51
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Hoang C. [Rare incidentalomas: diagnostic procedure]. Ann Pathol 2008; 28 Spec No 1:S45-8. [PMID: 18984297 DOI: 10.1016/j.annpat.2008.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Catherine Hoang
- Service d'anatomie et de cytologie pathologique, groupe hospitalier Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
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Huang H, Abraham J, Hung E, Averbuch S, Merino M, Steinberg SM, Pacak K, Fojo T. Treatment of malignant pheochromocytoma/paraganglioma with cyclophosphamide, vincristine, and dacarbazine: recommendation from a 22-year follow-up of 18 patients. Cancer 2008; 113:2020-8. [PMID: 18780317 PMCID: PMC9094399 DOI: 10.1002/cncr.23812] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/14/2023]
Abstract
BACKGROUND A long-term follow-up was conducted of 18 patients with a diagnosis of pheochromocytoma/paraganglioma treated with a combination of cyclophosphamide, vincristine, and dacarbazine (CVD). METHODS The study design was a nonrandomized, single-arm trial conducted at a government medical referral center. Eighteen patients with metastatic malignant pheochromocytoma/paraganglioma were studied. After controlling symptoms of catecholamine excess, patients were treated with cyclophosphamide at 750 mg/m(2), vincristine at 1.4 mg/m(2), and dacarbazine at 600 mg/m(2) on Day 1 and dacarbazine at 600 mg/m(2) on Day 2, every 21 to 28 days. RESULTS Combination chemotherapy with CVD produced a complete response rate of 11% and a partial response rate of 44%. Median survival from a landmark was 3.8 years for patients whose tumors responded to therapy and 1.8 years for patients whose tumors did not respond (P = .65). All patients with tumors scored as responding reported improvement in their symptoms related to excessive catecholamine release and had objective improvements in blood pressure. CVD was well tolerated with only grade I/II toxicities. CONCLUSIONS Combination chemotherapy with CVD produced objective tumor responses in patients with advanced malignant pheochromocytoma/paraganglioma. In this 22-year follow-up there was no difference in overall survival between patients whose tumors objectively shrank and those with stable or progressive disease. However, patients reported improvement in symptoms, had objective improvements in blood pressure, and had tumor shrinkage that made surgical resection possible. The authors conclude that CVD therapy is not indicated in every patient with metastatic pheochromocytoma/paraganglioma, but should be considered in the management of patients with symptoms and where tumor shrinkage might be beneficial.
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Affiliation(s)
- Hui Huang
- Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jame Abraham
- Mary Babb Cancer Center, University of West Virginia, Morgantown, West Virginia
| | - Elizabeth Hung
- Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Maria Merino
- Anatomic Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Seth M. Steinberg
- Biostatistics and Data Management Section, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland
| | - Karel Pacak
- Reproductive Biology and Adult Endocrinology Program, National Institutes of Child Health, National Institutes of Health, Bethesda, Maryland
| | - Tito Fojo
- Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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53
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Bernichtein S, Alevizaki M, Huhtaniemi I. Is the adrenal cortex a target for gonadotropins? Trends Endocrinol Metab 2008; 19:231-8. [PMID: 18691899 DOI: 10.1016/j.tem.2008.06.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 06/29/2008] [Accepted: 06/30/2008] [Indexed: 11/17/2022]
Abstract
The human adrenal cortex expresses low levels of luteinizing hormone/chorionic gonadotropin receptors (LHCGR), a characteristic gonad-specific G-protein coupled receptor (GPCR). LHCGR levels increase in the adrenal cortex after exposure to chronically elevated gonadotropins (e.g. after gonadectomy). In fact, heightened ectopic LHCGR levels are observed in a subclass of human adrenocortical tumors, and gonadotropin-responsive adrenocortical hyperplasia and tumors occur in several animal species. These findings suggest that adrenocortical responsiveness to LH/CG might be a physiological phenomenon that is amplified in the presence of elevated gonadotropin levels. Such increased gonadotropin action can induce pathologies ranging from adrenocorticotropic hormone (ACTH)-independent Cushing syndrome to malignant adrenal tumors. The authors review the current information on adrenocortical responses to gonadotropins in experimental animals and humans.
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Affiliation(s)
- Sophie Bernichtein
- Department of Reproductive Biology, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK
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54
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Müssig K, Bares R, Horger M. Imaging of hyperfunctioning adrenal masses. Expert Rev Endocrinol Metab 2008; 3:547-555. [PMID: 30290410 DOI: 10.1586/17446651.3.5.547] [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
Adrenal imaging not only aims to detect hyperfunctioning adrenal lesions responsible for distinct clinical syndromes (pheochromocytoma, Cushing's syndrome or primary aldosteronism) but also to differentiate malignant from benign disease. Computed tomography (CT), MRI and high-resolution ultrasound imaging methods are available for detection of adrenal masses with high sensitivities. Although the risk of malignancy increases with the size of the adrenal mass, this criterion does not discriminate malignant from benign disease with sufficient specificity. Attenuation values on unenhanced CT, contrast washout characteristics on CT and chemical-shift imaging on MRI help differentiate adrenal adenomas and nonadenomas. Adrenal lesions with equivocal results on CT and MRI can be characterized further by functional nuclear medicine imaging. Radiopharmaceutical agents specifically detect masses derived from the adrenal cortex (e.g.,131I-6-iodomethyl-norcholesterol) and from the adrenal medulla (e.g., 123I- and 131I-meta-iodobenzylguanidine). Unspecific tracers, such as 18F-fluorodeoxyglucose, are very useful in discriminating malignant and benign adrenal tumors.
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Affiliation(s)
- Karsten Müssig
- a Division of Endocrinology, Diabetes, Nephrology, Angiology and Clinical Chemistry, Department of Internal Medicine, University Hospital of Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany.
| | - Roland Bares
- b Department of Nuclear Medicine, University Hospital of Tübingen, Otfried-Müller-Str. 14, 72076 Tübingen, Germany.
| | - Marius Horger
- c Department of Diagnostic Radiology, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany.
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55
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O'Malley R, Chughtai B, Sukkarieh T, Kirschenbaum A, Naik R, Sawas A, Khan SA, Rehman J. Case and Management of Incidentalomas in Patients with Von Hippel-Lindau Disease. Urol Int 2008; 75:189-91. [PMID: 16123578 DOI: 10.1159/000087178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2004] [Accepted: 11/23/2004] [Indexed: 11/19/2022]
Abstract
Adrenal incidentalomas, those adrenal masses discovered on imaging studies undertaken for other indications, represent an evaluation and management conundrum. Evaluating every incidentaloma for functional status and/or resecting all incidentalomas would not be cost-effective because the vast majority of incidentalomas are benign, non-functioning adenomas. Current management strategies focus on size, functionality and imaging characteristics. These strategies do not take into account individual patient characteristics, for example, comorbid hereditary syndromes. In this article we report a case of a pheochromocytoma presenting as a small incidentaloma in a patient with Von Hippel-Lindau disease. We review the current literature describing the appropriate evaluation and management of adrenal incidentalomas and investigate the nuances of evaluation of these masses in patients with Von Hippel-Lindau disease.
