignancy marker, miR-483-3p, has been validated by real-time RT PCR. Conclusions As a result of the study we propose clinically valid and easily detectable biomarkers of adrenocortical malignancy that may significantly facilitate morphological examination. Since microRNAs can be detected in blood, the study brings tools for development of non-invasive diagnostics of adrenocortical carcinomas.
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Affiliation(s)
- Łukasz Koperski
- Department of Pathology, Medical University of Warsaw, Warsaw, Poland
| | - Marta Kotlarek
- Laboratory of Human Cancer Genetics, Center of New Technologies, CENT, University of Warsaw, Warsaw, Poland
| | - Michał Świerniak
- Laboratory of Human Cancer Genetics, Center of New Technologies, CENT, University of Warsaw, Warsaw, Poland.,Genomic Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Monika Kolanowska
- Laboratory of Human Cancer Genetics, Center of New Technologies, CENT, University of Warsaw, Warsaw, Poland.,Genomic Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Anna Kubiak
- Laboratory of Human Cancer Genetics, Center of New Technologies, CENT, University of Warsaw, Warsaw, Poland.,Genomic Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Barbara Górnicka
- Department of Pathology, Medical University of Warsaw, Warsaw, Poland
| | - Krystian Jażdżewski
- Laboratory of Human Cancer Genetics, Center of New Technologies, CENT, University of Warsaw, Warsaw, Poland.,Genomic Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Anna Wójcicka
- Laboratory of Human Cancer Genetics, Center of New Technologies, CENT, University of Warsaw, Warsaw, Poland.,Genomic Medicine, Medical University of Warsaw, Warsaw, Poland
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Minimally Invasive Adrenalectomy for Adrenocortical Carcinoma: Five-Year Trends and Predictors of Conversion. World J Surg 2017; 42:473-481. [DOI: 10.1007/s00268-017-4290-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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55
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Taïeb D, Sebag F, Pacak K. A Large Adrenal Tumor With Marked 18F-Fluorodeoxyglucose Uptake. JAMA 2017; 318:84-85. [PMID: 28672297 PMCID: PMC7440816 DOI: 10.1001/jama.2017.6326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- David Taïeb
- Department of Nuclear Medicine, La Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
| | - Frédéric Sebag
- Department of Endocrine Surgery, Conception University Hospital, Aix-Marseille University, Marseille, France
| | - Karel Pacak
- Eunice Kennedy Shriver National Institute of Child Health & Human Development, Section on Medical Neuroendocrinology, National Institutes of Health, Bethesda, Maryland
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Guerin C, Pattou F, Brunaud L, Lifante JC, Mirallié E, Haissaguerre M, Huglo D, Olivier P, Houzard C, Ansquer C, Hindié E, Loundou A, Archange C, Tabarin A, Sebag F, Baumstarck K, Taïeb D. Performance of 18F-FDG PET/CT in the Characterization of Adrenal Masses in Noncancer Patients: A Prospective Study. J Clin Endocrinol Metab 2017; 102:2465-2472. [PMID: 28431167 DOI: 10.1210/jc.2017-00254] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/14/2017] [Indexed: 02/04/2023]
Abstract
CONTEXT Few prospective studies have evaluated the role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in the characterization of adrenal masses. OBJECTIVE To assess the performance of 18F-FDG PET/CT in the malignancy diagnosis of adrenal masses in noncancer patients. DESIGN Prospective multicenter study. MATERIAL AND METHODS The study population consisted of 87 patients (87 adrenal masses) referred to endocrine surgeons: 56 with mass diameter ≥40 mm and 31 with a diameter <40 mm and of indeterminate nature based on unenhanced and washout CT attenuation densities. Fourteen patients had hypercortisolism. Adrenal masses were characterized by 18F-FDG PET/CT. Histology was the gold standard for the diagnosis of malignancy. In the absence of pathological proof (n = 23), the nature of the lesion was based on the 12-month imaging follow-up. RESULTS Fifteen adrenal masses were classified as malignant (including 11 adrenocortical carcinomas) and 72 as benign. Compared with benign lesions, malignant lesions were larger in size (P = 0.003), had higher unenhanced densities (P = 0.002), lower relative washout values (P = 0.007), and higher 18F-FDG uptake parameters (P < 10-3). The optimal threshold value of (Tumor SUVmax:Liver SUVmax) the ratio for malignancy was >1.5 with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 86.7%, 86.1%, 56.5%, 96.9%, and 86.2%, respectively. CONCLUSIONS Our results show that 18F-FDG PET/CT complements adrenal washout CT in the evaluation of adrenal masses and should be recommended in the evaluation of large and/or indeterminate adrenal masses.
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Affiliation(s)
- Carole Guerin
- Service de Chirurgie Générale et Endocrinienne, Centre Hospitalier Conception, APHM, Aix Marseille Univ, 13005 Marseille, France
| | - François Pattou
- Service de Chirurgie Endocrinienne, Centre Hospitalier Régional Universitaire de Lille, 59037 Lille, France; Université Lille Nord de France, INSERM, Lille, France
| | - Laurent Brunaud
- Université de Lorraine, Service de Chirurgie Digestive, Hépatobiliaire et Endocrinienne, Centre Hospitalo-Universitaire Nancy Brabois, 54511 Nancy, France
| | - Jean-Christophe Lifante
- Service de Chirurgie Générale et Endocrinienne, Centre Hospitalier Lyon Sud, Pierre Bénite, 69495 Lyon, France
| | - Eric Mirallié
- Clinique de Chirurgie Digestive et Endocrinienne, Hôtel Dieu, CHU Nantes, 44000 Nantes, France
| | - Magalie Haissaguerre
- Service d'Endocrinologie, Diabétologie et Nutrition, Centre Hospitalo-Universitaire de Bordeaux, Hôpital Haut-Lévêque Pessac, 33600 Pessac, France
| | - Damien Huglo
- Service de Médecine Nucléaire, Centre Hospitalo-Universitaire de Lille, OncoTHAI, INSERM U 1189, Univ, 59037 Lille, France
| | - Pierre Olivier
- Service de Médecine Nucléaire, Centre Hospitalo-Universitaire Nancy Brabois, 54511 Nancy, France
| | - Claire Houzard
- Service de Médecine Nucléaire, Centre Hospitalier Lyon Sud, Pierre-Bénite, 69495 Lyon, France
| | - Catherine Ansquer
- Service de Médecine Nucléaire, Hôtel Dieu, CHU Nantes, 44000 Nantes, France
| | - Elif Hindié
- Service de Médecine Nucléaire, Centre Hospitalo-Universitaire de Bordeaux, Hôpital Haut-Lévêque Pessac, 33600 Pessac, France
| | - Anderson Loundou
- Service de Santé Publique, Faculté de Médecine de la Timone, Aix Marseille Univ, 13005 Marseille, France
| | - Cendrine Archange
- Service de Médecine Nucléaire, Centre Hospitalo-Universitaire de la Timone, APHM, Centre Européen de Recherche en Imagerie Médicale, Aix Marseille Univ, 13385 Marseille, France
| | - Antoine Tabarin
- Service d'Endocrinologie, Diabétologie et Nutrition, Centre Hospitalo-Universitaire de Bordeaux, Hôpital Haut-Lévêque Pessac, 33600 Pessac, France
| | - Fréderic Sebag
- Service de Chirurgie Générale et Endocrinienne, Centre Hospitalier Conception, APHM, Aix Marseille Univ, 13005 Marseille, France
| | - Karine Baumstarck
- Service de Santé Publique, Faculté de Médecine de la Timone, Aix Marseille Univ, 13005 Marseille, France
| | - David Taïeb
- Service de Médecine Nucléaire, Centre Hospitalo-Universitaire de la Timone, APHM, Centre Européen de Recherche en Imagerie Médicale, Aix Marseille Univ, 13385 Marseille, France
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Ru W, Yang M, Xu S, Li M, Tang D. Management and prognosis of adrenocortical tumors in children: can we find out an appropriate points-scoring system to predict prognosis? Pediatr Surg Int 2017; 33:705-711. [PMID: 28260193 DOI: 10.1007/s00383-017-4073-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND/PURPOSE Adrenocortical tumors (ACTs) are rare in childhood. There are no recognized criteria to exactly distinguish between benign and malignant forms, or predict prognosis. The incidence of tumor varies across geographic regions or ethnicities, as well as malignant proportion. The aim of this study is to examine a single institution's experience with pediatric ACTs and to validate the prognostic value of the biologic/pathologic criteria of Wienecke. METHODS Records of 26 pediatric ACTs between 1994 and 2016 in our center were reviewed retrospectively. The data recorded of each patient included clinical characteristics, treatment, pathologic findings, disease stating, and outcome. Tumors were categorized according to the Wienecke criteria. RESULTS All patients underwent primary surgical excision, including negative margins in 20 cases. Stage distribution at diagnosis was: ST I 12, ST II 8, ST III 5, and ST IV 1. According to Wienecke scoring system, 13 cases were <3 criteria, 6 cases were =3 criteria, and 7 cases were >3 criteria. At median follow-up of 34.5 months, 18 patients survived without evidence of disease and 8 patients had lethal outcome. There was a strong association between high Wienecke score and both high stage and adverse outcome. CONCLUSIONS Wienecke criteria can be an appropriate points-scoring system to predict prognosis for adrenocortical tumors in children. Complete surgical resection with negative margins is optimal for survival.
