Hormonal evaluation of the patient with an incidentally discovered adrenal mass

[Laparoscopic adrenalectomy in adrenal carcinoma]

There is general agreement on the suitability of the laparoscopic approach for benign adrenal lesions against open procedures because of the efficacy and less morbidity. For suspected adrenal malignancies laparoscopic use is controversial. We report our experience in 6 cases of laparoscopic adrenalectomy in patients with the suspicion of adrenal malignancy confined in the gland. In medium a follow up of 24 months (range 12 to 48 months) we observed no recurrences. We concluded that in a suspected adrenal malignancy organ confined laparoscopic adrenalectomy presents the advantage compared with open surgery of reduced morbidity and similar results in the follow up of the patient.

A case of postpartum hypopituitarism accompanied by Cushing's syndrome as a result of an adrenocortical carcinoma

Sheehan's syndrome frequently causes hypopituitarism either immediately or after a delay of several years, depending on the degrees of postpartum ischemic pituitary necrosis. A 55 year-old woman whose last child was born 27 yr ago with massive hemorrhage was diagnosed as postpartum hypopituitarism. She had deficiency of growth hormone, prolactin, gonadotropins and thyrotropin. However, she interestingly had apparent hypercortisolism without suppression response to the dexamethasone tests. We found an adrenal mass with distant metastases to the liver and lung while investigating the origin of the hypercortisolism. Hyperandrogenism and very high levels of 17alpha hydroxyprogesterone were present. Accordingly, the patient was diagnosed as hypopituitarism due to Sheehan's syndrome accompanied by Cushing's syndrome as a result of an adrenocortical carcinoma.

Laparoscopic Adrenal Surgery: New Frontiers

After about 10 years of experience, laparoscopic adrenalectomy has become the gold standard for the treatment of adrenal lesions. Here, we describe the presenting features, imaging methods, and current surgical approaches to diseases of the adrenal gland. There is general agreement on the suitability of the laparoscopic approach for benign adrenal lesions, but controversy exists about using laparoscopy for suspected adrenal malignancy, metastasis, and partial adrenalectomy. This article reviews the literature on laparoscopic adrenalectomy. In particular, we focus our attention on the new surgical approaches to the gland. We evaluate the indications, operative techniques, and tools for partial adrenalectomy, and we discuss new surgical strategies such as cryosurgery and radiofrequency ablation.

Myofibrosarcoma of the Adrenal Gland

Adrenal masses have varying presentations. Most commonly, adrenal masses are discovered incidentally on CT or MRI during an evaluation for an unrelated complaint. Although the majority of these are nonfunctional cortical adenomas, hormonally active tumors and adrenocortical carcinoma must also be considered in the differential diagnosis. Rarely, retroperitoneal tumors may mimic an adrenal mass. We report a case of a 49-year-old man with anemia and weight loss who was found to have a large retroperitoneal mass arising from the adrenal gland. Surgical treatment involved en bloc resection of the right kidney, adrenal gland, segments 7 and 8 of the liver, and a portion of the right hemidiaphragm. Final pathology revealed a low-grade myofibrosarcoma. We believe that this is the first case report of a myofibrosarcoma of the adrenal gland. Myofibrosarcomas are rare malignant tumors composed of myofibroblasts that arise from the deep soft tissues. These tumors have a predilection for the head and neck, trunk, or extremities. Myofibrosarcomas can be differentiated from other sarcomas by immunohistochemical staining and pathologic features. We will briefly discuss the workup of an adrenal mass and focus on the diagnosis of myofibrosarcoma.

Work-up of the functional adrenal mass

Evaluation of a functional adrenal mass may be initiated based on symptomatic presentation or the detection of an incidental adrenal mass. Recent literature suggests that 10% to 20% of adrenal incidentalomas demonstrate subclinical hormonal dysfunction, which may place patients at a higher risk for metabolic or cardiovascular disorders. Many diagnostic algorithms have been proposed for the evaluation of pheochromocytoma, Cushing's adenoma, aldosteronoma, and hormonally active adrenal cortical carcinoma. In this article, the available literature on functional adrenal masses is reviewed and up-to-date methods of efficient diagnosis are proposed.

Adrenocortical Carcinoma: A Single Institution Experience

Adrenocortical carcinoma (ADCC) ranks among the least common malignant endocrine tumors. Surgical resection is considered the most important treatment for this neoplasm. Medical records of patients with the diagnosis of ADCC between 1990 and 2000 were reviewed. Patient and pathologic factors were analyzed with overall survival as the primary endpoint. Statistical analysis was performed by the method of Kaplan-Meier. There were a total of 17 patients, with a mean age of 56 years. Twelve per cent presented as an asymptomatic mass, 41 per cent as a functional tumor, and 47 per cent as a nonfunctioning tumor. Primary treatment was surgical resection in 71 per cent. There was no operative mortality and one complication. Seven patients presented with stage II, five with stage III, four with stage IV, and in one could not be determined. Median follow-up was 12.8 months, median survival 67, 13, and 3 months for stages II, III, and IV, respectively. Older age, distant metastasis, nonoperative management, positive margins, advanced tumor stage, and venous invasion were significantly associated with worse overall actuarial survival. Survival for ADCC is poor. Factors associated with a worse prognosis were stage of disease, nonoperative management, positive surgical margins, vascular invasion, and older age.

Laparoscopic adrenalectomy for malignancy

Laparoscopic adrenalectomy for primary malignancies and tumors metastatic to the adrenal is controversial. Most studies demonstrate that results of laparoscopic adrenalectomy for malignant lesions are similar to those of open adrenalectomy, without its morbidity. The results of laparoscopic adrenalectomy for tumor metastases suggest that it may benefit patients who have a metachronous metastasis from any of a variety of primary tumors. Selective laparoscopic adrenalectomy for potentially malignant tumors requires seeking signs of local invasion, lymphadenopathy, or distant metastasis; there are no other reliable preoperative criteria of malignancy. Diagnostic laparoscopy may be useful, and in some cases, may establish a diagnosis. Laparoscopic adrenalectomy should be cautiously performed, with the goals of achieving complete tumor resection without disruption of the adrenal capsule.