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Affiliation(s)
- Rebecca O'Malley
- Department of Urology, SUNY at Stony Brook, Stony Brook, NY 11794-8093, USA
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56
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Schaberg FJ, Doyle MM, Chapman WC, Vollmer CM, Zalieckas JM, Birkett DH, Miner TJ, Mazzaglia PJ. Incidental Findings at Surgery—Part 1. Curr Probl Surg 2008; 45:325-74. [DOI: 10.1067/j.cpsurg.2008.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Baker MS, Knuth JL, DeWitt J, LeBlanc J, Cramer H, Howard TJ, Schmidt CM, Lillemoe KD, Pitt HA. Pancreatic cystic neuroendocrine tumors: preoperative diagnosis with endoscopic ultrasound and fine-needle immunocytology. J Gastrointest Surg 2008; 12:450-6. [PMID: 18157720 DOI: 10.1007/s11605-007-0219-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 06/13/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic cystic neuroendocrine tumors (CNETs) are rare premalignant conditions. Computed tomography (CT) occasionally demonstrates the hypervascular border characteristic of NETs. Endoscopic ultrasound (EUS) with fine-needle aspiration and immunocytology may be a more consistent means to establish the diagnosis, but no data on the role of EUS are available. This report represents the largest series of CNETs treated to date, documents the role of EUS in preoperative diagnosis, and describes current management. METHODS Retrospective review of our experience with CNETs treated at an academic center between 1999 and 2006. RESULTS Thirteen patients with CNETs were identified. One had symptoms consistent with a functional tumor; the others were nonfunctional. Twelve were detected by CT; only three had peripheral hypervascularity. Nine were studied with preoperative EUS/immunocytology; each of these demonstrated strong staining for chromogranin and synaptophysin. All were resected: four by pancreaticoduodenectomy, one by total pancreatectomy, and one by enucleation. Perioperative morbidity occurred in 39%. Perioperative mortality was 0%. Average follow-up was 3.3 + 0.5 years. One patient had late hepatic recurrence and ultimately died of disease. Two developed recurrent NET in the context of MEN I and required additional surgery. Twelve are alive with no evidence of disease. CONCLUSIONS EUS-guided immunocytology with staining for neuroendocrine markers is an accurate method to establish the diagnosis of CNET preoperatively. Short- and long-term outcomes after resection are excellent.
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Affiliation(s)
- Marshall S Baker
- Department of Surgery, Indiana University School of Medicine, IU Medical Center Cancer Pavilion RT 130D, 535 Barnhill Drive, Indianapolis, IN 46202, USA
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58
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Bruzoni M, Johnston E, Sasson AR. Pancreatic incidentalomas: clinical and pathologic spectrum. Am J Surg 2008; 195:329-32; discussion 332. [DOI: 10.1016/j.amjsurg.2007.12.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 12/12/2007] [Accepted: 12/12/2007] [Indexed: 01/07/2023]
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Bernichtein S, Petretto E, Jamieson S, Goel A, Aitman TJ, Mangion JM, Huhtaniemi IT. Adrenal gland tumorigenesis after gonadectomy in mice is a complex genetic trait driven by epistatic loci. Endocrinology 2008; 149:651-61. [PMID: 18006632 PMCID: PMC2556873 DOI: 10.1210/en.2007-0925] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Postgonadectomy adrenocortical tumorigenesis is a strain-specific phenomenon in inbred mice, assumed to be caused by elevated LH secretion and subsequent ectopic LH receptor (LHR) overexpression in adrenal gland. However, the molecular mechanisms of this cascade of events remain unknown. In this study, we took advantage of the mouse strain dependency of the phenotype to unravel its genetic basis. Our results present the first genome-wide screening related to this pathology in two independent F2 and backcross populations generated between the neoplastic DBA/2J and the nonsusceptible C57BL/6J strains. Surprisingly, the postgonadectomy elevation of serum LH was followed by similar up-regulation of adrenal LHR expression in both parental strains and their crosses, irrespective of their tumor status, indicating that it is not the immediate cause of the tumorigenesis. Linkage analysis revealed one major significant locus for the tumorigenesis on chromosome 8, modulated by epistasis with another quantitative trait locus on chromosome 18. Weight gain, a secondary phenotype after gonadectomy, showed a significant but separate quantitative trait locus on chromosome 7. Altogether, postgonadectomy adrenocortical tumorigenesis in DBA/2J mice is a dominant trait that is not a direct consequence of adrenal LHR expression but is driven by a complex genetic architecture. Analysis of candidate genes in the tumorigenesis linkage region showed that Sfrp1 (secreted frizzled-related protein 1), a tumor suppressor gene, is differentially expressed in the neoplastic areas. These findings may have relevance to the human pathogenesis of macronodular adrenal hyperplasia and adrenocortical tumors in postmenopausal women and why some of them develop obesity.
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Affiliation(s)
- Sophie Bernichtein
- Department of Reproductive Biology, Physiological Genomics and Medicine Group, Medical Research Council, Clinical Sciences Center, Faculty of Medicine, Imperial College London, London, UK
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60
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Iyer RB, Ng CS. Incidental Extracolonic Lesions. Cancer Imaging 2008. [DOI: 10.1016/b978-012374212-4.50105-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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61
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Gallagher SF, Wahi M, Haines KL, Baksh K, Enriquez J, Lee TM, Murr MM, Fabri PJ. Trends in adrenalectomy rates, indications, and physician volume: A statewide analysis of 1816 adrenalectomies. Surgery 2007; 142:1011-21; discussion 1011-21. [PMID: 18063089 DOI: 10.1016/j.surg.2007.09.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 09/06/2007] [Accepted: 09/11/2007] [Indexed: 12/01/2022]
Abstract
BACKGROUND Adrenalectomy rates seem to be increasing in Florida, possibly due to increased availability of laparoscopic adrenalectomy, identification of incidentalomas, and access to care for minorities. We hypothesized that the rate of adrenalectomies in Florida increased from 1998-2005 while characteristics of patients, diagnoses, operations, and operating physicians changed over this period. METHODS Prospectively-collected, mandatory-reported, hospital discharge data for all inpatient adrenalectomies undertaken in Florida from 1998-2005 were obtained along with Florida census and physician certification and education data. Characteristics of adrenalectomy patients, diagnoses, operations, and physicians were analyzed. RESULTS 1816 adrenalectomies were available for analysis. Yearly rates of adrenalectomy nearly doubled from 1.20 to 2.26 per 100,000 Florida residents (P = .0024). Overall, patient characteristics such as demographics, indications and comorbidities did not change, whereas hospital charges increased and length-of-stay (LOS) significantly decreased (P = .0031 and P < .0001, respectively). There was a non-significant trend toward a yearly increase in physician volume and an inverse relationship between physician volume categories and mean LOS (P < .0001). CONCLUSIONS The rate of adrenalectomies is increasing in Florida. This increase was not associated with distinct trends in patient characteristics, although a significant decrease in LOS was identified. As these trends continue and adrenalectomy is applied more liberally, indications for adrenalectomy may need to be re-evaluated.
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Affiliation(s)
- Scott F Gallagher
- Department of Surgery, USF Health, University of South Florida College of Medicine, Tampa, Florida 33606, USA.
