Indications for laparoscopic adrenalectomy for non-functional adrenal tumor with hypertension: Usefulness of adrenocortical scintigraphy

Impact of adrenalectomy on hypertension in patients with nonfunctional adrenal tumors: a retrospective study

OBJECTIVE

To investigate the impact of adrenalectomy on hypertension in patients with nonfunctional adrenal tumors.

SUBJECTS AND METHODS

Between January 2020 and October 2022, patients with adrenal lesions were retrospectively screened for nonfunctional adrenal tumors at the Zhongnan Hospital of Wuhan University. All patients underwent detailed endocrinological examination and computed tomography to characterize the lesions. One year after discharge, follow-up blood pressure (BP) was assessed and compared to the blood pressure on admission. Univariate analysis and multivariate regression analysis were performed to determine factors predicting favorable hypertension outcomes after adrenalectomy.

RESULTS

A total of 309 patients were found to be eligible, including 123 who underwent adrenalectomy. Patients who underwent adrenalectomy were stratified into two groups: (Bancos I (2022) Adrenal Incidentalomas: Insights Into Prevalence. Ann Intern Med 175:1481-1482. https://doi.org/10.7326/M22-2600 ) those with improved hypertension (n = 71), and (Fassnacht M, Tsagarakis S, Terzolo M, Tabarin A, Sahdev A, Newell-Price J et al. (2023) European Society of Endocrinology clinical practice guidelines on the management of adrenal incidentalomas, in collaboration with the European Network for the Study of Adrenal Tumors. Eur J Endocrinol 189:G1-42. https://doi.org/10.1093/ejendo/lvad066 ) those without improved hypertension (n = 52). In contrast, the blood pressure levels of conservatively treated patients remained relatively stable 1 year after discharge. Univariate analysis and multivariate regression analysis showed that body mass index (BMI) and duration of hypertension were significantly different between the hypertension improvement group and the non-improvement group (p < 0.05).

CONCLUSION

Adrenalectomy has been shown to be effective in improving hypertension in certain patients with nonfunctional adrenal tumors. BMI and duration of hypertension were independent factors associated with favorable hypertension outcomes after adrenalectomy.

The improvement of postoperative blood pressure and associated factors in patients with hormone-negative adrenal adenoma and hypertension

OBJECTIVE

To investigate the effect of adrenal surgery on blood pressure (BP) improvements in patients with hormone-negative adrenal adenoma (HNA) concomitant with hypertension and analyze associated prognostic factors.

METHODS

We retrospectively reviewed the clinical data of patients with HNA and hypertension and patients with aldosterone-producing adenoma (APA) and hypertension who underwent adrenal surgery at our center between 2019 and 2022. Hypertension outcomes were evaluated in all patients and subjects were divided into three groups according to follow-up BP and the administration of anti-hypertensive agents: a clinical curation group, an improvement group, and a no-improvement group. Logistic regression analysis was performed to predict factors associated with clinical curation in patients with HNA post-surgery.

RESULTS

Of the 182 patients with HNA, clinical curation was achieved in 58 patients (31.9%), improvement in 72 (39.5%), and no improvement in 52 (28.6%). The clinical curation, improvement and no improvement rates in patients with APA were 64.8% (n = 118), 15.9% (n = 29), and 19.2% (n = 35). Multivariate logistic regression analysis indicated that a duration of hypertension ≤6 years and a plasma aldosterone level >160 pg/ml were both independent factors for the clinical curation of hypertension in patients with HNA after adrenal surgery.

CONCLUSION

Adrenal surgery can cure or improve hypertension in most patients with HNA, especially in a short duration of hypertension and high plasma levels of aldosterone.

Using CT radiomic features based on machine learning models to subtype adrenal adenoma

BACKGROUND

Functioning and non-functioning adrenocortical adenoma are two subtypes of benign adrenal adenoma, and their differential diagnosis is crucial. Current diagnostic procedures use an invasive method, adrenal venous sampling, for endocrinologic assessment.

METHODS

This study proposes establishing an accurate differential model for subtyping adrenal adenoma using computed tomography (CT) radiomic features and machine learning (ML) methods. Dataset 1 (289 patients with adrenal adenoma) was collected to develop the models, and Dataset 2 (54 patients) was utilized for external validation. Cuboids containing the lesion were cropped from the non-contrast, arterial, and venous phase CT images, and 1,967 features were extracted from each cuboid. Ten discriminative features were selected from each phase or the combined phases. Random forest, support vector machine, logistic regression (LR), Gradient Boosting Machine, and eXtreme Gradient Boosting were used to establish prediction models.

RESULTS

The highest accuracies were 72.7%, 72.7%, and 76.1% in the arterial, venous, and non-contrast phases, respectively, when using radiomic features alone with the ML classifier of LR. When features from the three CT phases were combined, the accuracy of LR reached 83.0%. After adding clinical information, the area under the receiver operating characteristic curve increased for all the machine learning methods except for LR. In Dataset 2, the accuracy of LR was the highest, reaching 77.8%.