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Affiliation(s)
- Wei Ru
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Min Yang
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Shan Xu
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China.
| | - Minju Li
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
| | - Daxing Tang
- Zhejiang University School of Medicine Children's Hospital, Hangzhou, China
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58
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Foo E, Turner R, Wang KC, Aniss A, Gill AJ, Sidhu S, Clifton-Bligh R, Sywak M. Predicting malignancy in adrenal incidentaloma and evaluation of a novel risk stratification algorithm. ANZ J Surg 2017; 88:E173-E177. [DOI: 10.1111/ans.13868] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 10/23/2016] [Accepted: 11/01/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Elizabeth Foo
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Robin Turner
- School of Public Health; The University of New South Wales; Sydney New South Wales Australia
| | - Kuan-Chi Wang
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Adam Aniss
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Anthony J. Gill
- Department of Anatomical Pathology; Royal North Shore Hospital; Sydney New South Wales Australia
- Cancer Diagnosis and Pathology Research Group; Kolling Institute of Medical Research; Sydney New South Wales Australia
| | - Stanley Sidhu
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology; Royal North Shore Hospital; Sydney New South Wales Australia
| | - Mark Sywak
- Endocrine Surgical Unit; The University of Sydney; Sydney New South Wales Australia
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Hirsutismo y amenorrea en carcinoma adrenocortical oncocítico hormonalmente activo. Aportación de un caso y revisión de la literatura. Rev Int Androl 2017. [DOI: 10.1016/j.androl.2016.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Fergany AF. Adrenal masses: A urological perspective. Arab J Urol 2016; 14:248-255. [PMID: 27900213 PMCID: PMC5122797 DOI: 10.1016/j.aju.2016.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/07/2016] [Accepted: 09/13/2016] [Indexed: 11/24/2022] Open
Abstract
Adrenal masses have become increasingly common due to widespread use of sectional imaging. Urologists are commonly faced with management decisions in patients with adrenal masses. Systemic review of available literature related to surgical adrenal disease was performed to summarise the most pertinent information related to adrenal masses, diagnostic evaluation and surgical treatment. Detailed hormonal evaluation of adrenal disease was not included, being part of endocrinological rather than urological practice. Adrenal masses exhibit a wide spectrum of presentation and pathology, and treatment requires different surgical techniques. Full understanding of the pathology and management of such masses should be completely familiar to practicing urologists.
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Affiliation(s)
- Amr F Fergany
- Glickman Urological and Kidney Foundation, 9500 Euclid Ave - Q10, Cleveland, OH 44195 USA
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61
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Wells SA. Progress in Endocrine Neoplasia. Clin Cancer Res 2016; 22:4981-4988. [PMID: 27742784 DOI: 10.1158/1078-0432.ccr-16-0384] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/24/2016] [Indexed: 01/17/2023]
Abstract
Most endocrine tumors are benign, and afflicted patients usually seek medical advice because of symptoms caused by too much, or too little, native hormone secretion or the impingement of their tumor on a vital structure. Malignant endocrine tumors represent a more serious problem, and patient cure often depends on early diagnosis and treatment. The recent development of novel molecular therapeutics holds great promise for the treatment of patients with locally advanced or metastatic endocrine cancer. In this CCR Focus, expert clinical investigators describe the molecular characteristics of various endocrine tumors and discuss the current status of diagnosis and treatment. Clin Cancer Res; 22(20); 4981-8. ©2016 AACR
See all articles in this CCR Focus section, "Endocrine Cancers Revising Paradigms".
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Affiliation(s)
- Samuel A Wells
- Genetics Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland.
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62
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McDuffie LA, Aufforth RD. Adrenocortical carcinoma: modern management and evolving treatment strategies. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2016; 3:161-174. [PMID: 27213037 DOI: 10.2217/ije-2015-0003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare cancer with a poor prognosis. Unlike many other cancers, there has been little improvement in patient outcome over the past several decades. However, as scientific advancements are made and our understanding of the molecular genetics involved in ACC improve then progress may be achieved in this devastating disease. This review focuses on recent literature published in the field of ACC from 2010 to 2015 with an emphasis on improving diagnosis, staging and treatment for ACC.
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Affiliation(s)
- Lucas A McDuffie
- Thoracic & Gastrointestinal Oncology Branch, National Cancer Institute, NIH, Bethesda, MD, USA
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63
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Natkaniec M, Pędziwiatr M, Wierdak M, Major P, Migaczewski M, Matłok M, Budzyński A, Rembiasz K. Laparoscopic Transperitoneal Lateral Adrenalectomy for Large Adrenal Tumors. Urol Int 2016; 97:165-72. [PMID: 26963130 DOI: 10.1159/000444146] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 01/19/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy is the gold standard for treatment of benign adrenal lesions. Tumor size is a factor that might influence decision-making concerning the use of laparoscopic approach. The aim of this study was to analyze the results of adrenalectomy for tumors ≥6 cm in diameter. METHODS Two groups of patients were analyzed: first group comprised 441 patients with tumors <6 cm in diameter and second group consisted of 89 patients with tumors ≥6 cm. Both groups were compared with regard to the duration of surgery, intraoperative blood loss, conversion and complications rate. RESULTS Median duration of surgery in groups 1 and 2 amounted to 86.6 and 111.9 min (p < 0.0001), respectively. Median intraoperative blood loss in groups 1 and 2 was 56.5 and 172.8 ml (p < 0.0001), respectively. There was a linear relationship between tumor size and the duration of surgery, and between tumor size and intraoperative blood loss (p < 0.0001). There were 2 (0.5%) and 6 (6.7%) conversions in groups 1 and 2, respectively. There were 41 (9.3%) and 14 (15.7%) complications in groups 1 and 2 (p = 0.0692), respectively. CONCLUSIONS Laparoscopic adrenalectomy of tumors ≥6 cm is more difficult, but it can be regarded safe and beneficial for patients.