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62
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Modern management of pheochromocytoma. ACTA ACUST UNITED AC 2007; 4:630-3. [DOI: 10.1038/ncpuro0962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Accepted: 09/10/2007] [Indexed: 11/08/2022]
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63
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Fareau GG, Vassilopoulou-Sellin R. Diagnostic challenges in adrenocortical carcinoma: recommendations for surveillance after surgical resection of selected adrenal nodules. Endocr Pract 2007; 13:636-41. [PMID: 17954420 DOI: 10.4158/ep.13.6.636] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To discuss challenges in the diagnosis of adrenocortical carcinoma and to suggest surveillance measures after removal of selected adrenal nodules. METHODS We present the case of a 65-year-old man with worsening hypertension and new-onset hypokalemia attributed to primary hyperaldosteronism due to a 3-cm right adrenal nodule. RESULTS A laparoscopic right adrenalectomy was performed, and the histologic diagnosis was a benign adenoma. The patient's hypertension and hypokalemia improved postoperatively but recurred 8 months later, and florid Cushing's syndrome developed. Magnetic resonance imaging showed an 8-cm mass in the right adrenal bed and multiple hepatic metastatic lesions. Fine-needle biopsy confirmed the presence of adrenocortical carcinoma. CONCLUSION Despite a comprehensive biochemical, radiologic, and histologic assessment, the diagnosis of adrenocortical carcinoma can be missed. Particularly, we caution against undue reliance on the initial tumor size. We recommend that abdominal imaging be performed every 3 months for the first year and every 6 months for the second year after surgical removal of selected adrenal nodules.
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Affiliation(s)
- Gilbert G Fareau
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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64
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Quayle FJ, Spitler JA, Pierce RA, Lairmore TC, Moley JF, Brunt LM. Needle biopsy of incidentally discovered adrenal masses is rarely informative and potentially hazardous. Surgery 2007; 142:497-502; discussion 502-4. [DOI: 10.1016/j.surg.2007.07.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2007] [Revised: 06/28/2007] [Accepted: 07/01/2007] [Indexed: 10/22/2022]
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65
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van't Sant HP, Bouvy ND, Kazemier G, Bonjer HJ, Hop WCJ, Feelders RA, de Herder WW, de Krijger RR. The prognostic value of two different histopathological scoring systems for adrenocortical carcinomas. Histopathology 2007; 51:239-45. [PMID: 17593212 DOI: 10.1111/j.1365-2559.2007.02747.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To compare two different multiparameter histopathological scoring indices and determine their prognostic value in patients presenting with adrenocortical carcinoma (ACC). METHODS AND RESULTS Seventy-nine adrenal cortical tumours were divided into adenomas (n = 17), non-metastatic carcinomas (n = 24) and carcinomas with metastatic disease and/or local recurrence during follow-up (n = 19) or at time of presentation (n = 19). All cases were scored according to the Weiss revisited index (WRI) and the Van Slooten index (VSI). Both scoring indices yielded a significantly different score (P < 0.005) between adenomas and carcinomas. Non-metastasized carcinomas had a lower score with both indices compared with carcinomas with metastases at the time of presentation (VSI, P = 0.017; WRI, P = 0.019). The VSI also distinguished ACC that had metastasized at any time from those that had not (P = 0.015). Cancer-specific survival in patients with metastasized ACC correlated with the scores for both indices (VSI, P = 0.0078; WRI, P = 0.0025). Time from diagnosis of ACC to development of metastatic disease was correlated with the WRI (P = 0.036, r = -0.350). CONCLUSIONS The VSI and the WRI have equal validity in the correct categorization of ACC and adenomas. Furthermore, both indices show a correlation with survival for metastasizing ACC.
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Affiliation(s)
- H P van't Sant
- Department of Surgery, Josephine Nefkens Institute, Erasmus MC-University Medical Centre, Rotterdam, The Netherlands
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Waldmann J, Bartsch DK, Kann PH, Fendrich V, Rothmund M, Langer P. Adrenal involvement in multiple endocrine neoplasia type 1: results of 7 years prospective screening. Langenbecks Arch Surg 2007; 392:437-43. [PMID: 17235589 DOI: 10.1007/s00423-006-0124-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Accepted: 11/03/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adrenal tumors are a common manifestation of the multiple endocrine neoplasia type 1 (MEN-1) syndrome. Prevalence in recent studies varies between 9 and 45%. A genotype-phenotype correlation has been described as well as the development of adrenocortical carcinomas. Long-term prospective data are still lacking. MATERIALS AND METHODS Thirty-eight MEN-1 patients with proven germline mutations have been prospectively observed in a regular screening program in our hospital. Adrenal glands have been screened by biochemical analysis and either by endoscopic ultrasound (EUS) or computed tomography (CT) or both. Median follow-up was 48 months (12-108 months). Age at diagnosis of MEN-1, type of adrenal tumor, genotype, therapy, and clinical characteristics have been analyzed. RESULTS In 21 (55%) patients, adrenal involvement of the disease was detected. Adrenal lesions were detected in average 6.9 years after the initial diagnosis of MEN-1. Median tumor size was 12 mm (5-40 mm). Tumor size smaller than 10 mm was observed in 11 patients. Twelve patients had unilateral while nine had bilateral adrenal lesions. EUS detected all adrenal tumors, whereas CT failed in seven cases. In three patients, functioning tumors (one pheochromocytoma, one bilateral Cushing adenoma, and one adrenocortical carcinoma) and one nonfunctioning adenoma were diagnosed by histology and biochemical assessment. Two laparoscopic adrenalectomies and one laparoscopic subtotal resection were performed. Nonfunctioning adrenal lesions, not characterized by histology yet, were found in 18 patients. There was no statistical difference with regard to adrenal involvement between patients with germline mutations in exons 2 and 10 (12/21) and those with mutations in exons 3-9 (6/11). CONCLUSION MEN-1-associated adrenal tumors are mostly small, benign, and nonfunctioning and much more common than previously reported. EUS was the most sensitive imaging procedure. The genotype-pheotype correlation previously suggested by our group could not be confirmed.
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Affiliation(s)
- J Waldmann
- Department of General Surgery, Philipps-University, Marburg, Germany
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67
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Lho SR, Park SH, Jung MH, Lee BC. A case of adrenocortical adenoma following long-term treatment in a patient with congenital adrenal hyperplasia. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.3.302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Seung Rim Lho
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - So Hyun Park
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Ho Jung
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung Churl Lee
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Lin J, Wasco MJ, Korobkin M, Doherty G, Giordano TJ. Leiomyoma of the adrenal gland presenting as a non-functioning adrenal incidentaloma: case report and review of the literature. Endocr Pathol 2007; 18:239-43. [PMID: 18197480 DOI: 10.1007/s12022-008-9013-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A 31-year-old woman was incidentally found to have a large right adrenal mass by computed tomography imaging and underwent a workup that included endocrinological evaluation and positron emission tomography imaging. Laboratory results revealed the mass to be non-functioning. Imaging studies revealed a 9-cm heterogeneous mass that was not FDG avid. Because of concern for adrenal cortical carcinoma, the patient underwent a successful right adrenalectomy. Pathology examination demonstrated an 11-cm circumscribed mass consisting of uniform spindle cells without nuclear pleomorphism, necrosis, or mitotic activity. The diagnosis of leiomyoma was supported by a panel of immunohistochemical stains. Adrenal leiomyomas have been reported in the literature, although most are small and not preoperatively suspicious for malignancy. This case illustrates that benign tumors such as leiomyomas, when large and heterogeneous on imaging, can clinically mimic adrenal cortical carcinomas and should be included in the differential diagnosis of adrenal incidentalomas.
