Clinical characteristics of adrenal tumors in children: a retrospective review of a 15-year single-center experience

Laparoscopic Transperitoneal Adrenalectomy for Adrenal Tumors in Children: Technical Considerations and Surgical Experience

Aims: This study aimed to review our surgical experience of laparoscopic adrenalectomy (LA) for adrenal masses in the pediatric age group. Materials and Methods: The electronic medical records of all patients younger than 18 years of age who underwent LA between 2016 and 2023 were retrospectively reviewed. Children with adrenal tumors localized to the site of origin without evidence of encasement of major vasculature or involvement of adjacent organs were considered for LA. Patients with diagnosis of malignant adrenal tumor on preoperative work-up underwent open adrenalectomy. Data were collected regarding demography, clinical presentation, hormonal workup, imaging, duration of surgery, transfusion requirement, conversion rate, postoperative recovery, duration of intravenous (i.v.) analgesia and hospital stay, pathology, complications, and status at follow-up. Results: Between 2016 and 2023, LA adrenalectomy was performed in 11 patients (6 boys and 5 girls) with a mean age of 46.3 (8-120) months. A functional tumor was detected in 6 (54.5%) children, manifesting clinically with Cushing's syndrome (3), virilization (1), feminization (1), or Conn's syndrome (1). Seven (63.6%) tumors originated from the right adrenal, and 4 (36.4%) from the left adrenal gland. The mean tumor weight and size was 49.1 (10-80) g and 5.6 (3-8) cm, respectively. Histopathology included adrenal adenoma (5), ganglioneuroma (3), ganglioneuroblastoma (1), myelolipoma (1), and intermediate adrenocortical tumor (1). The mean surgery duration was 186.6 (120-265) minutes. Intraoperative blood transfusion was required in 2 (18.2%) patients and none required conversion. Full feeds were resumed at 42.7 (24-60) hours, i.v. analgesia requirement was for 54.5 (36-72) hours and mean hospital stay was 5.1 (3-8) days. All patients were symptom-free with no recurrence at mean follow-up period of 50.6 (3-83) months. Conclusions: In children with well-circumscribed, localized, and noninvasive adrenal tumors, LA is feasible, effective, and safe with all advantages of minimally invasive surgery.

Adrenocortical carcinoma in a 10-month-old infant: A literature review and a rare case report

Adrenocortical carcinoma (ACC) in children is a rare condition. The annual incidence of ACC is extremely low, with only 0.2-0.3 cases per million children. The clinical presentations of ACC are numerous, such as terminal hair appearance, pubertal progress, hypercortisolism, enlarged clitoris, acne, systemic arterial hypertension, weight gain, and voice change.

Case presentation

A 10-month-old female infant presented by her parents to the Department of Endocrinology with a mass on the right adrenal gland and Cushing's syndrome symptoms. Surgery was performed. The death occurred after two times resuscitation due to sudden cardiac arrest.

Clinical discussion

The adrenal gland consists of two distinct parts. Different types of tumors arise from each part of the adrenal gland. The most common tumor in adrenomedullary tumors was neuroblastoma which accounted for 60.4% of adrenal tumors. ACC in children is a rare condition. The etiology of ACTs is unclear.

Conclusion

This case emphasizes that early diagnosis has a considerable role in preventing major complications. Also to advise considering ACC as a differential diagnosis when similar symptoms are found in an infant.

Genitourinary Tract Tumors in Children: An Update

BACKGROUND

Genitourinary tract tumors in children are less common than in adults. Most of these tumors have different genetic backgrounds, clinical presentation, and oncologic behavior than their adult counterpart. As a result of low prevalence in children, some of the treatment approaches and recommendations are based on treatment experience in adult patients. However, thanks to scientific and technological development, survival rates have risen considerably.

OBJECTIVE

This paper presents a review of the principal features of the tumors involving the genitourinary tract in children and an update in genetic background, diagnosis, and treatment.

METHODS

A narrative review was performed on published literature about genitourinary tract tumors in pediatric patients. Papers presented in English and Spanish literature were reviewed. PubMed, Science Direct, and SciELO databases were used to collect information and present this article.

RESULTS

Kidney tumors are the most common type of genitourinary tumors in children. Among those, Wilms tumor represents the majority of cases and shows the successful work of clinical trial groups studying this tumor type. Other tumors involving the genitourinary tract in children include Rhabdomyosarcoma, Transitional cell carcinoma, Testicular, and Adrenal tumors.

