Management of adrenal incidentaloma by laparoscopic transperitoneal anterior and submesocolic approach

Is transperitoneal laparoscopic adrenalectomy for pheochromocytoma really more challenging? A propensity score-matched analysis

PURPOSE

Minimally invasive surgery is the gold standard treatment for adrenal masses, but it may be a challenging procedure in the case of pheochromocytoma (PHEO). The aim of the present study is to report the results of transperitoneal laparoscopic adrenalectomy (TLA) in cases of PHEO in comparison to other types of adrenal lesions.

METHODS

From 1994 to 2021, 629 patients underwent adrenalectomy. Twenty-two and thirty-five patients, respectively, were excluded because they underwent bilateral and open adrenalectomy, leaving 572 patients for inclusion. Of these, 114 patients had PHEO (Group A), and 458 had other types of lesions (Group B). To adjust for potential baseline confounders, a propensity score matching (PSM) analysis was conducted.

RESULTS

After PSM, 114 matched pairs of patients were identified from each group. Statistically significant differences were not observed when comparing the median operative time (85 and 90 min in Groups A and B, respectively, p = 0.627), conversion rate [6 (5.3%) in each group, p = 1.000], transfusion rate [4 (3.5%) and 3 (2.6%) in Groups A and B, respectively, p = 1.000], complication rate [7 (6.1%) and 9 (7.9%) in Groups A and B, respectively, p = 0.796), median postoperative hospital stay (3.9 and 3.6 days in Groups A and B, respectively, p = 0.110), and mortality rate [1 (0.9%) in each group, p = 1.000].

CONCLUSIONS

Based on this analysis, the results of TLA for PHEO are equivalent to those of TLA for other types of adrenal lesions, but the fundamental requirements are multidisciplinary patient management and adequate surgeon experience. Further prospective studies are required to draw definitive conclusions.

The Mount Sinai Clinical Pathway for the Diagnosis and Management of Hypercortisolism due to Ectopic ACTH Syndrome

Neoplasms that secrete ectopic ACTH may cause severe, life-threatening hypercortisolism. These tumors are often difficult to localize and treat, requiring a comprehensive and systematic management plan orchestrated by a multidisciplinary team. The Mount Sinai Adrenal Center hosted an interdisciplinary retreat of experts in adrenal disorders and neuroendocrine tumors with the aim of developing a clinical pathway for the management of Cushing syndrome due to ectopic ACTH production. The result was institutional recommendations for the diagnosis, localization, surgical approaches to intrathoracic tumors and bilateral adrenalectomy, perioperative and postoperative medical management of hypercortisolism and its sequelae. Specific recommendations were made regarding the timing and selection of therapies based on the considerations of our team as well as a review of the current literature. Our clinical pathway can be applied by other institutions directly or serve as a guide for institution-specific management.

Laparoscopic adrenalectomy for suspected adrenal mass in lung cancer: ganglioneuroma

BACKGROUND

Adrenalectomy is the gold standard for the treatment of primary adrenal ganglioneuroma. Preoperative differential diagnosis of ganglioneuroma is difficult and histopathologic examination is required to confirm the diagnosis.

PATIENT

A 61-year-old woman, who was followed and treated by the medical oncology department because of lung carcinoma pathology squamous cell T4N0Mx, presented to our clinic due to a 15×8-mm nodule with a calculated relative wash-out rate of 40% in the right adrenal gland lateral edge, which was observed on computed tomography examination.

CONCLUSION

Adrenal ganglioneuroma is a rarely seen, hormonally inactive, benign tumor. Final diagnosis can be made with histopathologic examination. Adrenalectomy is the standard treatment preferred for ganglioneuroma. Knowing the clinical appearance and good pathologic specialization are important adjunct matters in diagnosis. Laparoscopic adrenalectomy has become the gold standard in most patients with adrenal tumors.

Unusual presentation of primary myelofibrosis with spontaneous bleeding after laparoscopic adrenalectomy: A case report

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Uncommon presentation.

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Primary myelofibrosis.

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Laparoscopic adrenalectomy.

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Spontaneous bleeding.

Introduction

We described unusual presentation of primary myelofibrosis with spontaneous bleeding after laparoscopic adrenalectomy. This case is written following the SCARE criteria.

Presentation of case

A 73 years old Caucasian man underwent laparoscopic right adrenalectomy for a rapidly increasing expansive mass (3.5 × 2.5 cm) of the right adrenal gland. The night of intervention, patient underwent urgent explorative laparotomy, that highlighted massive haemoperitoneum, clots in the abdomen, on the splenic side, on Morrison’s space, and at the confluence between right renal vein and inferior vena cava.

Surgical specimen examination showed extra-medullary myeloid proliferation of the right periadrenal tissue.

Discussion

Bone marrow biopsy was performed. The list of differential diagnoses included: chronic myelomonocitic leukaemia, atypical CML and primary myelofibrosis (PMF). After discharge, several results became available: conventional cytogenetics was normal, PDGFR-α, PDGFR-β and FGFR1 mutations were negative but V617 F mutation of the JAK2 gene was positive. Therefore, the final diagnosis was pre-fibrotic primary myelofibrosis according to the 2016 WHO classification, Dynamic International Prognostic Scoring System (DIPSS) plus 2 (intermediate-2).

Conclusion

To our knowledge, we report uncommon case of primary myelofibrosis associated with extra-medullary myeloid proliferation of the right periadrenal tissue.

Minimally invasive approach to the adrenal gland in obese patients with Cushing's syndrome

Introduction: The combination of Cushing's syndrome and obesity, one of the most common manifestations of the syndrome itself, may be associated with the worsening of post-operative outcomes in case of laparoscopic adrenalectomy. This study focused on the laparoscopic treatment of Cushing's syndrome with the purpose to identify any relevant difference between morbidly obese, mildly obese and non-obese patients.Material and methods: Patients were retrospectively divided into three groups according to their Body Mass Index (BMI). Demographic characteristics, operative and post-operative data were collected. Data about different hemostatic devices were also collected and compared. Differences were analyzed with the Fisher's exact test for categorical variables, and the Mann-Whitney test for continuous variables.Results: No differences were found in operative time (101.5 ± 50.9 min; p = .919), conversion rate (2.6%; p = .655) or length of stay (4.3 ± 2.9 days; p = .886). Complication rate was 3% (p = .32), without any mortality. 95% of patients showed a complete resolution of hypercotisolyism-related symptoms, and a mean BMI reduction of 5 ± 3.2 kg/m² (follow up = 6.3 ± 4.2 years). Conclusions: Laparoscopic adrenalectomy is safe and feasible in obese patients affected with Cushing's disease and it can lead to the resolution of the related symptoms.

Laparoscopic adrenalectomy for ganglioneuroma presenting as an adrenal incidentaloma

Adrenal incidentaloma (AI) has now become a common finding in clinical practice with advances in abdominal imaging. The prevalence of AI as reported in the literature is 0.2%–3%. Ganglioneuroma (GN) is often a benign non-functioning adrenal tumour, which has been rarely reported as AI in literature. Confirmed diagnosis of GN can only be done by histopathological examination. GNs are often asymptomatic even if they are large, and adrenalectomy is treatment for GN, with good prognosis after surgical removal. Here, we report a patient with an incidental adrenal mass that was managed laparoscopically and diagnosed as an adrenal GN on histopathology.