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Affiliation(s)
- Jingmei Lin
- Department of Pathology, University of Michigan Health System, 1150 West Medical Center Drive, MSRB-2, C570D, Ann Arbor, MI 48109-0669, USA
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69
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Freel EM, Connell JMC. Diagnosis of adenomatous primary aldosteronism in a patient with severe hypertension. ACTA ACUST UNITED AC 2006; 1:111-5; quiz following 115. [PMID: 16929379 DOI: 10.1038/ncpendmet0047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2005] [Accepted: 09/20/2005] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 27-year-old woman presented to her primary-care physician with severe hypertension after complaining of fatigue over the preceding months. She was otherwise asymptomatic. She was referred to a hypertension clinic and was found to be hypokalemic. She was immediately commenced on amlodipine, with atenolol added 2 weeks later. After 4 weeks of this drug therapy, her hypertension persisted and investigations to exclude secondary causes of hypertension were performed. INVESTIGATIONS Aldosterone and renin levels were measured under controlled conditions and the results expressed as an aldosterone-to-renin ratio. CT of the adrenal glands was also performed. DIAGNOSIS Adenomatous primary aldosteronism (Conn's syndrome). MANAGEMENT The patient was initially treated with spironolactone before undergoing a laparoscopic left adrenalectomy.
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Meyer A, Behrend M. Indications and Results of Surgery for Incidentally Found Adrenal Tumors. Urol Int 2006; 77:173-8. [PMID: 16888426 DOI: 10.1159/000093915] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2005] [Accepted: 02/10/2006] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The accidental discovery of an adrenal mass called incidentaloma has become an increasingly frequent clinical problem with the question of a correct and appropriate therapeutic approach being the subject of controversial discussions. MATERIALS AND METHODS Clinical charts of 52 patients (22 male, 30 female) who underwent adrenalectomy for an incidentaloma at our institution between 1987 and 2001 were reviewed. RESULTS Median age was 56.4 years. Reasons for surgery were unclear significance in 22 patients, suspicion of malignancy in 5, increase in size in 8, maximum tumor diameter of more than 5 cm in 7, fear of malignancy in 1, and subclinical secretion of cortisol in 5 patients. No data were available for 4 patients. Surgical resection was performed using a conventional transabdominal approach in 28 patients, a conventional dorsal approach in 17 patients, and an endoscopic retroperitoneal approach in 7 patients. Histopathologic examination ruled out adrenal adenoma in 32 patients, adrenal myelolipoma in 12, unilateral nodular hyperplasia in 4, cystic lesion in 3, and adrenocortical carcinoma in 1 patient. The mean size of all lesions was 5.5 cm. Evaluating the criteria for surgical treatment regarding age of the patients and size of the lesions, 25 patients (48%), including the patient with the adrenocortical carcinoma, were younger than 60 years and had an adrenal lesion exceeding 4 cm in size. During postoperative follow-up that was available for 39 patients, 3 developed contralateral tumors that were treated by resection in 1 and by close follow-up in 2. CONCLUSIONS Size should not be the sole criterion; treatment should be tailored to the individual patient. Especially in patients younger than 60 years with an adrenal lesion exceeding 4 cm in size, an adrenalectomy, predominantly via an endoscopic approach, should be carried out, because a repeated and life-long close follow-up of an anxious patient who has been informed of the diagnosis will in some cases exceed the cost of a single endoscopic operation.
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Affiliation(s)
- A Meyer
- Klinik fur Strahlentherapie und spezielle Onkologie, Medizinische Hochschule Hannover, Hannover, Deutschland
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71
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Winter JM, Cameron JL, Lillemoe KD, Campbell KA, Chang D, Riall TS, Coleman J, Sauter PK, Canto M, Hruban RH, Schulick RD, Choti MA, Yeo CJ. Periampullary and pancreatic incidentaloma: a single institution's experience with an increasingly common diagnosis. Ann Surg 2006; 243:673-80; discussion 680-3. [PMID: 16633003 PMCID: PMC1570557 DOI: 10.1097/01.sla.0000216763.27673.97] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND While incidental masses in certain organs have received particular attention, periampullary and pancreatic incidentalomas (PIs) remain poorly characterized. METHODS We reviewed 1944 consecutive pancreaticoduodenectomies (PD) over an 8-year period (April 1997 to October 2005). A total of 118 patients (6% of all PDs) presented with an incidental finding of a periampullary or pancreatic mass. The PI patients were analyzed and compared with the rest of the cohort (NI, nonincidentaloma group, n = 1826). RESULTS Thirty-one percent of the PI patients (n = 37) had malignant disease (versus 76% of the NI patients, P < 0.001), 47% (n = 55) had premalignant disease, and the remaining 22% (n = 26) had little or no risk for malignant progression. The 3 most common diagnoses in the PI group were IPMN without invasive cancer (30%), cystadenoma (17%), and pancreatic ductal adenocarcinoma (10%). The PI group had a higher overall complication rate (55% versus 43%, P = 0.02), due in part to a significantly increased rate of pancreatic fistulas (18.4% PI versus 8.5% NI, P < 0.001). Patients in the PI group with malignant disease had a superior long-term survival (median, 30 months, P = 0.01) compared with patients in the NI group with malignant disease (median, 21 months). CONCLUSIONS Incidentally discovered periampullary and pancreatic masses comprise a substantial proportion of patients undergoing PD. Roughly three fourths of these lesions are malignant or premalignant, and amenable to curative resection. Resected malignant PIs have favorable pathologic features as compared with resected malignant NIs, and resection of these early lesions in asymptomatic individuals is associated with improved survival, compared with patients with symptomatic disease.
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Affiliation(s)
- Jordan M Winter
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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72
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Abstract
Prior to anesthesia a 65-year-old patient received 8 mg dexamethasone to prevent postoperative nausea and vomiting (PONV). Instantly she reported tingling and burning followed by intense pain in the genital region spreading to the whole body. Shortly later she complained about shortness of breath and pre-cordial pain. Acute hypertension could only be lowered by NTG, beta-blockade and induction of anesthesia. The ECG showed ST-segment depressions and troponin-T was elevated (0.3 ng/ml). Coronary angiography revealed no significant stenosis and an abdominal CT scan showed no evidence of a pheochromocytoma. Urine metabolites of catecholamines were negative. Thus, the most likely diagnosis was stimulation of endogenous catecholamines by painful stress after dexamethasone injection with the consequence of myocardial ischemia. As a result we now routinely inject dexamethasone after anesthesia induction as prophylaxis for PONV.
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Affiliation(s)
- W Funk
- Klinik für Anästhesiologie, Klinikum St. Marien, Mariahilfbergweg 7, 92224, Amberg.