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Affiliation(s)
- Michał Natkaniec
- 2nd Department of General Surgery, Jagiellonian University, Krakow, Poland
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Abstract
BACKGROUND Adrenocortical cancer (ACC) is a rare malignancy. In the absence of metastatic disease, the suspicion of ACC is based on size and radiological appearance. The aim of this study was to analyse the long-term outcome of patients with large adrenal cortical tumours (>8 cm). METHODS A prospective database recorded clinical, biochemical, operative and histological data on patients operated for cortical adrenal tumours between January 2000 and February 2013. Out of 130 patients operated for cortical adrenal tumours, analysis was restricted to 37 cortical tumours >8 cm. RESULTS There were 31 (84 %) ACCs and 6 (16 %) benign adenomas (p < 0.01). The most common presentation was that of an abdominal mass [17 (55 %) vs. 3 (50 %), ACC vs. benign, respectively]. There was no difference in size between stage II and stage III-IV tumours; however, there was a trend for tumours to be heavier in advanced stages (920 ± 756 vs. 1,435 ± 1,022 g, p = 0.08, stage II vs. stage III-IV, respectively). No mortality was observed in patients with benign tumours during a median follow-up of 70 months (range 36-99 months). Mortality in the ACC group occurred in 17/31 (55 %) patients. Mitotane was administered in 12 (71 %) patients with stage III-IV ACCs with a 5-year survival rate 25 % compared to 20 % in patients who did not receive Mitotane. In stage II ACC, eight (57 %) patients received Mitotane with a 50 % mortality at 5 years. CONCLUSIONS The high incidence of ACC in cortical tumours >8 cm underlines the need for adequate surgical resection via open surgery aiming to avoid local recurrence. Beyond surgery, the impact of other therapies is not fully characterised and the efficacy of adjuvant Mitotane treatment is yet to be proven.
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Libé R. Adrenocortical carcinoma (ACC): diagnosis, prognosis, and treatment. Front Cell Dev Biol 2015; 3:45. [PMID: 26191527 PMCID: PMC4490795 DOI: 10.3389/fcell.2015.00045] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 06/22/2015] [Indexed: 12/16/2022] Open
Abstract
Adrenocortical carticnoma (ACC) is a rare malignancy with an incidence of 0.7-2.0 cases/million habitants/year. The diagnosis of malignancy relies on careful investigations of clinical, biological, and imaging features before surgery and pathological examination after tumor removal. Most patients present with steroid hormone excess or abdominal mass effects, but 15% of patients with ACC is initially diagnosed incidentally. After the diagnosis, in order to assess the ACC prognosis and establish an adequate basis for treatment decisions different tools are proposed. The stage classification proposed by the European Network for the Study of Adrenal Tumors (ENSAT) is recommended. Pathology reports define the Weiss score, the resection status and the proliferative index, including the mitotic count and the Ki67 index. As far as the treatment is concerned, in case of tumor limited to the adrenal gland, the complete resection of the tumor is the first option. Most patients benefit from adjuvant mitotane treatment. In metastatic disease, mitotane is the cornerstone of initial treatment, and cytotoxic drugs should be added in case of progression. Recently, the First International Randomized (FIRM-ACT) Trial in metastatic ACC reported the association between mitotane and etoposide/doxorubicin/cisplatin (EDP) as the new standard in first line treatment of ACC. In last years, new targeted therapies, including the IGF-1 receptor inhibitors, have been investigated, but their efficacy remains limited. Thus, new treatment concepts are urgently needed. The ongoing "omic approaches" and next-generation sequencing will improve our understanding of the pathogenesis and hopefully will lead to better therapies.
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Affiliation(s)
- Rossella Libé
- Department of Endocrinology, French Network for Adrenal Cancer, Cochin Hospital Paris, France
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Yoo JY, McCoy KL, Carty SE, Stang MT, Armstrong MJ, Howell GM, Bartlett DL, Tublin ME, Yip L. Adrenal Imaging Features Predict Malignancy Better than Tumor Size. Ann Surg Oncol 2015; 22 Suppl 3:S721-7. [DOI: 10.1245/s10434-015-4684-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Indexed: 12/21/2022]
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Ioachimescu AG, Remer EM, Hamrahian AH. Adrenal incidentalomas: a disease of modern technology offering opportunities for improved patient care. Endocrinol Metab Clin North Am 2015; 44:335-54. [PMID: 26038204 DOI: 10.1016/j.ecl.2015.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Adrenal incidentalomas (AIs) are found in approximately 4% of patients undergoing abdominal imaging, with peak prevalence in the sixth and seventh decades of life. Detection of AI warrants clinical, biochemical, and radiological evaluation to establish its secretory status and risk of malignancy. Careful review of the lipid content, size, and imaging phenotype of an adrenal mass is needed to evaluate the risk for malignancy. Identification of an AI may be an opportunity to identify an underlying secretory tumor that may have been otherwise unrecognized. A practical approach to investigation and follow-up of AIs is presented in this article.
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Affiliation(s)
- Adriana G Ioachimescu
- Emory University School of Medicine, 1365 B Clifton Road, Northeast, B6209, Atlanta, GA 30322, USA
| | - Erick M Remer
- Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, A21, Cleveland, OH 44195, USA
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Chatterjee G, DasGupta S, Mukherjee G, Sengupta M, Roy P, Arun I, Datta C, Mishra PK, Banerjee S, Chatterjee U. Usefulness of Wieneke criteria in assessing morphologic characteristics of adrenocortical tumors in children. Pediatr Surg Int 2015; 31:563-71. [PMID: 25895073 DOI: 10.1007/s00383-015-3708-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/07/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Adrenocortical tumors (ACT) occur rarely in pediatric age group. Pediatric ACTs behave differently from their histologically similar adult counterparts and standard adult criteria often cannot accurately predict their clinical behavior. The aim of the present study was to document the clinicopathologic spectrum of pediatric ACTs and to assess the utility of Wieneke scoring system in predicting clinical behavior of these tumors. METHODS This multi-institutional study comprised of 13 cases of pediatric ACTs from January 2005 to May 2014. Clinical features and gross pathologic characteristics were obtained from records. Comprehensive analyses of microscopic features were performed. Each tumor was assessed according to criteria proposed by Wieneke et al. and was assigned to benign, intermediate for malignancy or malignant group. The standard adult Weiss criteria were also applied for comparison. RESULTS There were total 6 cases of adrenocortical adenomas and 7 cases of adrenocortical carcinomas. Most of the children (76.9%) presented with endocrine dysfunction. Lower age of presentation was significantly associated with better prognosis. Applying Wieneke criteria, there were 6 benign and 6 malignant cases and one case was assigned to intermediate for malignancy group. The clinical behavior of all the cases was consistent with Wieneke criteria categorization. Applying Weiss criteria, 3 cases with benign clinical behavior were assigned to malignant group. CONCLUSION Our study validates the reliability of Wieneke scoring system in predicting malignancy in pediatric ACTs. It is simple and easy to use and therefore useful in day-to-day practice.
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Mihai R. Diagnosis, treatment and outcome of adrenocortical cancer. Br J Surg 2015; 102:291-306. [PMID: 25689291 DOI: 10.1002/bjs.9743] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 10/31/2014] [Accepted: 11/11/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Adrenocortical cancer (ACC) is a rare disease with a dismal prognosis. The majority of patients are diagnosed with advanced disease and raise difficult management challenges. METHODS All references identified in PubMed, published between 2004 and 2014, using the keywords 'adrenocortical cancer' or 'adrenal surgery' or both, were uploaded into a database. The database was interrogated using keywords specific for each field studied. RESULTS In all, 2049 publications were identified. There is ongoing debate about the feasibility and oncological outcomes of laparoscopic adrenalectomy for small ACCs, and data derived from institutional case series have failed to provide an evidence level above expert opinion. The use of mitotane (1-(2-chlorophenyl)-1-(4-chlorophenyl)-2,2-dichloroethane) in combination with chemotherapy in the treatment of metastatic disease has been assessed in an international randomized trial (FIRM-ACT trial) involving patients with ACC. Based on this trial, mitotane plus etoposide, doxorubicin and cisplatin is now the established first-line cytotoxic therapy owing to a higher response rate and longer median progression-free survival than achieved with streptozocin-mitotane. For patients with tumours smaller than 5 cm and with no signs of lymph node or distant metastases, survival is favourable with a median exceeding 10 years. However, the overall 5-year survival rate for all patients with ACC is only 30 per cent. CONCLUSION Open and potentially laparoscopic adrenalectomy for selected patients is the main treatment for non-metastatic ACC, but the overall 5-year survival rate remains low.