CONCLUSION

Genitourinary tract tumors in children represent significant morbidity and economic burden, so awareness in early diagnosis represents improvement in treatment, clinical, and oncological outcomes.

Long-term survival outcomes of pediatric adrenal malignancies: An analysis with the upstaged SEER registry during 2000-2019

OBJECTIVE

To investigate the clinicopathological characteristics and long-term survival outcomes of pediatric adrenal malignancies.

METHOD

This study retrospectively analyzed children with pathologically confirmed pediatric adrenal malignancies from Surveillance, Epidemiology, and End Results Database from 2000 to 2019. Kaplan-Meier curve was used to assess the overall survival (OS) and cancer-special survival (CSS), and the Log-Rank method was used to calculate statistical differences. Cox proportional hazards model and Fine-and-Grey model were used to calculate the hazard ratio (HR) of all-cause mortality risk and the sub-distribution HR (sHR) of disease-specific mortality risk, respectively, and their corresponding 95% confidence intervals (CI).

RESULTS

1601 children were included in the study in which 1335 (83.4%) neuroblastoma, 151 (9.4%) ganglioneuroblastoma, 89 (5.6%) adrenocortical carcinoma, and 26 (1.6%) were diagnosed with other types malignancies. Metastatic disease accounted for the largest proportion (69.3%), and the proportion of metastases diagnosed by neuroblastoma was higher than that of adrenocortical carcinoma and ganglioneuroblastoma (73.9% vs. 45.7% vs. 47.2%). The 5-year OS and CSS of all cohort were 69.5% and 70.5%, respectively. Adrenal cortical carcinoma had the worst prognosis, with 5-year OS and CSS of 52.5% and 53.1%, respectively. Patients in recent years had no better OS and CSS than in previous years at diagnosis. The tumor stage remained the main prognostic predictor. Compared to metastatic adrenal tumors, the risk of all-cause mortality (adjusted HR: 0.12, 95% CI: 0.06-0.25, P < 0.001) and the risk of disease-specific mortality (adjusted sHR: 0.11, 95% CI: 0.05-0.25, P<0.001) was significantly lower for patients with localized diseases. Additionally, higher age, adrenal cortical carcinoma, and lack of complete tumor resection are independent risk factors for poor prognosis. Furthermore, it was found that the prognosis of patients who received chemotherapy was worse than those who did not, mainly because the former mostly had metastasis at the presentation and complete resection of the tumor cannot be achieved.

CONCLUSION

The clinicopathological characteristics of pediatric adrenal malignancies have not changed significantly in the past two decades, while the prognosis of patients has improved. Early diagnosis of disease and complete resection of local tumors are the keys to improving prognosis.

Adrenal ganglioneuroma resected for suspicious malignancy: multicenter review of 25 cases and review of the literature

Purpose

We reviewed the experience with adrenal ganglioneuroma (AGN) pathologically confirmed following adrenalectomy in medium- to high-volume medical centers.

Methods

The medical records of all adrenalectomy cases in 4 medical centers between 2006 and 2020 were retrospectively reviewed for demographics, clinical, radiological and laboratory findings, surgical treatment, pathology results, and outcomes.

Results

Twenty-five out of 875 adrenalectomy cases (2.9%) were pathologically confirmed as AGN. Those patients' average age was 40.5 years (range, 4-76 years), 13 (52.0%) were males, and 18 lesions (72.0%) were right-sided. One patient had a family history of neurofibromatosis, and another had a succinate dehydrogenase gene mutation. Abdominal/back pain attributed to mass effect was the most common symptom. All 25 patients underwent abdominal computerized tomography scanning in which the average maximal tumor diameter was 6.61 cm. The mean pre- and postcontrast Hounsfield units (HU) values were 35.2 and 59, respectively; and the mean late-phase HU value was 71.1. Twenty-two patients (88.0%) underwent minimally invasive surgery. The average tumor diameter recorded in the final pathology report was 7 cm. Isolated AGN was diagnosed in 21 cases (84.0%), and the additional components reported for the remaining 4 cases included pheochromocytoma (2), ganglioneuroblastoma (1), and neurofibroma (1). The average follow-up length was 16.8 months (range, 1-136 months), during which there was no recurrence or death.

Conclusion

AGN is a rare, slow-growing, large benign tumor with radiological characteristics similar to those seen in malignant tumor. Final diagnosis is established by pathology after surgical resection, preferably minimally invasive, with an overall excellent prognosis.

Management of functioning pediatric adrenal tumors

AIM

The aim of this study is to present our experience in the management of hormonally active adrenal tumors in children.