Spinal volumetric bone mineral density and vertebral fractures in female patients with adrenal incidentalomas: the effects of subclinical hypercortisolism and gonadal status

Although adrenal incidentalomas (AI) are not associated with clinically evident syndromes, some patients display biochemical features of subclinical hypercortisolism (SH). Previous studies indicated a negative effect of SH on bone in AI patients, but the prevalence of vertebral fractures and the roles of SH and gonadal status in volumetric bone mineral density are unknown. In 70 female AI patients and 84 controls, the prevalence of vertebral fractures and spinal bone mineral density (by quantitative computed tomography) were evaluated. Subjects were subdivided according to menopausal status into groups Pre (21 patients and 23 controls) and Post (49 patients and 61 controls); there were 14 and 35 patients without SH (SH(-)) and 7 and 14 patients with SH (SH(+)) in groups Pre and Post, respectively. The prevalence of fractures was higher in SH(+) than in controls and in SH(-) subjects in both groups Pre [SH(+), 42.9%; controls, 0% (P = 0.001); SH(-), 7.1% (P = 0.049)] and post [SH(+), 78.6%; controls, 37.7% (P = 0.006); SH(-) 42.9% (P = 0.024)]. In group Post, the mean z-score quantitative computed tomography values were lower in SH(+) patients (-0.78 +/- 0.29) than in controls (0.06 +/- 0.14; P = 0.011) and SH(-) patients (0.02 +/- 0.19; P = 0.034). Evaluation of spinal bone is indicated in female AI patients with SH.

Evaluation of the incidentally discovered adrenal mass

The increased use of abdominal ultrasonography, computed tomography, and magnetic resonance imaging has led to the classification of adrenal lesions termed the incidentally identified adrenal mass or adrenal incidentaloma. Unlike for the large, clinically, or biochemically symptomatic adrenal mass, the evaluation of patients with small, asymptomatic, or nonfunctional adrenal lesions remains controversial. The evaluation of these adrenal incidentalomas presents a challenge to endocrinologists, radiologists, and urologic surgeons alike. A multidisciplinary approach with biochemical screening and radiologic evaluation is essential to assess the nature and function of these lesions. Furthermore, it is of great importance to identify patients who are morbidly affected by hormonal hypersecretion or malignant potential. This article describes the emerging guidelines for the evaluation of the incidental adrenal mass.

The clinically inapparent adrenal mass: update in diagnosis and management

Clinically inapparent adrenal masses are incidentally detected after imaging studies conducted for reasons other than the evaluation of the adrenal glands. They have frequently been referred to as adrenal incidentalomas. In preparation for a National Institutes of Health State-of-the-Science Conference on this topic, extensive literature research, including Medline, BIOSIS, and Embase between 1966 and July 2002, as well as references of published metaanalyses and selected review articles identified more than 5400 citations. Based on 699 articles that were retrieved for further examination, we provide a comprehensive update of the diagnostic and therapeutic approaches focusing on endocrine and radiological features as well as surgical options. In addition, we present recent developments in the discovery of tumor markers, endocrine testing for subclinical disease including autonomous glucocorticoid hypersecretion and silent pheochromocytoma, novel imaging techniques, and minimally invasive surgery. Based on the statements of the conference, the available literature, and ongoing studies, our aim is to provide practical recommendations for the management of this common entity and to highlight areas for future studies and research.

Management of adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare neoplasm with poor prognosis. Patients present with signs of steroid hormone excess (e.g. Cushing's syndrome, virilization) or an abdominal mass. Tumour size at presentation (mean diameter at diagnosis > 10 cm) is the most important indicator of malignancy. In addition, computed tomography (CT) typically demonstrates an inhomogeneous adrenal lesion with irregular margins and variable enhancement of solid components after intravenous contrast media. Magnetic resonance imaging (MRI) is equally effective as CT and is particularly helpful to visualize invasion into large vessels. Complete tumour removal (R0 resection) offers by far the best chance for long-term survival and therefore surgery is the treatment of choice in stage I-III ACC. Despite tumour resection for cure most patients will eventually develop local recurrence or distant metastases. Thus adjuvant treatment options need to be evaluated in high-risk patients (e.g. radiation therapy of the tumour bed and/or chemotherapy). In tumour recurrence re-operation should always be considered. In metastatic disease (stage IV ACC) not amenable to surgery mitotane (o,p'DDD) remains the first-line therapy. Drug monitoring is needed for effective treatment aiming at concentrations between 14 and 20 mg/l. Patients not responding to mitotane may benefit from cytotoxic chemotherapy (23% partial remissions, 4% complete remissions). Only large prospective multicentre trials comparing different treatment options will allow to make systematic progress in the management of ACC.

Adrenocortical cancer: recent clinical and molecular advances

PURPOSE OF REVIEW

Adrenocortical cancer (ACC) is an uncommon disorder that remains a challenge to the surgeon and oncologist. When the disease is localized to the adrenal gland and readily amenable to surgical resection, reasonable 5-year survival rates are possible. Locally invasive disease carries a poorer prognosis, and metastatic disease is uniformly fatal within 1 year. In this review, we summarize the current knowledge regarding the clinical management of ACC and the molecular mechanisms underlying the disease.

RECENT FINDINGS

The clinical manifestations, staging, and current treatment for ACC has been well documented. Surgery is still the mainstay of treatment, but identifying molecular targets for chemotherapeutic agents or monoclonal antibodies would be a great advance. At present, our understanding of pathogenic mechanisms is crude; however, the molecular events regulating this aggressive disease are beginning to emerge, especially in the last few years. The advent of laparoscopic adrenalectomy has also created its own dilemmas regarding the appropriate surgical approach to the large, potentially malignant adrenal mass.