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Affiliation(s)
- R Mihai
- Department of Endocrine Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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70
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Wanis KN, Kanthan R. Diagnostic and prognostic features in adrenocortical carcinoma: a single institution case series and review of the literature. World J Surg Oncol 2015; 13:117. [PMID: 25889798 PMCID: PMC4384320 DOI: 10.1186/s12957-015-0527-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 02/28/2015] [Indexed: 01/18/2023] Open
Abstract
Background Adrenocortical carcinoma is a rare cancer, with an incidence in the literature of 0.5 to 2 cases per million population per year. Adult adrenocortical carcinoma has a poor prognosis, underscoring the importance of identifying diagnostic and prognostic markers. Methods We searched our laboratory database for all cases in the past 15 years with a diagnosis of adrenocortical carcinoma. The original slides were then reviewed for their histopathological features. A representative paraffin block was subjected to further immunohistochemical staining for Ki-67, inhibin, steroidogenic factor-1 (SF-1), p53, and Β-catenin. These slides were scored by the study pathologist who was blinded to all clinicopathological data. In addition, a comprehensive review of the relevant English literature in the past 15 years was conducted. Results Eight cases were identified, including two adrenal sarcomatoid carcinomas. Seven of the eight cases had a disrupted reticulin network. Six of the eight tumors had >10% Ki-67 expression. Five of the eight tumors had >10% p53 expression. Positive inhibin immunohistochemical staining was seen in three of the eight tumors, and positive SF-1 staining was seen in five of the seven stained tumors. Abnormal Β-catenin intracellular accumulation was noted in four of the eight tumors. The two tumors in our series with sarcomatoid histology did not stain positively for SF-1 or inhibin. Conclusions Eight cases of adrenocortical carcinoma, including two with sarcomatoid features are presented. The two sarcomatoid adrenocortical carcinomas in our series did not stain for SF-1 which suggests a possible de novo pathway of tumorigenesis for this rare variant. The reticulin staining method was a useful tool for rapid differentiation of adrenocortical adenomas and carcinomas. Diffuse p53 staining showed a trend for positive correlation with increased Ki-67 expression. Inhibin staining was inconsistently expressed in our cases of adrenocortical carcinoma. In conclusion, as adrenocortical carcinoma is a rare disease, we recommend future multicenter studies with appropriate sample sizes to further evaluate the efficacy of these diagnostic and prognostic markers.
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Affiliation(s)
- Kerollos N Wanis
- College of Medicine, University of Saskatchewan, Saskatoon, Canada.
| | - Rani Kanthan
- Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, Canada. .,Royal University Hospital, Room 2868G-Wing, 103 Hospital Drive, Saskatoon, Saskatchewan, S7N 0W8, Canada.
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Zografos GN, Perysinakis I, Kyrodimou E, Kassi E, Kaltsas G. Surgical treatment of potentially primary malignant adrenal tumors: an unresolved issue. Hormones (Athens) 2015; 14:47-58. [PMID: 25885103 DOI: 10.1007/bf03401380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Although the great majority of incidentalomas are adrenocortical adenomas, a number of them, depending on the size and radiological characteristics of the lesions, will turn out to be carcinomas. These tumors may present as suspicious on initial evaluation and potentially malignant or malignant on histology. Adrenocortical carcinoma is a rare and aggressive malignancy with evolving diagnostic and therapeutic approaches. Laparoscopic surgery has become the gold standard for surgery of benign adrenal tumors. Despite the extensive experience gained in laparoscopic adrenalectomy, controversy still remains in the management of adrenal tumors with high suspicion or evidence of malignancy. The aim of this review is to update the existing information regarding the diagnostic approach and surgical management of suspicious and potentially malignant primary adrenal tumors.The interpretation of radiologic characteristics is a cornerstone in pre-operative assessment of large adrenal masses, since open surgery remains the preferred procedure when malignancy is suspected in large tumors with possible local invasion. Despite the improvement of imaging techniques, they lack sufficient accuracy to exclude primary malignancy in tumors from 4 cm to 10 cm in size. An initial laparoscopic approach can be used in this group of patients, but early conversion to open technique is mandatory if curative resection cannot be performed. Adrenal tumors >10 cm of malignant potential should be treated by the open approach from the start. Solitary adrenal metastasis from another primary malignancy is usually amenable to laparoscopic surgery. Patients with suspected adrenal cancer should be referred to tertiary centers that perform laparoscopic and open adrenal surgery with minimal morbidity and mortality.
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Affiliation(s)
- George N Zografos
- Third Department of Surgery, General Hospital "G. Gennimatas", Athens, Greece
| | - Iraklis Perysinakis
- Third Department of Surgery, General Hospital "G. Gennimatas", Athens, Greece
| | | | - Eva Kassi
- Department of Biochemistry, National University of Athens; Athens, Greece
| | - Gregory Kaltsas
- Department of Pathophysiology, National University of Athens; Athens, Greece
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Birsen O, Akyuz M, Dural C, Aksoy E, Aliyev S, Mitchell J, Siperstein A, Berber E. A new risk stratification algorithm for the management of patients with adrenal incidentalomas. Surgery 2014; 156:959-65. [PMID: 25239353 DOI: 10.1016/j.surg.2014.06.042] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 06/23/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although adrenal incidentalomas (AI) are detected in ≤5% of patients undergoing chest and abdominal computed tomography (CT), their management is challenging. The current guidelines include recommendations from the National Institutes of Health, the American Association of Endocrine Surgeons (AAES), and the American Association for Cancer Education (AACE). The aim of this study was to develop a new risk stratification model and compare its performance against the existing guidelines for managing AI. METHODS A risk stratification model was designed by assigning points for adrenal size (1, 2, or 3 points for tumors <4, 4-6, or >6 cm, respectively) and Hounsfield unit (HU) density on noncontrast CT (1, 2, or 3 points for HU <10, 10-20, or >20, respectively). This model was applied retrospectively to 157 patients with AI managed in an endocrine surgery clinic to assign a score to each tumor. The utility of this model versus the AAES/AACE guidelines was assessed. RESULTS Of the 157 patients, 54 (34%), had tumors <4 cm with HU <10 (a score of 2). One third of these were hormonally active on biochemical workup and underwent adrenalectomy. The remaining two thirds were nonsecretory lesions and have been followed conservatively with annual testing. In 103 patients (66%), the adrenal mass was >4 cm and/or had indeterminate features on noncontrast CT (HU >10, irregular borders, heterogeneity), and adrenalectomy was performed after hormonal evaluation was completed (10 were hormonally active on biochemical testing). Seven of these patients (7%) had adrenocortical cancer on final pathology with tumor size <4 cm in 0, 4-6 cm in 1, and >6 cm in 5 patients. Of the hormonally inactive patients, 32% had a score of 3, 38% 4, and 30% 5 or 6. The incidence of adrenocortical cancer in these subgroups was 0, 0, and 25%, respectively. CONCLUSION This study shows that an algorithm that utilizes the hormonal activity at the first decision step followed by a consolidated risk stratification, based on tumor size and HU density, has a potential to spare a substantial number of patients from unnecessary "diagnostic" surgery for AI.
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Affiliation(s)
- Onur Birsen
- Department of Endocrine Surgery, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - Muhammet Akyuz
- Department of Endocrine Surgery, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - Cem Dural
- Department of Endocrine Surgery, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - Erol Aksoy
- Department of Endocrine Surgery, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - Shamil Aliyev
- Department of Endocrine Surgery, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - Jamie Mitchell
- Department of Endocrine Surgery, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - Allan Siperstein
- Department of Endocrine Surgery, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH
| | - Eren Berber
- Department of Endocrine Surgery, Endocrine and Metabolism Institute, Cleveland Clinic, Cleveland, OH.