MATERIAL AND METHODS

We did a retrospective chart review of all children with hormonally active adrenal tumors evaluated at the endocrinology clinic and operated at our institution between 1983 and 2019.

RESULTS

There were 75 patients included in the study, 58 with adrenocortical tumors (ACTs) and 17 with pheochromocytomas (PCCs). Within the group of patients with ACTs, there were 41 females and 17 males. The mean age was 58.3 (SD: 87.9; range: 9-211) months. The clinical manifestation of the tumor's hormonal activity was virilization in 37 cases, Cushing syndrome in 5, and mixed in 16. A positive family history was present in 11 patients (18.9%). The mean tumor size was 48.2 (SD: 22.4; range: 7-120) mm. The pathological diagnosis was adenoma in 42 cases, carcinoma in 15 cases, and macronodular hyperplasia in 1. Median follow-up was 192 (range: 50-290) months. Tumor recurrence occurred in 6 patients (10.3%), and there were three disease-related deaths (5%). Within the group of patients with PCCs, there were 11 males and 6 females. The mean age was 146.7 (SD: 71.2; range: 60-216) months. A positive family history was present in 7 patients (41.2%). The mean tumor size was 36.6 (SD: 16.7; range: 7-120) mm. The pheochromocytoma was classified as benign in 15 cases and as malignant in 2. During a median follow-up of 180 (range: 127-300) months, recurrence was observed in 6 cases (35.3%) and disease-related death in 1 case (5.9%).

CONCLUSIONS

Proper diagnosis and management at our referral center were associated with a high cure rate, even in cases of malignant tumors. Familial surveillance is highly recommended.

LEVEL OF EVIDENCE

Level IV.

Effects of pretreatment with terazosin and valsartan on intraoperative haemodynamics in patients with phaeochromocytoma

OBJECTIVE

Surgery is the primary strategy for treating phaeochromocytoma (PCC), but it can lead to severe hypertension and heart failure. Although valsartan is effective in reducing high blood pressure, clinical data on the potential role of valsartan in PCC are currently limited. Therefore, the aim of this study was to investigate the effects of pretreatment with terazosin and valsartan on patients with PCC.

METHODS

In this retrospective cohort study, 50 patients who underwent laparoscopic resection of PCC were enrolled. During preoperative preparation, the patients (n=25) in the control group were treated with terazosin, while those (n=25) in the combination treatment group were treated with terazosin and valsartan. The levels of catecholamine hormones before and after surgery were determined, and the intraoperative blood pressure and the incidence of complications were compared between the two groups.

RESULTS

The results showed no significant differences in baseline patient characteristics or surgical conditions between the two groups (p>0.05). However, on the third day after surgery, the levels of catecholamine hormones in the two groups were significantly lower than those before surgery (p<0.05), while the levels in the combination treatment group were notably lower than those in the control group (p<0.05). The patients in the combination treatment group showed lower intraoperative blood pressure fluctuations and incidence of perioperative complications compared with the control group (p<0.05).

CONCLUSIONS

Terazosin combined with valsartan can effectively improve perioperative haemodynamic instability and reduce postoperative complications in the preoperative management of PCC.

Laparoscopic adrenalectomy in children: A 25-case series and review of the literature

BACKGROUND

Laparoscopic adrenalectomy (LA) is the gold standard and is widely performed in adults, but its use in children is relatively new. We aim to present our experience in twenty-five children with diverse adrenal pathologies and to discuss an extensive review of pediatric LA in English literature.

METHODS

Medical records of children with adrenal tumors admitted to a tertiary center and treated with LA were reviewed. Characteristics and outcome of patients were compared with results of a systematic Pubmed/Medline literature review.

RESULTS

Transperitoneal LAs were performed for 12 malignant and 14 benign adrenal masses (size range: 2-8cm) in 25 children (median age:63months). Fourteen lesions were on the right side, and there was one bilateral case. There were no conversion and no complication within 36months of follow-up. A literature review revealed 437 pediatric LAs with left side predomination (51.4%). The indication was a malignant lesion in 60.2% of the cases (sizes range: 1-10cm). The transperitoneal route was preferred in 94.2% of the procedures. Conversion and complication rates were 7.5% and 3.1%, respectively.

CONCLUSION

LA should be preferred in selected children with adrenal pathologies. The transperitoneal route seems to be the standard approach for pediatric surgeons. Preoperative planning and surgical expertise are the keys to success.

TYPE OF THE STUDY

Case series with systematic literature review.

LEVEL OF EVIDENCE

IV.