SUMMARY

The challenge in the management of this disease lies in understanding the molecular mechanisms that underlie the development of ACC with the diagnostic and therapeutic benefits that would ensue.

Clinical and molecular aspects of adrenocortical tumourigenesis

Adrenal masses are a common problem affecting 3-7% of the population. The majority turn out to be benign adrenocortical adenomas, which may be functional or non-functional. Much more rarely, these masses represent a primary adrenal carcinoma. It is becoming increasingly recognized that of the benign functioning adenomas or hyperplasias, the majority will hypersecrete aldosterone and this will be more frequently detected when hypertensive populations are screened for this disease. In contrast, the incidence of primary adrenocortical carcinoma has remained steady and for this disease, surgery represents the mainstay of treatment. The advent of laparoscopic adrenal surgery has lowered the threshold size for recommending surgery for asymptomatic adrenal masses and as such, an increased proportion of adrenocortical cancers are being resected and detected at an earlier stage. Recent progress has been made in our understanding of the key genetic changes which underpin the biology of this disease. Progression from adrenal adenoma to carcinoma involves a monoclonal proliferation of cells which, among other defects, have undergone chromosomal duplication at the 11p15.5 locus leading to overexpression of the IGF2 gene and abrogation of expression of the CDKN1C and H19 genes. TP53 is involved in progression to carcinoma in a subset of patients and the frequency of ACTH receptor deletion needs to be more fully explored. Other key oncogenes and tumour suppressor genes remain to be identified although the chromosomal loci in which they lie can be identified at 17p, 1p, 2p16 and 11q13 for tumour suppressor genes and chromosomes 4, 5 and 12 for oncogenes.

Laparoscopic adrenalectomy--indications and technique

Laparoscopic adrenalectomy has become the procedure of choice for the surgical management of most adrenal tumors, including functional and non-functional lesions. The role of laparoscopic adrenalectomy in the management of malignant adrenal tumors is controversial and most adrenocortical cancers are generally treated by open adrenalectomy. Laparoscopic adrenalectomy can be performed by both the anterior or lateral trans-abdominal approach and by the lateral or posterior retro-peritoneal approach, with each method being suitable for specific indications. Although there are no randomized trials comparing laparoscopic with open adrenalectomy, the laparoscopic approach is associated with shorter hospital stay, reduced pain and improved cosmesis. This review discusses the indications and contraindications, technique and outcomes for laparoscopic adrenalectomy.

Virilizing adrenocortical adenoma with Cushing's syndrome, thyroid papillary carcinoma and hypergastrinemia in a middle-aged woman

We report a rare case of virilizing adrenocortical adenoma complicated with Cushing's syndrome, thyroid papillary carcinoma and hypergastrinemia. A 45-year-old woman had a history of amenorrhea for 10 years, hypertension for 8 years, and diabetes mellitus for 3 years. Physical examination showed a masculinized woman with severe hirsutism, male-like baldness, deep voice, acne in the precordia, and clitorism. Plasma testosterone, DHEA-S and urinary 17-KS were high, and plasma cortisol level was it at the upper limit of the normal range, but it did not show a diurnal rhythm nor was suppressed by 2 and 8 mg of dexamethasone. Abdominal CT scan showed a left adrenal tumor (4.5 cm in size). Adrenal scintigram revealed uptake of the tracer on the left side, and plasma cortisol concentration was high in a blood sample from the left adrenal vein. Left adrenalectomy was performed. Histopathological features of resected adrenal tumor were consistent with those of adrenocortical adenoma, consisting of tumor cells with eosinophilic compact cytoplasm. Immunohistochemical staining for steroidogenic enzymes showed reactivity for P450sec, 3 beta-HSD, P450c17, P450c21 and P450c11. Plasma testosterone and cortisol levels decreased to the normal range postoperatively. The patient was also found to have a papillary thyroid carcinoma and hypergastrinemia. Our patient is a rare case of virilizing adrenocortical adenoma associated with Cushing's syndrome, thyroid papillary carcinoma, and hypergastrinemia.

[Adrenal ganglioneuroma. Report of a new case]

Ganglioneuroma is a benign neoplasm arising from neural crest tissue and is composed of mature ganglion cells and Schwann's cells. Most ganglioneuromas arise in the posterior mediastinum followed by the retroperitoneum. Only a small proportion of ganglioneuromas are adrenal in origin and occur most commonly in children and young adults. Characteristically, ganglioneuromas do not secrete excess catecholamines or steroid hormones, and they are usually clinically silent lesions incidentally detected in imaging studies for unrelated reasons. Because it is an uncommon lesion, adrenal ganglioneuromas is not included in the differential diagnosis of adrenal incidentalomas in adults. We presents a new case of a 6.5 cm adrenal ganglioneuroma incidentally diagnosed in a 50-year old male patient. The exeresis of the adrenal mass and pathohistological study confirmed the diagnosis.

Adrenal-preserving minimally invasive surgery: the role of laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation of the adrenal gland

Adrenalectomy has become the standard of care for the management of hormonally active adrenal masses. Various surgical therapies have been proposed to excise completely or destroy these adrenal lesions, which may be benign or malignant. New minimally invasive, adrenal-sparing procedures have recently been introduced, among them laparoscopic partial adrenalectomy, cryosurgery, and radiofrequency ablation. These procedures focus on reducing patient morbidity and hastening postoperative recovery while preserving normal adrenal tissue. However, questions remain about the risks and benefits associated with routine application of minimally invasive therapies for adrenal-sparing surgery in terms of complete tumor extirpation. Clearly, more experience and longer follow-up is necessary to validate these procedures. Herein we describe the surgical techniques and early results of treatment with adrenal-sparing surgery.

Does subclinical hypercortisolism adversely affect the bone mineral density of patients with adrenal incidentalomas?