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Laparoscopic adrenalectomy for large adrenal masses: Single team experience. Int J Surg 2014; 12 Suppl 1:S72-4. [DOI: 10.1016/j.ijsu.2014.05.050] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2014] [Accepted: 05/03/2014] [Indexed: 11/18/2022]
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Kiernan CM, Shinall MC, Mendez W, Peters MF, Broome JT, Solorzano CC. Influence of adrenal pathology on perioperative outcomes: a multi-institutional analysis. Am J Surg 2014; 208:619-25. [PMID: 25129428 DOI: 10.1016/j.amjsurg.2014.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 05/17/2014] [Accepted: 06/03/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Endoscopic or open adrenalectomies are performed for variable pathologies. We investigated if adrenal pathology affects perioperative outcomes independent of operative approach. METHODS A multi-institutional retrospective review of 345 adrenalectomies was performed. A multivariate analysis was utilized. RESULTS Pathology groups included benign non-pheochromocytoma tumors (50.4%), pheochromocytomas (41%), adrenocortical carcinomas (5.2%), and metastatic tumors (3.4%). Controlling for age, body mass index, tumor size, procedure type, and pathology, pheochromocytomas exhibited greater blood loss (92 mL more, P = .007) and operative times (33 min more, P < .001) than benign non-pheochromocytoma tumors. Metastatic tumors demonstrated longer operative times (53 min more, P = .013). Open adrenalectomy was associated with greater blood loss (396 mL more, P = .001), transfusion requirement (P = .021), operative times (79 min more, P < .001), hospital stay (6.6 days more, P < .001) and complications (P < .001) when compared with endoscopic adrenalectomy. CONCLUSIONS The type of adrenal pathology appears to influence blood loss and operative time but not complications in patients undergoing adrenalectomy. Open adrenalectomy remains a major driver of adverse perioperative outcomes.
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Affiliation(s)
- Colleen M Kiernan
- Division of General Surgery, Vanderbilt University, Nashville, TN, USA.
| | - Myrick C Shinall
- Division of General Surgery, Vanderbilt University, Nashville, TN, USA
| | - William Mendez
- Division of Endocrine Surgery, University of Puerto Rico, San Juan, PR, USA
| | - Mary F Peters
- Department of Anesthesiology, Vanderbilt University, Nashville, TN, USA
| | - James T Broome
- Division of Surgical Oncology/Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
| | - Carmen C Solorzano
- Division of Surgical Oncology/Endocrine Surgery, Vanderbilt University, Nashville, TN, USA
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75
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Özgör F, Binbay M, Akbulut MF, Şimsek A, Şahan M, Berberoğlu AY, Sarılar Ö, Müslümanoğlu AY. Laparoscopic transperitoneal adrenalectomy: Our initial results. Turk J Urol 2014; 40:99-103. [PMID: 26328159 DOI: 10.5152/tud.2014.09076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/06/2014] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To present the first 24 laparoscopic adrenalectomies performed in our clinic because of an adrenal mass. MATERIAL AND METHODS The medical files of 24 patients who underwent laparoscopic adrenalectomy between December 2008 and March 2013 at Haseki Teaching and Research Hospital were analyzed retrospectively. The demographic characteristics of the patients were recorded. Lateral transperitoneal laparoscopic adrenalectomy was performed in all patients. The operation time was defined as the interval between the first incision of the skin and closure of the skin. Intraoperative complications, estimated blood loss and hospital stays of the patients were evaluated. Final pathologies were recorded. RESULTS The mean age of the patients was 44.2±8.58 years (range: 29-66 years). Nine patients were female and 15 were male. A total of 24 masses were identified in the right (n=11), and left (n=13) adrenal glands masses were identified., Eighteen patients (75%) had no symptoms, and the masses were identified incidentally. The mean operation time was 144±46.1 minutes (range: 90-320 minutes), and the mean blood loss was 74±12.3 mL (range: 50-130 mL). None of the patients required a blood transfusion. In one patient, liver injury was identified intraoperatively due to traction. The mean duration of hospitalization was 2.9±1.1 days (range: 2-5 days). Adrenocortical adenoma and pheochromocytoma were the most common pathologies. CONCLUSION Laparoscopic adrenalectomy is a safe and effective method for the treatment of adrenal masses with low complication rates.
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Affiliation(s)
- Faruk Özgör
- Department of Urology, Haseki Training and Research Hospital, İstanbul, Turkey
| | - Murat Binbay
- Department of Urology, Haseki Training and Research Hospital, İstanbul, Turkey
| | | | | | - Murat Şahan
- Department of Urology, Haseki Training and Research Hospital, İstanbul, Turkey
| | | | - Ömer Sarılar
- Department of Urology, Haseki Training and Research Hospital, İstanbul, Turkey
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Abstract
The surgical treatment of adrenal tumours has evolved over the past century, as has our understanding of which hormones are secreted by the adrenal glands and what these hormones do. This article reviews the preoperative evaluation of patients with adrenal tumours that could be benign or malignant, including metastases. The biochemical evaluation of excess levels of hormones is discussed, as are imaging characteristics that differentiate benign tumours from malignant tumours. The options for surgical management are outlined, including the advantages and disadvantages of various open and laparoscopic approaches. The surgical management of adrenocortical carcinoma is specifically reviewed, including controversies in operative approaches as well as surgical management of invasive or recurrent disease.
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Affiliation(s)
- Barbra S Miller
- University of Michigan Health System, 1500 East Medical Center Drive, 2920F Taubman Center, Ann Arbor, MI 48109-5331, USA
| | - Gerard M Doherty
- Department of Surgery, Boston University, 75 East Newton Street, Boston, MA 02118, USA
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77
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Else T, Kim AC, Sabolch A, Raymond VM, Kandathil A, Caoili EM, Jolly S, Miller BS, Giordano TJ, Hammer GD. Adrenocortical carcinoma. Endocr Rev 2014; 35:282-326. [PMID: 24423978 PMCID: PMC3963263 DOI: 10.1210/er.2013-1029] [Citation(s) in RCA: 564] [Impact Index Per Article: 56.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Adrenocortical carcinoma (ACC) is a rare endocrine malignancy, often with an unfavorable prognosis. Here we summarize the knowledge about diagnosis, epidemiology, pathophysiology, and therapy of ACC. Over recent years, multidisciplinary clinics have formed and the first international treatment trials have been conducted. This review focuses on evidence gained from recent basic science and clinical research and provides perspectives from the experience of a large multidisciplinary clinic dedicated to the care of patients with ACC.
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Affiliation(s)
- Tobias Else
- MEND/Division of Metabolism, Endocrinology, and Diabetes (T.E., T.J.G., G.D.H.), Division of Molecular Medicine and Genetics (V.M.R.), Department of Internal Medicine; Departments of Radiation Oncology (A.S., J.S.), Pathology (T.J.G.), and Radiology (A.K., E.M.C.); and Division of Endocrine Surgery (B.S.M.), Section of General Surgery, (A.C.K.), Department of Surgery, University of Michigan Hospital and Health Systems, Ann Arbor, Michigan 48109
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Cyriac J, Weizman D, Urbach DR. Laparoscopic adrenalectomy for the management of benign and malignant adrenal tumors. Expert Rev Med Devices 2014; 3:777-86. [PMID: 17280543 DOI: 10.1586/17434440.3.6.777] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Laparoscopic adrenalectomy has become the preferred approach for removal of the adrenal gland. Many published studies support the use of laparoscopic adrenalectomy, with comparisons to open adrenalectomy suggesting many advantages to laparoscopy, including less postoperative pain, shorter hospital stay and earlier return to work. Adrenalectomy is usually required for the removal of adrenal tumors causing excess hormone production or because a malignant adrenal tumor cannot be excluded. Current controversies include the appropriateness of laparoscopic adrenalectomy for large or malignant tumors, the role of partial adrenalectomy and the management of some conditions with uncertain natural history (such as subclinical hypercortisolism). With the increased use of sensitive cross-sectional imaging, the detection of clinically inapparent adrenal masses is likely to continue to increase. Due to the fact that malignancy cannot be excluded with certainty in some patients with cortical adenomas, it is expected that the rate of laparoscopic adrenalectomy will continue to increase.