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73
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Candel MF, Flores B, Albarracín A, Soria V, Miguel J, Campillo A, del Pozo P, Alcaraz MS, Aguayo JL. [Adrenal incidentalomas. A disease on the increase]. Cir Esp 2006; 79:237-40. [PMID: 16753104 DOI: 10.1016/s0009-739x(06)70859-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Adrenal incidentalomas are unsuspected, clinically silent adrenal lesions discovered incidentally by imaging tests performed a priori for problems unrelated to the adrenal glands. The aim of this study was to present a series of incidentalomas and review the diagnostic process and treatment techniques. PATIENTS AND METHOD Of a series of 63 patients studied and/or treated for adrenal disease, there were 34 patients with adrenal incidentalomas. The mean age of the patients with incidentaloma was 50.6 years. There were 23 women (67.6%) and 11 men (32.3%). All patients underwent hormonal investigations to rule out hyperfunction. Imaging techniques consisted of ultrasonography, computed tomography (CT) and/or magnetic resonance imaging (MRI) to determine the size and characteristics of the lesion. In patients with an indication for surgery, the lateral transabdominal approach was used in laparoscopic surgery and the anterior approach was used in open surgery. RESULTS Of the 34 patients, 23 patients (67.6%) (18 women and 5 men) with a mean age of 50.9 years underwent surgery. The mean tumoral diameter was 10.18 cm. Incidentalomas were located in the right adrenal gland in 16 patients and in the left adrenal gland in 7 patients. Laparoscopic surgery was performed in 9 patients (39.1%) and open surgery was performed in the remaining 14 (60.8%). The mean length of hospital stay was 8.6 days in open surgery and 4 days in laparoscopic surgery. Complications consisted of pneumonia in 2 patients (8.6%). There was no intraoperative mortality in the series. Surgery was not performed in 11 patients (32.3%) (5 women and 6 men) with a mean age of 56.3 years. The mean size of the tumor in these patients, identified by CT, was 2.5 cm. These patients underwent subsequent monitoring with a mean follow-up of 32 months. CONCLUSIONS Due to the high resolution of ultrasonography, CT and MRI, as well as the greater number of radiological investigations performed, identification of adrenal incidentalomas has increased. In our series these tumors represented 53.9% of adrenal disease.
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Affiliation(s)
- M Fe Candel
- Servicio de Cirugía General, Hospital J.M. Morales Meseguer, Murcia, Spain.
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74
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Mattsson C, Young WF. Primary aldosteronism: diagnostic and treatment strategies. ACTA ACUST UNITED AC 2006; 2:198-208; quiz, 1 p following 230. [PMID: 16932426 DOI: 10.1038/ncpneph0151] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Accepted: 02/10/2006] [Indexed: 01/19/2023]
Abstract
Primary aldosteronism is caused by bilateral idiopathic hyperplasia in approximately two-thirds of cases and aldosterone-producing adenoma in one-third. Most patients with primary aldosteronism are normokalemic. In the clinical setting of normokalemic hypertension, patients who have resistant hypertension and hypertensive patients with a family history atypical for polygenic hypertension should be tested for primary aldosteronism. The ratio of plasma aldosterone concentration to plasma renin activity has been generally accepted as a first-line case-finding test. If a patient has an increased ratio, autonomous aldosterone production must be confirmed with an aldosterone suppression test. Once primary aldosteronism is confirmed, the subtype needs to be determined to guide treatment. The initial test in subtype evaluation is CT imaging of the adrenal glands. If surgical treatment is considered, adrenal vein sampling is the most accurate method for distinguishing between unilateral and bilateral adrenal aldosterone production. Optimal treatment for aldosterone-producing adenoma or unilateral hyperplasia is unilateral laparoscopic adrenalectomy. The idiopathic bilateral hyperplasia and glucocorticoid-remediable aldosteronism subtypes should be treated pharmacologically. All patients treated pharmacologically should receive a mineralocorticoid receptor antagonist, a drug type that has been shown to block the toxic effects of aldosterone on nonepithelial tissues.
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Affiliation(s)
- Cecilia Mattsson
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden
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75
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Sturgeon C, Shen WT, Clark OH, Duh QY, Kebebew E. Risk Assessment in 457 Adrenal Cortical Carcinomas: How Much Does Tumor Size Predict the Likelihood of Malignancy? J Am Coll Surg 2006; 202:423-30. [PMID: 16500246 DOI: 10.1016/j.jamcollsurg.2005.11.005] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Revised: 10/24/2005] [Accepted: 11/04/2005] [Indexed: 12/30/2022]
Abstract
BACKGROUND Laparoscopic adrenalectomy for tumors > 6 cm is controversial because of the risk of malignancy, but data to support this position are mostly from small series. The recent NIH consensus conference did not make a definitive recommendation about management of 4- to 6-cm nonfunctioning incidentalomas. STUDY DESIGN Adrenocortical carcinomas (ACC) recorded in the Surveillance, Epidemiology, and End Results (SEER) database (1988 to 2000) were compared with benign functional or nonfunctional adrenal cortical adenomas (excluding aldosteronomas) operated on at our institution between January 1, 1993, and July 1, 2003. Data were compared using t-tests, chi-square tests, likelihood ratios, and receiver operating characteristic (ROC) curves. RESULTS We identified 457 patients with ACC and 47 patients with adrenal cortical adenomas; 376 and 44 neoplasms, respectively, had tumor size data available. Tumor size was larger in ACC (12.0 +/- 5.6 versus 4.2 +/- 1.9 cm, mean +/- SD, p < 0.05). For ACC presenting with local disease, the sensitivity, specificity, and likelihood ratios of tumor size to predict malignancy were 96%, 52%, and 2.0, respectively, for tumors > or = 4 cm; 90%, 80%, and 4.4 for tumors > or = 6 cm; 77%, 95%, and 16.9 for tumors > or = 8 cm; and 55%, 98%, and 24.4 for tumors > or = 10 cm. Assuming a pretest probability of malignancy of 5%, the likelihood ratios derived from this study yield a posttest probability of 10%, 19%, and 47% for cancer in adrenal cortical tumors > or = 4 cm, > or = 6 cm, and > or = 8 cm, respectively. CONCLUSIONS These data suggest that size is useful for predicting malignancy, and that at a size threshold of > or = 4 cm, the likelihood of malignancy doubles (to 10%) and it is more than ninefold higher for tumors > or = 8 cm (47%).
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Affiliation(s)
- Cord Sturgeon
- Department of Surgery, University of California, San Francisco, USA
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76
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Lerario AM, Mendonça BBD, Lin CJ. [Molecular mechanisms involved in adrenocortical tumorigenesis]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2005; 49:753-68. [PMID: 16444358 DOI: 10.1590/s0004-27302005000500016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The adrenocortical tumorigenesis is a complex process, which involves multiple genetic changes. A better knowledge on the mechanisms involved in tumor development would enable an early identification of malignant disease and also lead to the development of new treatment strategies. Although in the recent years a large amount of data was produced, the exact mechanisms that lead to adrenocortical tumor development remains poorly understood. Most of the studies produced were based on the candidate-gene strategy, which has its own limitations. A genome-wide approach, such as microarrays, will surely shed some light into the mechanisms responsible for adrenocortical tumorigenesis. In this review, we summarize the most recent data available on this complex process.
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77
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Grabellus F, Dereskewitz C, Schmitz KJ, Kaiser GM, Kühl H, Kersting C, Frilling A, Metz KA, Baba HA. [Two cystic retroperitoneal lesions mimicking adrenal cysts]. DER PATHOLOGE 2005; 26:226-30. [PMID: 15322819 DOI: 10.1007/s00292-004-0714-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Adrenal cysts are uncommon lesions and most of them are found incidentally during abdominal imaging. We report on two benign extraadrenal lesions mimicking adrenal tumors in abdominal imaging. The histopathological investigation of the lesions revealed a foregut duplication cyst of the lesser gastric curvature and an epithelial inclusion cyst (epidermoid cyst) in an intrapancreatic accessory spleen respectively.
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Affiliation(s)
- F Grabellus
- Institut für Pathologie, Universitätsklinikum Essen.