OBJECTIVE

Subclinical hypercortisolism (SH) is detected increasingly in a substantial proportion of patients with incidentally discovered adrenal adenomas. The clinical implications of SH are currently unclear. Osteoporosis is a well-known complication of glucocorticoid excess. So far, the impact of SH on bone mineral density (BMD) has been studied in a limited number of reports with discordant results. In the present study we evaluated the BMD in a large cohort of post-menopausal women with adrenal incidentalomas. : patients and measurements Forty-two post-menopausal women with incidentally discovered adrenal masses and radiological features highly suggestive of benign adrenal adenomas were investigated. All patients underwent a standard low-dose dexamethasone suppression test (LDDST; 0.5 mg 6-hourly for 2 days). The diagnosis of subclinical hypercortisolism (SH) was based on post-LDDST cortisol concentrations of > 70 nmol/l. According to this criterion patients were subdivided into two groups: with (n = 18; group A) or without (n = 24; group B) SH. There was no significant difference in age, years since menopause and body mass index between these groups. BMD was measured at L2-L4 vertebrae and three sites of the proximal femur by the dual energy X-ray absorptiometry (DEXA) method.

RESULTS

Post-menopausal women with SH (group A) exhibited slightly but significantly lower absolute and age-adjusted BMD values compared to group B patients in the femoral neck (BMD g/cm2: 0.72 +/- 0.08 vs. 0.79 +/- 0.09; Z-score: -0.20 +/- 0.82 vs. +0.43 +/- 0.94, P < 0.05) and trochanter (BMD g/cm2: 0.60 +/- 0.09 vs. 0.69 +/- 0.10; Z-score: -0.32 +/- 1.0 vs. +0.30 +/- 1.05, P < 0.01). BMD measurements of the Ward's triangle were also lower in group A patients but the difference did not reach statistical significance (BMD g/cm2: 0.60 +/- 0.10 vs. 0.68 +/- 0.13, P = 0.06). There was no difference in the lumbar vertebrae between the two groups (BMD g/cm2: 0.888 +/- 0.13 vs. 0.90 +/- 0.16, P = 0.78; z-score: +0.50 +/- 1.16 vs. +0.11 +/- 1.5, P = 0.36). The number of patients in the osteoporotic range was minimal with no significant difference between the two groups. However, the frequency of osteopenia in group A was significantly greater than in group B patients in the trochanter and Ward's triangle areas. Serum osteocalcin (BGP) levels were significantly lower in group A compared to group B patients (18.6 +/- 8.6 vs. 26.2 +/- 8.1 ng/ml, P < 0.01); no difference existed regarding parathyroid hormone (PTH) concentrations (43 +/- 15.6 vs. 41.2 +/- 14.8 pg/ml, P = 0.72).

CONCLUSIONS

In this series, post-menopausal women with subclinical hypercortisolism had lower absolute and age-adjusted BMD values and a higher rate of osteopaenia in the trabecular loaded and mixed cortical-trabecular bone of proximal femur. These data demonstrate that the subtle hypercortisolism of patients with adrenal incidentalomas may have an adverse effect on the bone mass of these patients.

Adrenocortical carcinoma: diagnosis, evaluation and treatment

PURPOSE

We describe the presenting features, imaging methods, prognosis of and treatment approach to adrenocortical carcinoma.

MATERIALS AND METHODS

A comprehensive literature review of adrenal carcinoma was performed using PubMed and a review of current urology, oncology, radiology and pathology journals.

RESULTS

The incidence of adrenocortical tumors has been reported to be approximately 2/1 x 10(6) population, although this value may be an underestimate due to an increase in the incidence of unexpected adrenal masses or incidentalomas in the last decade. There has been a bimodal age incidence of adrenal carcinoma with most patients 40 to 50 years old in the studies reviewed. Overall the prevalence of adrenal tumors was slightly higher in females with most presenting with Cushing's syndrome. Of the 602 adrenal tumors reviewed 62% were functional and 38% were nonfunctional. Modern day imaging, including ultrasound, computerized tomography (CT) and magnetic resonance imaging, have greatly improved the diagnosis and staging of adrenal carcinoma. Surgical removal of a localized tumor and absent metastatic disease were associated with improved survival. Medical therapy with mitotane and its successors in patients with metastatic disease appear to be of little benefit for improving survival.

CONCLUSIONS

Based on a review of the literature we recommend that hormone levels should be determined in symptomatic and asymptomatic patients with adrenal masses. CT should be the first study done to define an adrenal mass. All solid incidentalomas greater than 5 cm. on CT or magnetic resonance imaging should be removed surgically. The best chance of survival was achieved by surgical extirpation with the value of adjuvant therapy yet to be determined.

Adrenal cortical adenoma with adrenalin-type neurosecretory granules clinically mimicking a pheochromocytoma

Adrenal tumors often present with clinical features that are specific and unique to their endocrine metabolism. When these features are in conflict with the pathologic appearance of the tumor, there can be great consternation for both the pathologist and the surgeon. In the case reported herein, an adrenalectomy was performed for clinical features of pheochromocytoma that on gross and histologic examination had the pathologic features of an adrenal cortical adenoma. Electron microscopy subsequently revealed that the tumor cells contained adrenalin-type granules, explaining the clinical outcome. It is crucial for both the surgeon and the surgical pathologist to be aware of this possibility when the clinical and pathologic features of an adrenal tumor are not congruent.

Comparison of laparoscopic and open adrenalectomy--a Singapore experience

OBJECTIVE

We present our experience with laparoscopic adrenalectomy for benign adrenal diseases and compare clinical outcomes with the conventional open approach.

METHODS

Between 1990 and 2001, two consecutive series of patients who underwent adrenalectomy for small, benign adrenal diseases were reviewed retrospectively. Patients with large tumours(> 7 cm), cancer and phaeochromocytoma were excluded. Fifty-eight patients underwent laparoscopic adrenalectomy and 48 patients had open surgery for benign adrenal diseases. Perioperative and postoperative records of both approaches were reviewed.