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Affiliation(s)
- Jamie Cyriac
- University of Toronto, Toronto, Ontario, Canada.
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79
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Suh I, Guerrero MA, Kebebew E. Gene-expression profiling of adrenocortical carcinoma. Expert Rev Mol Diagn 2014; 9:343-51. [DOI: 10.1586/erm.09.13] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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80
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Chuan-yu S, Yat-faat H, Wei-hong D, Yuan-cheng G, Qing-feng H, Ke X, Bin G, Guo-wei X. Laparoscopic adrenalectomy for adrenal tumors. Int J Endocrinol 2014; 2014:241854. [PMID: 25132851 PMCID: PMC4123616 DOI: 10.1155/2014/241854] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 07/01/2014] [Indexed: 11/17/2022] Open
Abstract
Objective. To evaluate the indication and the clinical value of laparoscopic adrenalectomy of different types of adrenal tumor. Methods. From 2009 to 2014, a total of 110 patients were diagnosed with adrenal benign tumor by CT scan and we performed laparoscopic adrenalectomy. The laparoscopic approach has been the procedure of choice for surgery of benign adrenal tumors, and the upper limit of tumor size was thought to be 6 cm. Results. 109 of 110 cases were successful; only one was converted to open surgery due to bleeding. The average operating time and intraoperative blood loss of pheochromocytoma were significantly more than the benign tumors (P < 0.05). After 3 months of follow-up, the preoperative symptoms were relieved and there was no recurrence. Conclusions. Laparoscopic adrenalectomy has the advantages of minimal invasion, less blood loss, fewer complications, quicker recovery, and shorter hospital stay. The full preparation before operation can decrease the average operating time and intraoperative blood loss of pheochromocytomas. Laparoscopic adrenalectomy should be considered as the first choice treatment for the resection of adrenal benign tumor.
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Affiliation(s)
- Sun Chuan-yu
- Department of Urology, Huashan Hospital of Fudan University, Shanghai 200040, China
| | - Ho Yat-faat
- Department of Urology, Huashan Hospital of Fudan University, Shanghai 200040, China
| | - Ding Wei-hong
- Department of Urology, Huashan Hospital of Fudan University, Shanghai 200040, China
| | - Gou Yuan-cheng
- Department of Urology, Huashan Hospital of Fudan University, Shanghai 200040, China
| | - Hu Qing-feng
- Department of Urology, Huashan Hospital of Fudan University, Shanghai 200040, China
| | - Xu Ke
- Department of Urology, Huashan Hospital of Fudan University, Shanghai 200040, China
| | - Gu Bin
- Department of Urology, Huashan Hospital of Fudan University, Shanghai 200040, China
| | - Xia Guo-wei
- Department of Urology, Huashan Hospital of Fudan University, Shanghai 200040, China
- *Xia Guo-wei:
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Musella M, Conzo G, Milone M, Corcione F, Belli G, De Palma M, Tricarico A, Santini L, Palazzo A, Bianco P, Biondi B, Pivonello R, Colao A. Preoperative workup in the assessment of adrenal incidentalomas: outcome from 282 consecutive laparoscopic adrenalectomies. BMC Surg 2013; 13:57. [PMID: 24279337 PMCID: PMC4222495 DOI: 10.1186/1471-2482-13-57] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 11/21/2013] [Indexed: 12/03/2022] Open
Abstract
Background To confirm the efficacy of preoperative workup, the authors analyse the results of a multicentre study in a surgical series of patients diagnosed with an adrenal incidentaloma. Methods The retrospective review of a prospectively collected database was conducted. The data was obtained by six surgical units operating in the Campania Region, Italy. Five-hundred and six (506) adrenalectomies performed between 1993 and 2011 on 498 patients were analysed. Final histology in patients with a preoperative diagnosis of incidentaloma and studied according to guidelines (230/282 patients group A) was compared with final histology coming from patients presenting the same preoperative diagnosis but studied not according to guidelines (52/282 patients group B). Results In group A preoperative diagnosis was confirmed at final histology in 76/81 (93.8%) cases of subclinical functioning lesions presenting as an incidentaloma. The preoperative detection of pheochromocytoma and primary adrenocortical cancer (ACC) reached 91.6% and 84.6% respectively. In group B conversion rate to open surgery was higher than in group A (p = 0.02). One pheochromocytoma was missed at preoperative diagnosis whereas one ACC smaller than 4 centimetres (cm) and coming from an incidental lesion was discovered. In both groups a significant association between increasing dimensions of incidentaloma and cancer has been observed (p = 0.001). Conclusions This surgical series confirm the high efficacy of suggested guidelines. A significant preoperative detection rate of adrenal lesions presenting as incidentaloma is observed. The unnecessary number of adrenalectomies performed in understudied patients, causing higher morbidity, was not associated to a higher detection rate of primary adrenocortical cancer.
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Affiliation(s)
- Mario Musella
- General and Emergency Surgery, "Federico II" University, Naples, Italy.
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Contribution 2013 du CCAFU au référentiel INCa : Tumeurs malignes de la surrénale. Prog Urol 2013; 23 Suppl 2:S167-74. [DOI: 10.1016/s1166-7087(13)70054-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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83
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Varón de 78 años con fiebre y afectación meníngea recurrente. Rev Clin Esp 2013. [DOI: 10.1016/j.rce.2013.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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84
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Agha A, Hornung M, Iesalnieks I, Schreyer A, Jung EM, Haneya A, Schlitt HJ. Predictors of malignancy in primary aldosteronism. Langenbecks Arch Surg 2013; 399:93-8. [PMID: 24048685 DOI: 10.1007/s00423-013-1121-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 09/08/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Primary aldosteronism (PA, also Conn syndrome) is a benign disease in majority of cases. However, malignant transformation has been described. Present study reports on three cases of aldosterone producing adrenocortical carcinoma (APAC) in comparison to patients with benign PA. PATIENTS AND METHODS Data of patients undergoing adrenalectomy for benign PA were compared to patients with APAC. Retrospective chart analysis was performed. All patients received spironolactone for 6-8 weeks preoperatively. RESULTS Seventy-four patients underwent adrenalectomy for PA between 1994 and 2011. Three of them revealed an APAC. Patients with APAC presented with a significantly lower serum potassium level (1.7 mmol/l vs. 3.4 mmol/l, p = 0.001) and significant larger tumors (5.2 vs. 1.8 cm, p = 0.002). In addition, aldosterone/renin (A/R) ratio 675 in patients with APAC as compared to 74 in patients with benign PA (p = 0.0001). Sixty-eight of 71 patients with benign PA underwent minimal invasive surgery, whereas all three patients with APAC were operated conventionally. All patients with APAC developed disease recurrence 6-18 months postoperatively. CONCLUSION Tumor size >4 cm and a very high A/R ratio seems to predictors of malignancy in patients with PA. If these criteria are present, open adrenalectomy should be performed instead of endoscopic procedure.
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Affiliation(s)
- Ayman Agha
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
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Trastornos de la glándula suprarrenal: diagnóstico y tratamiento. REVISTA MÉDICA CLÍNICA LAS CONDES 2013. [DOI: 10.1016/s0716-8640(13)70222-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Wang TS, Cheung K, Roman SA, Sosa JA. A cost-effectiveness analysis of adrenalectomy for nonfunctional adrenal incidentalomas: is there a size threshold for resection? Surgery 2012; 152:1125-32. [PMID: 22989893 DOI: 10.1016/j.surg.2012.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 08/10/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare, but aggressive, malignancy. Current American Association of Clinical Endocrinologists (AACE)/American Association of Endocrine Surgeons (AAES) guidelines recommend resection of nonfunctional adrenal neoplasms ≥ 4 cm. This study evaluates the cost-effectiveness of this approach. METHODS A decision tree was constructed for patients with a nonfunctional, 4-cm adrenal incidentaloma with no radiographic suspicion for ACC. Patients were randomized to adrenalectomy, surveillance per AACE/AAES guidelines, or no follow-up ("sign-off"). Incremental cost-effectiveness ratio (ICER) includes health care costs, including missed ACC. ICER (dollar/life-year-saved [LYS]) was determined from the societal perspective. Sensitivity analyses were performed. RESULTS In the base-case analysis, assuming a 2.0% probability of ACC for a 4-cm tumor, surgery was more cost-effective than surveillance (ICER $25,843/LYS). Both surgery and surveillance were incrementally more cost-effective than sign-off ($35/LYS and $8/LYS, respectively). Sensitivity analysis demonstrated that the model was sensitive to patient age, tumor size, probability of ACC, mortality of ACC, and cost of hospitalization. The results of the model were stable across different cost and complications related to adrenalectomy, regardless of operative approach. CONCLUSION In our model, adrenalectomy was cost-effective for neoplasms >4 cm and in patients <65 years, primarily owing to the aggressiveness of ACC. Current AACE/AAES guideline recommendations for the resection of adrenal incidentalomas ≥ 4 cm seem to be cost-effective.