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78
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Bielinska M, Genova E, Boime I, Parviainen H, Kiiveri S, Leppäluoto J, Rahman N, Heikinheimo M, Wilson DB. Gonadotropin-induced adrenocortical neoplasia in NU/J nude mice. Endocrinology 2005; 146:3975-84. [PMID: 15919738 DOI: 10.1210/en.2004-1643] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In response to prepubertal gonadectomy certain inbred mouse strains, including DBA/2J, develop sex steroid-producing adrenocortical neoplasms. This phenomenon has been attributed to a lack of gonadal hormones or a compensatory increase in gonadotropins. To assess the relative importance of these mechanisms, we created a new inbred model of adrenocortical neoplasia using female NU/J nude mice. These mice developed adrenocortical neoplasms in response to either gonadectomy or gonadotropin elevation from xenografts of human chorionic gonadotropin (hCG)-secreting Chinese hamster ovary cells. In each instance the adrenal tumors resembled the neoplasms found in gonadectomized DBA/2J mice and were composed of spindle-shaped A cells and lipid-laden B cells. Both cell populations were defined by ectopic expression of GATA-4 and an absence of the adrenocortical markers melanocortin-2-receptor and steroid 21-hydroxylase, but only B cells expressed the gonadal steroidogenic markers inhibin-alpha, LH receptor, P450c17, and P450c19. Expression of sex steroidogenic markers was attenuated in the neoplastic adrenal cortex of hCG-treated vs. gonadectomized mice. Whereas neoplastic adrenals were an obvious source of estradiol in gonadectomized mice, ovaries appeared to be the major source of this hormone in hCG-treated mice. Gonadectomy and hCG treatment elicited comparable increases in serum estradiol, but testosterone levels increased significantly only in hCG-treated mice. We conclude that chronic gonadotropin elevation, caused by either gonadectomy or hCG administration, signals a population of cells in the adrenal subcapsular region of permissive mice to undergo differentiation along a gonadal rather than an adrenal lineage. Thus, NU/J nude mice can be used as a model to study both neoplasia and adrenogonadal lineage specification.
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Affiliation(s)
- Malgorzata Bielinska
- Department of Pediatrics, Box 8208, Washington University School of Medicine, St. Louis Children's Hospital, 660 South Euclid Avenue, St. Louis, MO 63110, USA
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79
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Abstract
Although clinical conditions associated with dysfunction of the ad-renal gland are often subtle, even insidious, in their presentation,and diagnosis and treatment usually are confined to outpatient clinics and offices, there are several situations that warrant the attention of emergency physicians. Recognition of the spectrum of presentations of pheochromocytoma, adrenal insufficiency, and pituitary apoplexy, and the sequelae of corticosteroid therapy and withdrawal, are critically important areas to emergency medicine. Prompt diagnosis with appropriate treatment and referral will reduce morbidity and mortality in many patients each year. A related topic pertinent to emergency physicians is the management of incidental adrenal masses that are discovered on abdominal radio-logic imaging.
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Affiliation(s)
- Susan P Torrey
- Tufts University School of Medicine, 136 Harrison Avenue Boston, MA 02111, USA.
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80
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Chavez-Rodriguez J, Pasieka JL. Adrenal lesions assessed in the era of laparoscopic adrenalectomy: a modern day series. Am J Surg 2005; 189:581-5; discussion 585-6. [PMID: 15862500 DOI: 10.1016/j.amjsurg.2005.02.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Revised: 02/01/2005] [Accepted: 02/01/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND To evaluate if laparoscopic adrenalectomy (LA) has changed the indications for adrenalectomy. METHODS Retrospective analysis of patients with adrenal lesions referred from 1992 to 2004. Patients were divided into 2 groups, those before and those after the introduction of LA. RESULTS One hundred eighty patients were assessed. Functioning lesions were found in 120 (66%) patients. Sixty patients had nonfunctioning tumors. Before the introduction of LA, 13% had primary hyperaldosteronism (PA), 23% had pheochromocytoma (Pheo), 20% had Cushing's syndrome (CS), and 7% had adrenal cortical cancer (ACC). No difference was seen in the percentage of patients referred after LA with Pheo (20%), CS (16%), or ACC (6%). There was, however, a significant increase in the percentage of patients referred with PA after introducing LA (13% vs. 27%), P < .05. CONCLUSION Indications for adrenalectomy have not changed since introduction of LA. There was, however, an increased percentage of patients with PA referred since the introduction of LA.
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Affiliation(s)
- J Chavez-Rodriguez
- Department of Surgery, University of Calgary, 1403 29th St. N.W., Calgary, Alberta, Canada T2N 2T9
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81
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Benitah N, Yeh BM, Qayyum A, Williams G, Breiman RS, Coakley FV. Minor Morphologic Abnormalities of Adrenal Glands at CT: Prognostic Importance in Patients with Lung Cancer. Radiology 2005; 235:517-22. [PMID: 15858092 DOI: 10.1148/radiol.2352031708] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the prognostic importance of minor morphologic abnormalities of the adrenal glands at computed tomography (CT) in patients with lung cancer. MATERIALS AND METHODS The study was approved by the committee on human research; written informed consent was not required. The authors retrospectively identified 197 patients with lung cancer who underwent serial chest or abdominal CT and did not have a focal adrenal mass at baseline CT. Two readers independently classified the morphologic features of each adrenal gland as normal, smoothly enlarged, or nodular at initial CT examination. They separately recorded the presence or absence of metastases to the adrenal glands (ie, any new focal adrenal mass) at final CT examination; a third independent reader arbitrated when interpretations were discordant (n = 11). Multivariate Cox proportional hazard models were used to assess for associations between baseline adrenal gland morphologic features and subsequent development of adrenal metastases. RESULTS At initial CT, reader 1 classified 253 (64%), 70 (18%), and 71 (18%) of the 394 adrenal glands and reader 2 classified 258 (65%), 45 (11%), and 91 (23%) of these glands as normal, smoothly enlarged, or nodular, respectively. The readers had moderate interobserver agreement regarding the classification of adrenal gland morphologic features (kappa = 0.54). Metastases subsequently developed in 13 adrenal glands in 11 patients. Cox proportional hazard models revealed no significant association between baseline adrenal gland morphologic features and subsequent development of adrenal metastases (P = .50 and P = .20 for readers 1 and 2, respectively). CONCLUSION In patients with lung cancer, smooth enlargement or nodularity of the adrenal glands at baseline CT is not associated with increased risk of subsequently developing adrenal metastases.