RESULTS

The two groups were comparable in terms of patient age, sex, weight and side of lesion.The common indications for surgery were Conn's syndrome and Cushing's syndrome. The sizes of tumour were comparable between the laparoscopic and open groups (mean, 2.1 cm vs 2.4 cm). Despite the longer operating time (mean, 128 minutes vs 87 minutes), the postoperative morbidity, parenteral analgesic requirement and length of postoperative hospital stay (3.2 days vs 7.2 days) were less inpatients undergoing laparoscopic adrenalectomy. Patients also enjoyed earlier return to oral intake and ambulation. There were fewer complications in the laparoscopic group. There was no conversion to open surgery.

CONCLUSION

Laparoscopic adrenalectomy is safe and has become the treatment of choice for small, benign adrenal lesions at our institution.

Adrenal incidentaloma--experience of a standardized diagnostic programme in the Swedish prospective study

OBJECTIVE

To report the 5-year experience of a diagnostic programme for adrenal incidentaloma with special emphasis to diagnose hormonally active and malignant lesions.

DESIGN

A prospective study in which new cases of adrenal incidentalomas in Sweden have been evaluated by a standardized diagnostic protocol between January 1996 and July 2001.

SETTING

Thirty-three different Swedish hospitals have contributed with cases.

SUBJECTS

A total of 381 patients (217 females, 164 males) with adrenal incidentalomas were studied.

INTERVENTIONS

Diagnostic procedures were undertaken according to a standardized programme. Operation was recommended if the incidentaloma had a size of more than 3-4 cm or if there was a suspicion of a hypersecreting tumour.

MAIN OUTCOME MEASURES

The size of the incidentaloma, clinical characteristics of the patients and results of biochemical diagnostic tests were registered.

RESULTS

The median age of the patients was 64 years (18-84 years), and the median size of the incidentalomas was 3 cm (1-20 cm). A total of 85(22%) patients were operated. Twenty of these patients were diagnosed with a benign hypersecreting tumour and 14 with a malignant tumour. Fourteen of 15 operated patients with diagnosed pheochromocytoma had elevated 24-h urinary noradrenaline and all of the patients operated because of a biochemical suspicion of aldosterone or cortisol hypersecretion (n = 6) were found to have adrenal adenomas. Of the 14 operated patients with malignant diseases, 10 were adrenal carcinomas (median size 10 cm; range 4-16 cm). In a multiple logistic regression model, incidentaloma size was significantly associated with the risk of a malignant tumour (P = 0.009), and there was a tendency of an association between age/male sex and the risk of a malignancy (both, P = 0.07).

CONCLUSION

In this Swedish multicentre study of 381 cases with adrenal incidentalomas, 5% had benign hypersecreting tumours and nearly 4% had malignant tumours. The results of the biochemical diagnostic tests used had a high compatibility with the histological diagnosis found at operation in the patients with hypersecreting tumours. Tumour size, male gender and high age were predictive for the risk of a malignant tumour. A follow-up of the patients is warranted in order to establish whether there are undiscovered cases of malignant or hypersecreting tumours amongst the nonoperated patients.

Evaluation and management of adrenal masses

BACKGROUND

The widespread use of abdominal imaging has led to increased detection of adrenal tumors. The significance of these masses, as well as the optimal management approach to treatment, has generated some controversy regarding further evaluation and therapy.

METHODS

The authors reviewed the literature regarding the evaluation and management of these masses, particularly adrenal incidentalomas. Based on their institutional experience, they propose a diagnostic, evaluation, and management algorithm for treating adrenal masses.

RESULTS

Appearance and clinical history should indicate how to perform the biochemical evaluation, keeping in mind that the presence of pheochromocytomas must be ruled out. Radiological evaluation by CT or MRI provides useful parameters to identify malignant lesions. Surgery is indicated for masses that are larger than 5 cm in diameter or suspected of malignancy. Fine-needle aspiration biopsy should be used when other extra-adrenal malignancies are suspected and after pheochromocytoma has been ruled out.

CONCLUSIONS

Careful analysis of each adrenal mass is essential to effectively avoid potential problems. Guidelines to manage patients with adrenal masses are needed.

[Bone mineral density and biological markers of bone repair in patients with adrenal incidentaloma: effect of subclinical hypercortisolism]

PURPOSE

Some adrenal incidentalomas produce cortisol in mild excess ('subclinical' Cushing's adenomas) and can potentially induce osteopenia. Their diagnosis is usually based on exclusive tumour uptake on adrenal scintigraphy using 131I-6 beta-methyl-iodo-19-norcholesterol and on inadequate cortisol response to dexamethasone (DXM) suppression tests. The aims of the present study were to evaluate bone mineral density (BMD) and metabolic markers of bone turnover in patients with incidentalomas and to test the effect of mild hypercortisolism on bone parameters.

METHODS

Thirty-five patients (13 men, 22 postmenopausal women, 49-76 years) with unilateral incidentaloma were studied. BMD was measured by dual X-ray absorptiometry. Two biochemical markers of bone formation, serum osteocalcin (BGP) and bone alkaline phosphatase (bALP), and two markers of bone resorption, urinary free deoxypyridinoline (D-Pyr) and urinary carboxy-telopeptide of bone type 1 collagen (CTX), were measured by radioimmunoassay. D-Pyr and CTX were corrected for creatinine excretion.

RESULTS

Median values of lumbar and femoral T-score were -1.125 and -0.920, respectively, whereas corresponding Z-score values where normal (0.105 and 0.120, respectively). Thirty-nine percent of patients had low serum BGP values and 3% had low bALP values; 16% showed elevated D-Pyr/creatinine values and 23% increased CTX/creatinine values. Patients both with suppression of the contralateral adrenal on scintigraphy and with an inadequate cortisol response to 1 mg DXM (> 50 nmol/L) (n = 14) presented a lower femoral T-score (P < 0.02) and, to a lesser extent, a lower femoral Z-score (P = 0.11) than other patients (n = 21). The proportion of increased values of CTX/creatinine (42% versus 11%, P = 0.08) also tended to be higher in the first than in the second group of patients. These two groups of patients were similar in terms of age, but tumour size was larger (P < 0.04) and plasma ACTH value was lower (P < 0.02) in patients with scintigraphic and endocrine abnormalities.

