Evaluation and management of adrenal neoplasms: endocrinologist and endocrine surgeon perspectives

Retroperitoneal laparoscopic partial adrenalectomy (RLPA) for 20-40 mm nonfunctional adrenal tumors in the day surgery mode

OBJECTIVES

To investigate the outcome and safety of retroperitoneal laparoscopic partial adrenalectomy in the treatment of nonfunctional unilateral adrenal tumors in the day surgery mode.

METHODS

Nineteen patients bearing nonfunctional unilateral 20-40 mm adrenal tumors were prospectively enrolled and underwent retroperitoneal laparoscopic partial adrenalectomy in the day surgery unit of our hospital between June 2021 and March 2022. All patients were diagnosed with non-functional adrenal tumors as outpatients before being admitted to the day surgery unit with their consent. Patient demographics and perioperative data were prospectively documented. The patients were followed up by telephone on day 1, 3 and 7 after discharge and followed up for 6 months.

RESULTS

The patient's age was 50.5 ± 11.9 yr (range from 19.0 - 69.0). Seven patients were female. Twelve patients underwent surgery on the left side. The maximal diameter of tumor was 28.3 ± 5.7 mm (20.0 - 40.0 mm). Operation time was 72.1 ± 14.9 min (58.0 - 120.0 min). Mean blood loss was 64.7 ± 50.4 ml (30.0 - 200.0 ml). The gastrointestinal function recovery time was 9.7 ± 2.6 h (6.0 - 16.0 h). Retroperitoneal drainage was removed 24.8 ± 13.3 h (range 18.0 - 72.0) after surgery. Four patients were transferred to the general ward for postoperative management, while others were discharged within 24 hours after surgery. Length of hospital stay was 48.8 ± 13.1 h (38.0 - 85.0h). Hospitalization expense was 24168.4 ± 2910.3 RMB¥ (20844.3 - 34369.8 RMB¥). Postoperative pathology revealed 17 cortical adenoma, 1 pheochromocytoma and 1 lymphatic duct tumor.

CONCLUSION

Retroperitoneal laparoscopic partial adrenalectomy for nonfunctional unilateral adrenal tumors in the day surgery mode is safe when strict selection criteria and perioperative management protocol are followed, which has the potential to shorten length of hospital stay and reduce lower hospitalization costs.

The Role of Biomarkers in Adrenocortical Carcinoma: A Review of Current Evidence and Future Perspectives

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy arising from the adrenal cortex often with unexpected biological behavior. It can occur at any age, with two peaks of incidence: in the first and between fifth and seventh decades of life. Although ACC are mostly hormonally active, precursors and metabolites, rather than end products of steroidogenesis are produced by dedifferentiated and immature malignant cells. Distinguishing the etiology of adrenal mass, between benign adenomas, which are quite frequent in general population, and malignant carcinomas with dismal prognosis is often unfeasible. Even after pathohistological analysis, diagnosis of adrenocortical carcinomas is not always straightforward and represents a great challenge for experienced and multidisciplinary expert teams. No single imaging method, hormonal work-up or immunohistochemical labelling can definitively prove the diagnosis of ACC. Over several decades' great efforts have been made in finding novel reliable and available diagnostic and prognostic factors including steroid metabolome profiling or target gene identification. Despite these achievements, the 5-year mortality rate still accounts for approximately 75% to 90%, ACC is frequently diagnosed in advanced stages and therapeutic options are unfortunately limited. Therefore, imperative is to identify new biological markers that can predict patient prognosis and provide new therapeutic options.

Application of adrenal maximum standardized uptake value to 131I-6β-iodomethyl-19-norcholesterol SPECT/CT for characterizing unilateral hyperfunctioning adrenocortical masses

PURPOSE

To evaluate the maximum standardized uptake value (SUVmax) by ¹³¹I-6β-iodomethyl-19-norcholesterol (NP-59) single-photon emission computed tomography (SPECT)/computed tomography (CT) for characterizing unilateral hyperfunctioning adrenocortical masses.

METHODS

Ten patients underwent NP-59 SPECT/CT to evaluate the following unilateral adrenocortical hyperfuncting masses: three with Cushing's syndrome (CS), three with subclinical CS, and four with primary aldosteronism (PA). Visual and quantitative or semiquantitative analyses (noncontrast CT HU [Hounsfield units], lesion SUVmax, contralateral SUVmax, and SUVmax ratio [lesion SUVmax/contralateral adrenal SUVmax]) were performed. The Mann-Whitney U test or Chi-squared test was used appropriately to assess differences between quantitative variables or compare categorical data. Diagnostic performance was evaluated by receiver operating characteristic (ROC) curve analysis.

RESULTS

All adrenal tumors were diagnosed as cortical adenomas. On visual analysis, unilateral uptake was noted in three patients with CS and one patient with subclinical CS, whereas bilateral uptake was noted in four patients with PA and two patients with subclinical CS (p = 0.046). No significant difference was observed in CT HU (p = 0.055). The lesion SUVmax and SUVmax ratio were significantly higher and the contralateral SUVmax was significantly lower in six patients with CS than in four patients with PA (each, p < 0.05). The area under the ROC curve and accuracy for differentiating between CS and PA were, respectively, 0.92 and 90.0 % for the lesion SUVmax, 1.00 and 100 % for the contralateral SUVmax, and 0.92 and 90.0 % for the SUVmax ratio.

CONCLUSIONS

Quantitative or semiquantitative analysis using the adrenal SUVmax in adrenocortical NP-59 SPECT/CT has potential for characterizing unilateral hyperfunctioning adrenocortical masses.

Adherence to guidelines for hormonal evaluation in patients with incidentally detected adrenal nodules: effects of radiology report wording and standardized reporting

OBJECTIVE

To compare the rates of hormonal evaluation in patients who had CT reports describing adrenal incidentalomas with and without a specific recommendation for hormonal evaluation.

MATERIALS AND METHODS

We performed a retrospective review of adult outpatients without a history of cancer who had a CT report describing an incidental adrenal nodule. Radiology reports were reviewed to determine whether a standardized macro was used which gave specific recommendations for hormonal evaluation and endocrinology consultation. If no macro was used it was determined whether the report had a recommendation for hormonal evaluation and endocrinology consultation.

RESULTS

A standardized macro recommending hormonal evaluation and endocrinology referral was used in 45/129 (34.8%) reports that described an incidental adrenal nodule. A recommendation for hormonal evaluation was made in 5/84 (6.0%) reports without a macro. Hormonal evaluation was performed in 24/50 (48.0%) patients whose reports recommended it and in 11/79 (13.9%) patients whose reports did not (p < 0.0001). A recommendation for endocrinology referral was made in 2/84 (2.4%) reports without a macro. Patients were seen by endocrinology in 12/47 (25.5%) patients whose reports recommended an endocrinology referral evaluation and 5/82 (6.1%) patients whose reports did not (p < 0.0001). Hormonal evaluation was performed in 17/17 (100%) patients who were seen by endocrinology and 18/112 (16.1%) patients who were not (p < 0.0001). Eleven patients (8.5%) had an evaluation suggesting hyperfunctioning nodules (4 cortisol producing, 6 aldosterone producing, and 1 pheochromocytoma).

CONCLUSIONS

Utilizing standardized macros that make specific recommendations for hormonal evaluation in patients with adrenal incidentalomas leads to improved adherence to clinical guidelines.