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Affiliation(s)
- Nicole Benitah
- Department of Radiology, University of California-San Francisco, Box 0628, M-372, 505 Parnassus Ave, San Francisco, CA 94143-0628, USA
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82
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Bernini GP, Moretti A, Oriandini C, Bardini M, Taurino C, Salvetti A. Long-term morphological and hormonal follow-up in a single unit on 115 patients with adrenal incidentalomas. Br J Cancer 2005; 92:1104-9. [PMID: 15770213 PMCID: PMC2361933 DOI: 10.1038/sj.bjc.6602459] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
We investigated the natural course of adrenal incidentalomas in 115 patients by means of a long-term endocrine and morphological (CT) follow-up protocol (median 4 year, range 1–7 year). At entry, we observed 61 subclinical hormonal alterations in 43 patients (mainly concerning the ACTH–cortisol axis), but confirmatory tests always excluded specific endocrine diseases. In all cases radiologic signs of benignity were present. Mean values of the hormones examined at last follow-up did not differ from those recorded at entry. However in individual patients several variations were observed. In particular, 57 endocrine alterations found in 43 patients (37.2%) were no longer confirmed at follow-up, while 35 new alterations in 31 patients (26.9%) appeared de novo. Only four alterations in three patients (2.6%) persisted. Confirmatory tests were always negative for specific endocrine diseases. No variation in mean mass size was found between values at entry (25.4±0.9 mm) and at follow-up (25.7±0.9 mm), although in 32 patients (27.8%) mass size actually increased, while in 24 patients (20.8%) it decreased. In no case were the variations in mass dimension associated with the appearance of radiological criteria of malignancy. Kaplan–Meier curves indicated that the cumulative risk for mass enlargement (65%) and for developing endocrine abnormalities (57%) over time was progressive up to 80 months and independent of haemodynamic and humoral basal characteristics. In conclusion, mass enlargement and the presence or occurrence over time of subclinical endocrine alterations are frequent and not correlated, can appear at any time, are not associated with any basal predictor and, finally, are not necessarily indicative of malignant transformation or of progression toward overt disease.
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Affiliation(s)
- G P Bernini
- Department of Internal Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy.
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83
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Shen WT, Sturgeon C, Duh QY. From incidentaloma to adrenocortical carcinoma: the surgical management of adrenal tumors. J Surg Oncol 2005; 89:186-92. [PMID: 15719374 DOI: 10.1002/jso.20180] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In this article we review the management of benign and malignant adrenal tumors, with an emphasis on oncologic concerns. Concise, logical guidelines for the diagnosis and operative treatment of incidentalomas, aldosteronomas, adrenal Cushing syndrome, virilizing and feminizing adrenal tumors, isolated adrenal metastases, and adrenocortical carcinoma are provided. We also discuss the choice of optimal surgical approach for performing adrenalectomy (laparoscopic, open, hand-assist).
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Affiliation(s)
- Wen T Shen
- Department of Surgery, University of California, San Francisco, California, USA
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84
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Plaggemars HJ, Targarona EM, van Couwelaar G, D Ambra M, García A, Rebasa P, Rius X, Trias M. ¿Qué ha cambiado en la adrenalectomía? De la cirugía abierta a la laparoscópica. Cir Esp 2005; 77:132-8. [PMID: 16420904 DOI: 10.1016/s0009-739x(05)70824-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION After the introduction of the laparoscopic approach in adrenal surgery, this technique has become the gold standard in surgical adrenal diseases. Nevertheless, comparative studies with open surgery are scarce and the impact of laparoscopic techniques on these diseases is unknown. OBJECTIVE To evaluate our experience of adrenal surgery over a 14-year period, before and after the introduction of laparoscopic adrenalectomy, and to analyze the influence of this technique on the surgical management of adrenal diseases. PATIENTS AND METHOD From January 1990 to June 2004, 78 patients underwent adrenalectomy. Between 1990 and 1998, open adrenalectomy was performed in 24 patients, while between 1999 and 2004, 54 patients underwent the laparoscopic approach and 1 underwent open surgery. Data for the open group were retrospectively reviewed while those for the laparoscopic group were prospectively registered in the advanced laparoscopic surgery database of Hospital Sant Pau (HSP). RESULTS The mean age was 47 years (16-75) in the open group and was 49 years (17-77) (p = NS) in the laparoscopic group. Distribution by surgical indication was similar in both periods concerning primary hyperaldosteronism, hypercortisolism, and pheochromocytoma, with a significant increase in surgical cases indicated by malignancy (1 vs 4) or incidentaloma (2 vs 13) (p<.001). Operating time was reduced from 150 min (65-210) in the open group to 90 min (30-300) in the laparoscopic group (p<.01). Morbidity was also reduced (20% vs 6%, p<.01). The size of lesions resected by open or laparoscopic surgery (4 cm [0.4-16] vs 3.5 cm [1.2-14]) was similar. The mean length of hospital stay was reduced from 8 days (3-13) to 3 days (2-12) (p<.01). The number of adrenalectomies performed in HSP was 24 in the first period (1990-1997) vs 40 in the second (1998-2004). This represented an increase from 3/year to 6.6/year mainly due to the increase in the number of incidentalomas. CONCLUSIONS The laparoscopic approach has improved immediate surgical results (operating time, morbidity, and length of hospital stay). There was a clear increase in the number of adrenalectomies, and especially of incidentalomas, due to improved diagnostic techniques and the availability of a less aggressive approach.
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Affiliation(s)
- Hendrik J Plaggemars
- Servicio de Cirugía, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, España
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85
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Hamrahian AH, Ioachimescu AG, Remer EM, Motta-Ramirez G, Bogabathina H, Levin HS, Reddy S, Gill IS, Siperstein A, Bravo EL. Clinical utility of noncontrast computed tomography attenuation value (hounsfield units) to differentiate adrenal adenomas/hyperplasias from nonadenomas: Cleveland Clinic experience. J Clin Endocrinol Metab 2005; 90:871-7. [PMID: 15572420 DOI: 10.1210/jc.2004-1627] [Citation(s) in RCA: 200] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Radiological characterization of an adrenal tumor as adenoma may decrease the need for follow-up imaging studies, biopsies, and unnecessary adrenalectomies. We retrospectively reviewed 299 adrenalectomies in 290 patients at Cleveland Clinic Foundation over a recent 5-yr period to assess the value of noncontrast Hounsfield units (HU) in characterizing whether an adrenal mass is adenoma or nonadenoma. The mean (+/- SD) HU value for the adrenocortical adenoma/hyperplasia group was 16.2 +/- 13.6 and significantly lower (P < 0.0001) than primary adrenocortical cancers (36.9 +/- 4.1), metastases (39.2 +/- 15.2), and pheochromocytomas (38.6 +/- 8.2). The sensitivity and specificity for 10- and 20-HU cutoff values to differentiate adenomas/hyperplasias from nonadenomas were 40.5 and 100% and 58.2 and 96.9%, respectively. The size of the adrenal tumor had less value with only 40.7 and 81.3% sensitivity and 94.7 and 61.4% specificity for 2- and 4-cm cutoff values. A combination of less than or equal to 4-cm adrenal mass size and noncontrast computed tomography HU less than or equal to 20 had 42.1% sensitivity and 100% specificity. Our study, the largest with surgical histopathology as the gold standard for diagnosis, supports a noncontrast computed tomography attenuation value of 10 HU as a safe cutoff value to differentiate adrenal adenomas/hyperplasias from nonadenomas.
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Affiliation(s)
- Amir H Hamrahian
- Department of Endocrinology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA.
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86
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Abstract
The advancement of laparoscopic adrenalectomy over the past decade has completely changed the surgical approach to adrenal tumors. As the incidence of incidentally discovered adrenal tumors increases, most patients with resectable lesions can undergo resection laparoscopically with minimal morbidity, shorter hospitalization, and low mortality. The spectrum of surgical approaches now available make it possible to provide an appropriate resection that is matched to the specific characteristics of each tumor. Experienced surgeons now resect some malignant tumors laparoscopically, with the option to convert to a hand-assisted or traditional open approach.