CONCLUSION

Subclinical hypercortisolism defined on the basis of scintigraphic and hormonal criteria seems to contribute to bone loss in patients with adrenal incidentaloma. As other possible side effects of mild hypercortisolism, these findings have to be taken into account in the therapeutic management of these patients.

Robotic-assisted adrenalectomy for adrenal incidentaloma: case and review of the technique

An incidental left adrenal mass was found in a patient during an evaluation for mediastinal widening. The patient had no symptoms attributable to adrenal excess. Preoperative biochemical screening was negative for a functioning medullary or cortical adrenal tumor. Surgical resection was successfully completed with the assistance of the da Vinci robotic system. Pathology demonstrated a rare adrenal oncocytoma.

The role of ultrasonography in the detection of adrenal masses: comparison with computed tomography and magnetic resonance imaging

To compare detection rates of adrenal tumors by ultrasonography, computed tomography and magnetic resonance image, we studied 61 patients with adrenal tumor, who underwent adrenalectomy. In 45 (73.8%) of the 61 patients. adrenal tumor was detected by ultrasonography. However, computed tomography and magnetic resonance imaging could detect all adrenal tumors. All adrenal tumors measuring more than 3.0 cm in diameter were detected by ultrasonography, computed tomography and magnetic resonance image. When adrenal tumors were smaller than 3.0 cm. however, ultrasonography, computed tomography and magnetic resonance imaging correctly found adrenal tumors in 30 (65.2%) and 46 (100.0%) of 46 patients and 30 (100.0%) of 30 patients, respectively. These facts suggest that ultrasonography seems to be an effective diagnostic procedure for the prevention of overlooking adrenal tumors larger than 3.0 cm.

The natural history of incidentally discovered adrenocortical adenomas: a retrospective evaluation

Adrenal adenoma is the most frequent lesion among adrenal incidentalomas. The present retrospective study was undertaken to investigate medium-term evolution of supposed or ascertained adrenocortical adenomas in a group of 53 subjects (16 males and 37 females, aged 31-83 yr), with bilateral (no.=8) or monolateral (no.=45) incidentally discovered adrenal masses (size 10-50 mm, median 25 mm), who were followed-up for 6-78 months (median 24 months). Diagnosis of adenoma was based on size and morphovolumetric aspect of the lesion at computed tomography (CT), scintigraphic pattern using NP59 as a tracer, and it was histologically confirmed in 7 patients. After an extensive hormonal investigation including morning (no.=53) and midnight (no.=28) serum cortisol, plasma ACTH (no.=50), serum DHEAS (no.=51), daily urinary free cortisol excretion (no.=52), post-dexamethasone (1 mg) cortisol (no.=42) and ACTH stimulation test for 17-hydroxyprogesterone (17-OHP) response (no.=48) at the time of diagnosis, patients were periodically re-evaluated for hormonal function and radiological aspect of the lesion(s) by CT. Seven patients underwent surgery 6-42 months after incidentaloma demonstration, with histological diagnosis of adrenal adenoma. During follow-up an increase in the size of the lesion was demonstrated in 22 patients (41.5%); the increase was greater than 10 mm in 8 cases. In 3 patients with unilateral mass, a contralateral lesion appeared 10-52 months after first demonstration. Six patients (11.3%) showed reduction or disappearance of the lesions. On the basis of the hormonal evaluation 3 patients were considered to have subclinical Cushing's syndrome and 10 patients exhibited 17-OHP hyperresponse to ACTH test consistent with partial 21 -hydroxylase deficiency. A significant difference in the size of the lesions was observed between patients with or without 17-OHP hyperresponse to ACTH test (31.1 1.9 vs 24.1 +/- 1.2 mm; p<0.01). No significant changes in the hormonal parameters were observed in the patients, when retested. In conclusion, although none of the patients of the present series exhibited evolution to hypersecretion or to aberrant growth, in more than 40% of patients an increase in the size of the mass was observed, even after a long period of "quiescence". This suggests that a radiological re-evaluation of lesions should be periodically undertaken.

Low basal androstenedione levels plus augmented 17alpha-hydroxyprogesterone and low dehydroepiandrosterone sulfate responses to adrenocorticotropic hormone stimulation in patients with adrenal incidentaloma

OBJECTIVE

To investigate the androstenedione, 17a-hydroxyprogesterone (17-OHP), and dehydroepiandrosterone sulfate (DHEAS) basal levels and responses to adrenocorticotropic hormone (ACTH) in patients with adrenal incidentalomas in order to determine which enzyme defects are present.

METHODS

In a study group of 23 patients (18 women and 5 men who ranged in age from 16 to 70 years) with incidentally discovered asymptomatic adrenal masses, ACTH stimulation was performed to evaluate the secretory responses of 17-OHP and DHEAS. The same test was performed in 15 age- and sex-matched control subjects.

RESULTS

Of the 23 patients, 16 (70%) had a 17-OHP peak >30 nmol/L. The 17-OHP response to ACTH stimulation was significantly higher in patients with adrenal incidentalomas than in control subjects (P<0.001). Fourteen patients had basal DHEAS levels below the 3rd percentile of the control group (1.4 +/- 0.1 mmol/L). The mean stimulated DHEAS level was 1.7 +/- 0.2 mmol/L (range, 0.8 to 4.1) in patients with incidentalomas and 4.2 +/- 0.4 mmol/L (range, 1.8 to 5.6) in the control group (P<0.001). In 13 patients, stimulated DHEAS levels were low in association with high 17-OHP levels. Basal ACTH levels did not differ significantly between patients (8.14 +/- 1.2 pmol/L) and control subjects (8.73 +/- 0.7 pmol/L). Basal androstenedione levels were significantly lower in patients (1.9 +/- 0.3 nmol/L) than in control subjects (5.7 +/- 2.5 nmol/L) (P<0.001). No significant correlation was found between 17-OHP levels and tumor size.