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Affiliation(s)
- Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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87
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Melck AL, Rosengart MR, Armstrong MJ, Stang MT, Carty SE, Yip L. Immediate laparoscopic adrenalectomy versus observation: cost evaluation for incidental adrenal lesions with atypical imaging characteristics. Am J Surg 2012; 204:462-7. [PMID: 22591697 DOI: 10.1016/j.amjsurg.2012.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 02/26/2012] [Accepted: 02/26/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Because of controversy in the management of nonfunctional adrenal masses <6 cm with lipid-poor imaging characteristics, the study was conducted to compare the costs of observation versus immediate laparoscopic adrenalectomy. METHODS A total of 370 patients who were evaluated for incidental adrenal masses between January 1999 and December 2007 were identified, and 32 (8.7%) patients had lesions with imaging characteristics that were inconsistent with a benign adenoma (ie, atypical appearing). Sixteen patients underwent immediate surgery and 16 had observation with serial imaging and biochemical studies. The associated total costs were subjected to intention-to-treat analysis. RESULTS In the observation cohort, 7 patients converted and underwent adrenalectomy after a mean of 13.1 months. Initially, costs of immediate surgery exceeded those of observation ($12,015.72 vs $11,601.18, P = .10). After projecting costs of annual surveillance, a cost advantage for immediate surgery was demonstrated after 9 years (P = .02). CONCLUSIONS In patients with <6 cm atypical-appearing adrenal lesions, the costs of surgery and of observation are initially equal. After 9 years, the costs of surveillance exceed that of initial laparoscopic adrenalectomy.
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Affiliation(s)
- Adrienne L Melck
- Division of Endocrine Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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88
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Mihai R, Iacobone M, Makay O, Moreno P, Frilling A, Kraimps JL, Soriano A, Villar del Moral J, Barczynski M, Durán MC, Sadler GP, Niederle B, Dralle H, Harrison B, Carnaille B. Outcome of operation in patients with adrenocortical cancer invading the inferior vena cava--a European Society of Endocrine Surgeons (ESES) survey. Langenbecks Arch Surg 2011; 397:225-31. [PMID: 22134748 DOI: 10.1007/s00423-011-0876-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 11/09/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND Most patients with adrenocortical cancer (ACC) continue to present with advanced disease. Invasion into the inferior vena cava (IVC) defines stage III disease and the management of such patients raises additional difficulties. METHOD A multicentre survey was organized by emailing a standardized proforma to members of the European Society of Endocrine Surgery (ESES). Anonymised retrospective clinical data were collected. RESULTS Replies were received from 18 centres in nine countries. ACC with IVC invasion was encountered in 38 patients (18F:20M, age 15-84 years, median 54 years). There were 16 nonfunctioning tumours and 22 functioning tumours predominantly right-sided (26R:12L) and measuring 18-255 mm (median 115 mm). Fourteen patients had metastatic disease at presentation. Tumour thrombus extended in the prehepatic IVC (n = 21), subdiaphragmatic IVC (n = 6) or into the SVC/right atrium (n = 3). Open adrenalectomy was associated with resection of surrounding viscera in 24 patients (nephrectomy n = 16, liver resection n = 14, splenectomy n = 3, Whipple procedure n = 2). IVC was controlled locally (n = 27), at suprahepatic levels (n = 6) or necessitated cardiac bypass (n = 5). Complete resection (R0, n = 20) was achieved in the majority of patients, with a minority having microscopic persistent disease (R1, n = 7) or macroscopic residual disease (R2, n = 4). Perioperative 30-day mortality was 13% (n = 5). Postoperative Mitotane was used in 23 patients and chemotherapy in eight patients. Twenty-five patients died 2-61 months after their operation (median 5 months). Currently, 13 patients are alive at 2-58 months (median 16 months) with known metastatic disease (n = 7) or with no signs of distant disease (n = 6). CONCLUSION This dataset is limited by the lack of a denominator as it remains unknown how many other patients with ACC presenting with IVC invasion did not undergo surgery. The relatively low perioperative mortality and the long disease-free survival achieved by some patients should encourage surgeons with adequate experience to offer surgical treatment to patients presenting with advanced adrenocortical cancers.
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Affiliation(s)
- Radu Mihai
- Endocrine Surgery Unit, Department of Surgery, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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89
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Kastelan D. Management of adrenal incidentaloma. Expert Rev Endocrinol Metab 2011; 6:811-817. [PMID: 30780866 DOI: 10.1586/eem.11.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The term adrenal incidentaloma covers a wide spectrum of adrenal pathologies sharing the method of discovery. The management of adrenal incidentaloma is controversial, and clinicians should determine whether the patient's health is affected by the presence of a tumor. Critical points in management include differentiating benign from malignant and hormonally active from nonfunctional adrenal masses. The probability of malignancy is related to tumor size and imaging phenotype. Masses smaller than 4 cm in diameter that exhibit low attenuation by unenhanced CT scan and rapid contrast washout by delayed contrast-enhanced CT scan are probably benign. All patients with adrenal incidentaloma should undergo biochemical evaluations for pheochromocytoma and subclinical or overt Cushing's syndrome, and hypertensive patients should undergo biochemical testing for hyperaldosteronism. Laparoscopic adrenalectomy is the treatment of choice in all hypersecretory tumors. If adrenocortical carcinoma is suspected, an open adrenalectomy is recommended. Patients who are not candidates for surgical resection of the tumor should be monitored radiographically for 2 years, and hormonal follow-up should be performed annually for 4 years.
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Affiliation(s)
- Darko Kastelan
- a School of Medicine, University of Zagreb, Zagreb, Croatia and Department of Endocrinology, University Hospital Zagreb, Zagreb, Croatia.
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90
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Harrison B. The indeterminate adrenal mass. Langenbecks Arch Surg 2011; 397:147-54. [DOI: 10.1007/s00423-011-0845-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 08/29/2011] [Indexed: 12/25/2022]
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91
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Determinants for malignancy in surgically treated adrenal lesions. Langenbecks Arch Surg 2011; 397:217-23. [DOI: 10.1007/s00423-011-0849-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 09/08/2011] [Indexed: 10/17/2022]
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92
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Arcos CT, Luque VR, Luque JA, García PM, Jiménez AB, Muñoz MM. Malignant giant pheochromocytoma: a case report and review of the literature. Can Urol Assoc J 2011; 3:E89-91. [PMID: 20019963 DOI: 10.5489/cuaj.1189] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Malignant pheochromocytoma is a rare disease and surgical resection is the only curative treatment. There are no definitive histological or cytological criteria of malignancy, as it is impossible to determine this condition in the absence of advanced locoregional disease or metastases. We report a case of a patient with a giant retroperitoneal tumour, the second largest to be published, which was diagnosed as a malignant pheochromocytoma; it was treated with surgery. The literature is reviewed to evaluate tumour features and criteria to distinguish between benign and malignant pheochromocytomas.