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87
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Chen M, Hawks CL, Huang Q, Sun B, Hornsby PJ. Telomerase is not required for experimental tumorigenesis of human and bovine adrenocortical cells. Endocr Res 2004; 30:555-65. [PMID: 15666792 DOI: 10.1081/erc-200043682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Telomerase has often been thought to be essential for tumorigenesis of human cells. Adrenocortical cancers, like other cancers, typically have telomerase activity. We reinvestigated the requirement for telomerase in the conversion of normal human and bovine adrenocortical cells to cancer cells. When primary adrenocortical cells were transduced with retroviruses encoding SV40 large T antigen and Ha-RasG12V and immediately transplanted into immunodeficient mice they produced invasive and metastatic tumors. Cells had negligible telomerase activity before transplantation and after recovery from tumors. However, these tumors were not immortal and cells entered crisis, limiting further growth of the tumor as well as invasion and metastasis. Infection of these tumor cells with a retrovirus encoding hTERT restored growth in culture and restored the malignant properties of the cells in immunodeficient animals. These experiments differ from previous studies in which telomerase was found to be essential for tumorigenicity: 1) we used tissue reconstruction techniques for introduction of cells into host animals and 2) we infected primary cells with retroviruses and immediately transplanted them without drug selection.
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Affiliation(s)
- Meizhen Chen
- Department of Physiology and Sam and Ann Barshop Center for Longevity and Aging Studies, University of Texas Health Science Center, San Antonio, Texas, USA
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88
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Abstract
The most striking age-related change in the human adrenal cortex is the decline in secretion of dehydroepiandrosterone and its sulfate, steroids synthesized by the inner zone of the cortex, the zona reticularis. Because these steroids are of essentially unknown function, the importance of this age-related change is the subject of considerable debate. It is likely that the age-related change in these steroids results from loss of zona reticularis cells or impairment of their function. During aging, cumulative damage to the zona reticularis could occur through ischemia-related infarcts and other causes of cell death. Cellular senescence could contribute to a loss of the ability of the tissue to replace lost cells. In contrast, feedback mechanisms that regulate adrenocortical growth cause compensatory local tissue hyperplasias called nodules. The effect of imperfect repair of damage combined with compensatory overgrowth in the form of nodules leads to an increasingly abnormal tissue architecture.
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Affiliation(s)
- Peter J Hornsby
- Department of Physiology and Sam and Ann Barshop Center for Longevity and Aging Studies, University of Texas Health Science Center, San Antonio, TX 78245, USA.
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89
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Abstract
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.
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Affiliation(s)
- Cord Sturgeon
- Department of Surgery, University of California, San Francisco Comprehensive Cancer Center at Mount Zion Medical Center, 1600 Divisadero Street, Hellman Building, Room C3-47, San Francisco, California 94143-1674, USA
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90
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Masiakos PT, Gerstle JT, Cheang T, Viero S, Kim PCW, Wales P. Is surgery necessary for incidentally discovered adrenal masses in children? J Pediatr Surg 2004; 39:754-8. [PMID: 15137013 DOI: 10.1016/j.jpedsurg.2004.01.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are no guidelines that exist to direct the management of incidental adrenal masses (IAM) in children. The aim of this study was to determine if there is a subset of IAMs that could be safely observed. METHODS A retrospective analysis was conducted of all adrenal masses that were either resected or biopsied between 1990 and 2002 (n = 91) at the Hospital for Sick Children, Toronto. IAM was defined as a solitary adrenal mass discovered by either physical examination (n = 6; 23.1%) or diagnostic imaging for other indications (n = 20; 76.9%), without metastases or biochemical activity. RESULTS Twenty-six (28.6%) IAMs were detected (mean age, 4.6 years [range, antenatal to 17 years]; 11 boys, 15 girls). Pathologic diagnoses included neuroblastoma (n = 7), ganglioneuroma (n = 6), adrenocortical adenoma (n = 4), adrenal cyst/pseudocyst (n = 3), adrenal hemorrhage (n = 3), ganglioneuroblastoma (n = 1), nodular cortical hyperplasia (n = 1), and teratoma (n = 1). Eight masses were malignant (30.8%). Two of the 5 masses discovered on antenatal ultrasound scan were neuroblastoma. In comparing the benign with malignant lesions, there was no significant difference in mean size (4.8 cm v 4.3 cm; P =.57), radiologic characteristics, or mode of presentation. Benign lesions occurred more frequently in older children (mean age, 6.5 years v 1.3 years; P =.03). CONCLUSIONS Clear guidelines cannot be established to predict benign IAM in children. Given the high proportion of malignant lesions, we recommend that all pediatric IAMs should be resected.
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Affiliation(s)
- Peter T Masiakos
- Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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91
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Mansmann G, Lau J, Balk E, Rothberg M, Miyachi Y, Bornstein SR. The clinically inapparent adrenal mass: update in diagnosis and management. Endocr Rev 2004; 25:309-40. [PMID: 15082524 DOI: 10.1210/er.2002-0031] [Citation(s) in RCA: 532] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Georg Mansmann
- Department of Endocrinology, Heinrich-Heine-University, Moorenstrasse 5, D-40225 Düsseldorf, Germany.
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92
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Bielinska M, Parviainen H, Porter-Tinge SB, Kiiveri S, Genova E, Rahman N, Huhtaniemi IT, Muglia LJ, Heikinheimo M, Wilson DB. Mouse strain susceptibility to gonadectomy-induced adrenocortical tumor formation correlates with the expression of GATA-4 and luteinizing hormone receptor. Endocrinology 2003; 144:4123-33. [PMID: 12933687 DOI: 10.1210/en.2003-0126] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Certain inbred strains of mice, including DBA/2J, develop adrenocortical tumors in response to gonadectomy. Spindle-shaped cells with limited steroidogenic capacity, termed A cells, appear in the subcapsular region of the adrenal gland, followed by sex steroid-producing cells known as B cells. These changes result from unopposed gonadotropin production by the pituitary, but the adrenocortical factors involved in tumorigenesis have not been characterized. GATA-4, a transcription factor normally expressed in fetal, but not adult, adrenocortical cells, was found in neoplastic cells that proliferate in the adrenal cortex of gonadectomized DBA/2J mice. GATA-4 mRNA was detected in the adrenal glands of female mice 0.5 months after ovariectomy and reached a maximum by 4 months. Castrated male mice developed adrenocortical tumors more slowly than gonadectomized females, and the onset of GATA-4 expression in the adrenal was delayed. In situ hybridization and immunohistochemistry revealed GATA-4 mRNA and protein in A and B cells, but not in normal adrenocortical cells. mRNA encoding another factor associated with adrenocortical tumorigenesis, LH receptor (LHR), was detected in A and B cells. In addition, transcripts for P450 17 alpha-hydroxylase/C17-C20 lyase, an enzyme essential for the production of sex steroids, and inhibin-alpha were found in B cells. Unilateral ovarian regeneration, a phenomenon known to occur in gonadectomized mice, was observed in a subset of DBA/2J mice undergoing complete ovariectomy. In these animals, adrenocortical tumor progression was arrested; A cells and GATA-4 expression were evident, but there was no expression of LHR or P450 17 alpha-hydroxylase/C17-C20 lyase. Strain susceptibility to adrenocortical tumorigenesis (DBA/2J >> FVB/N) correlated with the expression of GATA-4 and LHR, implicating these factors in the process of adrenocortical neoplasia in response to continuous gonadotropin stimulation.
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Affiliation(s)
- Malgorzata Bielinska
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri 63110, USA
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