CONCLUSION

Enzyme defects may have an important role in adrenal incidentalomas. Two possible explanations for the observed abnormalities of steroid metabolism in patients with incidentalomas are that (1) the incidentalomas are true primary tumors that have aberrant steroid metabolic pathways or (2) such patients have underlying congenital adrenal hyperplasia that leads, over time, to development of pseudotumors. To assess these two possibilities, we need further studies such as genetic investigations, postoperative test results, and evidence relating the size of the adrenal mass to steroid-suppressible treatment.

Differential expression of menin in various adrenal tumors. The role of menin in adrenal tumors

BACKGROUND

Adrenocortical tumors occur as sporadic tumors, as part of the multiple endocrine neoplasia type 1 (MEN1) syndrome, or as part of other hereditary disorders. MEN1 is a tumor suppressor gene located on chromosome 11q13 that encodes a 610-amino acid protein called menin, and plays an important role in the development of MEN1 syndrome. Recent reports indicate that heterozygous germline mutations of this gene are responsible for the disease onset of MEN1.

METHODS

To investigate the role of menin in sporadic adrenocortical tumors, the authors examined a series of adrenocortical adenoma cases and a single case of carcinoma and adrenomedulary tumors with the corresponding adjacent tumor tissues using reverse transcriptase-polymerase chain reaction (RT-PCR) for menin mRNA and Western blot analysis for menin protein. Both RNA and protein from these tumors were applied to RT-PCR and Western blot analysis, respectively, although they are not truly quantitative. Primers for RT-PCR were designed to amplify the sequence between exons 2 and 3 of the MEN1 gene. A specific antibody against menin was generated in guinea pigs immunized with the recombinant peptide from the amino acid residues 443-535 of menin made by using glutathione-S-transferase gene fusion.

RESULTS

Based on the results of RT-PCR and Western blot analysis, both MEN1 mRNA and menin protein appeared to be highly expressed in Cushing syndrome resulting from adrenocortical adenomas and carcinoma. However, their expression was found to be greatly decreased in primary aldosteronism compared with their expression in Cushing syndrome. Although weak expression of MEN1 mRNA also was detected in pheochromocytoma on RT-PCR, menin expression was not detected in any case of pheochromocytoma by Western blot analysis, possibly due to the lower sensitivity of this assay compared with RT-PCR. Neither MEN1 mRNA nor menin protein was detected in any of the corresponding adjacent tumor tissues examined.

CONCLUSIONS

The findings of the current study indicate that menin expression appears to be up-regulated in Cushing syndrome, suggesting that adrenocortical proliferation might be one of the primary lesions in the MEN1 syndrome in which menin might play a significant role in some specific cellular functions.

Adrenal cortical carcinoma

Adrenal cortical carcinoma is a rare endocrine tumor, and complete surgical resection is the only potentially curative treatment. Accurate preoperative biochemical and radiographic evaluation of the patient who presents with an adrenal mass optimizes patient management and facilitates a complete margin-negative resection of the primary tumor--the most important prognostic variable for long-term survival. Response to mitotane or chemotherapy is modest in patients with advanced disease. It is hoped that an improved understanding of the molecular pathogenesis of this challenging tumor will lead to the development of novel treatment strategies.

Extramedullary plasmacytoma in the adrenal incidentaloma

High-resolution imaging has led to the increasingly frequent discovery of adrenal incidentalomas. Most are nonfunctioning tumours and adenomas, but it is difficult to distinguish benign from malignant tumours using only morphological and laboratory data, and the diagnosis often remains uncertain without histological examination. Here we report the case of a 52-year-old Japanese man who had a right adrenal incidentaloma 4 cm in diameter. The tumour was removed by laparoscopic adrenalectomy. The pathology specimen revealed the typical histology of plasmacytoma. Extramedullary plasmacytoma is a very rare type of plasma cell proliferative disorder. This is the first documented case of an extramedullary plasmacytoma in the adrenal gland.

FDG-PET in adrenocortical carcinoma

Adrenal cortical carcinoma (ACC) is a rare malignant neoplasm with a poor prognosis. Radical surgery of the primary tumor and of local as well as of distant recurrence is the only effective treatment, and requires accurate and early localization of recurrent tumors. In this regard, we prospectively scanned 10 patients with ACC, 8 during follow-up and 2 at primary work-up. In all patients PET scans from the neck to the upper thighs were obtained 45 minutes after injection of 370 MBq [18F]FDG. Reading was done visually, with the investigator blinded to the results of other diagnostic modalities. All known sites of ACC lesions showed markedly increased FDG uptake. In 3 patients, previously unknown lesions were identified by PET in the lung (one lesion), the abdomen (3 lesions), and the skeleton (multiple), respectively. One false positive liver focus was shown by PET aside from the true positive lung metastases in the same patient. The sensitivity/specificity of PET based on different organs was 100/97%, that based on the number of PET-detected lesions (N = 23) was 100/95%. PET altered or influenced the tumor stage in 3/10 patients, modifying the subsequent therapeutic management in 2/10 patients. We conclude that FDG-PET is highly useful in ACC and should be included in the work-up for initial staging as well as for follow-up.

Adrenal cortical carcinoma

Adrenal cortical carcinoma is a rare endocrine tumor for which complete surgical resection is the only potentially curative treatment. Accurate preoperative evaluation (biochemical and radiographic) of the patient who presents with an adrenal mass maximizes the opportunity for the patient to undergo a complete, margin-negative resection of the primary tumor, which is the most powerful prognostic variable for long-term survival. The response to chemotherapy or mitotane is modest in patients with advanced disease. Hopefully, an improved understanding of the molecular pathogenesis of this challenging tumor will lead to the development of more effective therapies in the future.