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93
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Sèbe P, Rigaud J, Avancès C, Brunaud L, Caillard C, Camparo P, Carnaille B, Culine S, Durand X, Mathonnet M, Mirallie E, Soulié M. [Malignant tumors of the adrenal: contribution to the repository CCAFU INCa]. Prog Urol 2010; 20 Suppl 4:S310-6. [PMID: 21129649 DOI: 10.1016/s1166-7087(10)70047-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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94
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Egbert N, Elsayes KM, Azar S, Caoili EM. Computed tomography of adrenocortical carcinoma containing macroscopic fat. Cancer Imaging 2010; 10:198-200. [PMID: 21067996 PMCID: PMC2999409 DOI: 10.1102/1470-7330.2010.0029] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The presence of macroscopic fat in an adrenal mass has classically been associated with myelolipoma. Adrenocortical carcinoma is typically an aggressive malignancy with a poor prognosis. The presence of macroscopic fat is not a characteristic finding in adreocortical carcinoma or other adrenal malignancies. We report a case of a newly discovered large adrenal mass containing multiple areas of macroscopic fat, which was pathologically proven to represent an adrenocortical carcinoma.
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Affiliation(s)
- Nathan Egbert
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI 48109-5030, USA
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95
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Grogan RH, Mitmaker E, Vriens MR, Harari A, Gosnell JE, Shen WT, Clark OH, Duh QY. Adrenal incidentaloma: does an adequate workup rule out surprises? Surgery 2010; 148:392-7. [PMID: 20576282 DOI: 10.1016/j.surg.2010.05.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2010] [Accepted: 05/14/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adrenal incidentaloma remains a diagnostic challenge. Despite well-established management guidelines, the long-term results of following these guidelines are unknown. We sought to determine how accurately these guidelines identify functioning incidentalomas and how often these guidelines result in adrenalectomy for benign tumors. METHODS We catalogued adrenal incidentalomas from a retrospective review of 500 consecutive adrenalectomies at a single institution. The outcome measures studied were patient demographics, preoperative biochemical analysis, imaging characteristics, tumor size, type of operation performed, and postoperative histologic diagnosis. RESULTS Eighty-one of the 500 adrenalectomies performed were for incidentalomas. Size was the only significant characteristic that distinguished cortical cancers from benign adenomas. Only 1 out of 26 functioning tumors was incorrectly identified on preoperative workup. We also found that 25% of cortisol-secreting incidentalomas were cystic, and that benign adenomas accounted for 42% of all tumors resected. CONCLUSION Current guidelines accurately predict the functional status of adrenal incidentalomas. Some cystic lesions may be functioning and should therefore be screened for hormonal hypersecretion. However, even with the most up-to-date diagnostic tools available, most adrenal incidentalomas resected are benign tumors.
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Affiliation(s)
- Raymon H Grogan
- Department of Endocrine Surgery, University of California San Francisco, San Francisco, CA 94143, USA
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96
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Large adrenocortical carcinoma. J Natl Med Assoc 2010; 101:1287-90. [PMID: 20070018 DOI: 10.1016/s0027-9684(15)31141-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Adrenal cortical carcinomas (ACCs) are rare, highly malignant tumors that carry a poor prognosis. The large size and possibility of adherence to adjacent structures can make these tumors difficult to excise. We present a patient who underwent successful resection of a massive 19-cm, nonfunctional ACC, which encased the right kidney. The goal of this report is to enrich the growing body of knowledge concerning the presentation, evaluation, and surgical intervention of these rare cancers.
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97
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Moalem J, Suh I, Duh QY. Incidentaloma. Cancer Treat Res 2010; 153:119-134. [PMID: 19957223 DOI: 10.1007/978-1-4419-0857-5_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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98
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Yip L, Tublin ME, Falcone JA, Nordman CR, Stang MT, Ogilvie JB, Carty SE, Yim JH. The adrenal mass: correlation of histopathology with imaging. Ann Surg Oncol 2009; 17:846-52. [PMID: 19960266 DOI: 10.1245/s10434-009-0829-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Computed tomography (CT) and magnetic resonance (MR) imaging can help diagnose benign adrenal adenomas, but prior studies rely on nonoperative follow-up as proof of a lesion's benign nature. We examined adrenalectomy tissues to determine if imaging characteristics correlate with histopathologic findings. METHODS We retrieved data for 196 consecutive adrenalectomies in 192 patients from 2000 to 2008. Imaging results were considered to signify benign adrenal adenoma if one or more of the following was present: Hounsfield units <10 on unenhanced CT, contrast-enhanced CT quantifying absolute contrast washout of >60% or relative contrast washout of >40%, or MR with chemical-shift imaging demonstrating loss of signal intensity on out-of-phase images. RESULTS The sensitivity and specificity of preoperative imaging in predicting benign adrenal adenoma were 57 and 94%, respectively. Histopathology confirmed that all 66 adrenal masses with imaging characteristics suggesting benign adenoma were indeed benign lesions and included 61 benign adrenal adenomas and 5 benign nonadenomatous lesions (3 myelolipomas, 1 composite myelolipoma/adenoma, and 1 ganglioliponeuroma). The specificity of imaging in predicting benignity was 100%. Malignant adrenal lesions were diagnosed in 17/130 (13%) masses: 8 metastases, 7 adrenal cortical carcinomas, 1 epithelioid angiosarcoma, and 1 ganglioneuroblastoma. The sensitivity of imaging in identifying malignancy was 100%. No malignancies were diagnosed during postoperative follow-up (mean 6 months, range 0.2-67 months). CONCLUSION CT or MR characteristics predicted the presence of benign lesions with 100% specificity. Every adrenal malignancy had CT or MR results that were inconsistent with benign adenoma (100% sensitivity). To exclude malignancy, adrenal masses with non-benign imaging characteristics should be resected.
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Affiliation(s)
- Linwah Yip
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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99
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Ballian N, Adler JT, Sippel RS, Chen H. Revisiting Adrenal Mass Size as an Indication for Adrenalectomy. J Surg Res 2009; 156:16-20. [DOI: 10.1016/j.jss.2009.03.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Revised: 02/07/2009] [Accepted: 03/23/2009] [Indexed: 11/17/2022]
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100
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Boylu U, Oommen M, Lee BR, Thomas R. Laparoscopic adrenalectomy for large adrenal masses: pushing the envelope. J Endourol 2009; 23:971-5. [PMID: 19456243 DOI: 10.1089/end.2008.0555] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To determine the role of laparoscopy for large adrenal tumors in terms of outcomes, pathology, operative time, and morbidity. PATIENTS AND METHODS A retrospective review of 24 patients who underwent laparoscopic adrenalectomy was performed to record the size of the lesions, surgical techniques used, operative times, estimated blood loss, duration of hospital stay, need for blood transfusion, conversion to open surgery, and complications. The laparoscopic adrenalectomy patients were divided into two groups based on tumor size: <8 cm (n = 16, group 1) and >or=8 cm (n = 8, group 2). RESULTS Mean tumor size was 5.6 cm for group 1 and 12.1 cm for group 2. Mean operative times were 143.12 and 188.75 minutes for groups 1 and 2, respectively. Mean estimated blood loss was 89.69 mL for group 1 and 334.38 mL for group 2. Operative time and blood loss were significantly higher in group 2. Pathologic examination revealed eight adrenal cortical adenomas, five myolipomas, four pheochromocytomas, four cysts/pseudocysts, and three adrenocortical hyperplasias. No significant difference was found between groups concerning transfusion rates, duration of hospital stay, and conversion to open surgery. CONCLUSION Laparoscopic adrenalectomy is a feasible procedure for large masses but results in longer operative times and higher total blood loss when compared with results for masses smaller than 8 cm. Our findings suggest, however, that laparoscopic adrenalectomy for masses larger than 8 cm can produce comparable results concerning hospital stay, conversion to open surgery rate, and pathologic outcome in comparison with results for adrenal masses smaller than 8 cm.
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Affiliation(s)
- Ugur Boylu
- Department of Urology, Tulane University School of Medicine, New Orleans, LA 70112, USA.
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