Adrenal incidentaloma

Because of the frequent use of computed tomography and other abdominal imaging modalities, clinicians more frequently see the incidentally discovered, clinically silent adrenal mass. Most adrenal incidentalomas should be evaluated for hormonal activity and assessed for their risk of malignancy. Adrenalectomy is indicated for hyperfunctioning tumors and for any potential primary malignant adrenal lesion. Nonfunctioning cortical adenomas < 4 to 5 cm in size should be followed clinically and radiographically. Laparoscopic adrenalectomy has been used increasingly as the preferred approach in patients who require surgical resection whereas open adrenalectomy is reserved for patients with large, malignant tumors. The indications for adrenalectomy in patients with nonfunctioning adrenal tumors should not be liberalized because of the laparoscopic approach.

Increased serum cortisol levels are associated with high tumour grade in patients with renal cell carcinoma

Cortisol and dehydroepiandrosterone (DHEA) and its sulphate (DHEAS) are the major steroid hormones produced by the human adrenal cortex. The serum levels of cortisol and DHEAS were analysed in 211 consecutive patients with renal cell carcinoma before initiation of therapy. Serum cortisol was significantly higher in patients with renal cell carcinoma compared with that in patients with benign cysts (p < 0.0001). Serum cortisol was independent of disease stage, but positively correlated to tumour diameter and grade. The serum levels of DHEAS were higher in men than in women, and decreased with age, but did not correlate with disease stage, tumour diameter or grade. The prognosis of patients with elevated serum cortisol tended to be poorer (p = 0.06) than the prognosis of those with lower levels. In a multivariate analysis, disease stage and tumour grade were independent predictors of prognosis. Age, gender and serum levels of cortisol and DHEAS were of limited value for prognosis.

Laparoscopic approach to adrenal carcinoma

There is general agreement on the suitability of the laparoscopic approach for benign adrenal lesions but controversy about using laparoscopy for suspected adrenal malignancy. This article reviews the literature on laparoscopic adrenalectomy for cancer: the operative techniques and indications and contraindications.

Limitations of size as a criterion in the evaluation of adrenal tumors

BACKGROUND

Size has been considered to be the single best predictor of malignancy in adrenal neoplasms that have been identified incidentally. However, small adrenal cortical cancers have been reported from multiple centers.

METHODS

We retrospectively evaluated the value of tumor size and other clinical parameters in the prediction of the presence of adrenal malignancy.

RESULTS

The records of 117 patients who underwent evaluation for tumors of the adrenal gland were reviewed. The median tumor size of the adrenal cortical carcinomas (n = 38 carcinomas) was 9.2 cm (range, 1.7-30 cm); 5 cancers (13.5%) were smaller than 5.0 cm. The median overall size of the benign tumors, excluding pheochromocytomas, was 4.0 cm (n = 38 carcinomas); 10 benign tumors (26%) were larger than 5.0 cm. The imaging features of 4 of 5 small adrenal cancers predicted malignancy; the remaining patients had hormonally functioning tumors. The imaging features of 7 of 10 large benign adrenal tumors predicted benign histologic features, including 5 of 5 myelolipomas.

CONCLUSIONS

Although size remains a good predictor of the histologic features and clinical behavior of adrenal neoplasms, both small adrenal cortical cancers and large benign tumors occur with measurable frequency. High-quality imaging studies may be helpful in the identification of relatively small adrenal cancers and of characteristic benign lesions that may be selectively followed.

A Young Female Patient with An Androgen-Secreting Tumor: A Rare Malignant Disease

A 23-year-old female patient presented with hirsutism and fatigue nine months after delivery. Endocrine assessment showed high testesterone, DHEA-S and androstenedione levels. Abdominal computed tomography and ultrasonography revealed the presence of a large tumor in the right renal region. Right adrenalectomy was performed resulting in a diagnosis of a functional adrenal tumor. Pathological examination showed a steroidogenically active tumor. Adjuvant chemothe-raphy was administered postoperatively. At three months following surgery all endocrinological tests normalized, but liver metastases were detected by abdominal CT. Eight months after the operation the patient died of hepatic and renal failure. Androgen-secreting adrenal tumors are seen very rarely, yet the prognosis is poor due to their agressive nature.

Laparoscopic approach to adrenal and endocrine pancreatic tumors

Laparoscopic adrenalectomy quickly has become the procedure of choice for benign adrenal lesions because it results in less pain, shorter hospital stay, comparable safety, and more patient satisfaction overall. The laparoscopic approach requires advanced laparoscopic surgical skills. Surgeons should be familiar with these techniques and the open approaches before attempting this procedure. When first learning the technique, small left-sided lesions are likely the easiest, and a more experienced surgeon should be present for the initial few cases; however, at this point, the laparoscopic approach to pancreatic endocrine tumors does not have a clear benefit, and it should be considered primarily investigational without clearly established benefits.

Posterior retroperitoneoscopic partial adrenalectomy using ultrasonic scalpel for aldosterone-producing adenoma

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy has become a standard procedure, but removal of the entire gland is not necessary in all cases.

PATIENTS AND METHODS

We performed 10 posterior retroperitoneoscopic partial adrenalectomies for aldosterone-producing adenoma (APA) using an ultrasonic scalpel to divide the normal adrenal gland and the adenoma.

RESULTS

The mean operation time and blood loss were 154 (110-231) minutes and 11 (5-32) mL, respectively. The mean weight of removed tissue was 5.7 g (2.3-10.2 g). Subcutaneous emphysema occurred in three patients, but there were no serious operative complications.

CONCLUSION

Posterior retroperitoneoscopic partial adrenalectomy using the ultrasonic scalpel may be a valuable treatment for typical solitary APA.