CONCLUSION

The radiomic features of the lesion in three-phase CT images can potentially suggest the functioning or non-functioning nature of adrenal adenoma. The resulting radiomic models can be a non-invasive, low-cost, and rapid method of minimizing unnecessary testing in asymptomatic patients with incidentally discovered adrenal adenoma.

Contralateral adrenal suppression on adrenocortical scintigraphy provides good evidence showing subclinical cortisol overproduction from unilateral adenomas

Unilateral and/or predominant uptake on adrenocortical scintigraphy (ACS) may be related to autonomous cortisol overproduction in patients with subclinical Cushing's syndrome (SCS). However, there is no information regarding whether increased tracer uptake on the tumor side or decreased uptake on the contralateral side on ACS is more greatly associated with inappropriate cortisol production. Therefore, we evaluated the relationship between quantitative ¹³¹I-6β-iodomethyl-norcholesterol (¹³¹I-NP-59) uptake in both adrenal glands and parameters of autonomic cortisol secretion and attempted to set a cut off for SCS detection. The study included 90 patients with unilateral adrenal adenoma who fulfilled strict criteria. The diagnosis of SCS was based on serum cortisol ≥3.0 μg/dL after 1-mg dexamethasone suppression test (DST) with at least 1 other hypothalamus-pituitary-adrenal axis function abnormality. Twenty-two (27.7%) subjects were diagnosed with SCS. The uptake rate on the affected side in the SCS group was comparable to that in the non-functioning adenoma group. In contrast, the uptake rate on the contralateral side was lower and the laterality ratio significantly higher in the SCS group. The two ACS indices were correlated with serum cortisol levels after a 1-mg DST, but uptake on the tumor side was not. Tumor size was also important for the functional statuses of adrenal tumors and NP-59 imaging patterns. The best cut-off point for the laterality ratio to detect SCS was 3.07. These results clearly indicate that contralateral adrenal suppression in ACS is good evidence showing subclinical cortisol overproduction.

THERAPY OF ENDOCRINE DISEASE: Improvement of cardiovascular risk factors after adrenalectomy in patients with adrenal tumors and subclinical Cushing's syndrome: a systematic review and meta-analysis

OBJECTIVE

Beneficial effects of adrenalectomy on cardiovascular risk factors in patients with subclinical Cushing's syndrome (SCS) are uncertain. We sought to conduct a systematic review and meta-analysis with the following objectives: (i) determine the effect of adrenalectomy compared with conservative management on cardiovascular risk factors in patients with SCS and (ii) compare the effect of adrenalectomy on cardiovascular risk factors in patients with SCS vs those with a nonfunctioning (NF) adrenal tumor.

METHODS

MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trial were searched on 17 November 2015. Reviewers extracted data and assessed methodological quality in duplicate.

RESULTS

We included 26 studies reporting on 584 patients with SCS and 457 patients with NF adrenal tumors. Studies used different definitions of SCS. Patients with SCS undergoing adrenalectomy demonstrated an overall improvement in cardiovascular risk factors (61% for hypertension, 52% for diabetes mellitus, 45% for obesity and 24% for dyslipidemia). When compared with conservative management, patients with SCS undergoing adrenalectomy experienced improvement in hypertension (RR 11, 95% CI: 4.3-27.8) and diabetes mellitus (RR 3.9, 95% CI: 1.5-9.9), but not dyslipidemia (RR 2.6, 95% CI: 0.97-7.2) or obesity (RR 3.4, 95% CI: 0.95-12). Patients with NF adrenal tumors experienced improvement in hypertension (21/54 patients); however, insufficient data exist for comparison to patients with SCS.

CONCLUSIONS

Available low-to-moderate-quality evidence from heterogeneous studies suggests a beneficial effect of adrenalectomy on cardiovascular risk factors in patients with SCS overall and compared with conservative management.

Systematic review of surgical treatment of subclinical Cushing's syndrome

BACKGROUND

Subclinical Cushing's syndrome (SCS) is a condition of biochemical cortisol excess without the classical clinical features of overt hypercortisolism; it may be associated with some consequences of metabolic syndrome. The most appropriate treatment remains controversial. This study aimed to assess the outcomes of adrenalectomy for SCS.

METHODS

A systematic review was performed. MEDLINE, Embase and Cochrane Databases (1980-2013) were searched for studies reporting the outcomes of unilateral adrenalectomy with respect to hypertension, diabetes, dyslipidaemia, obesity and osteoporosis in patients with SCS. Studies with a questionable diagnosis of SCS, bilateral adrenal involvement and insufficient data were excluded.

RESULTS

Of the 105 papers screened, seven were selected; there were six retrospective studies and one randomized clinical trial, including 230 patients. Data analysis was limited by heterogeneity in definition of SCS and endpoints. Hypercortisolism was cured in all operated patients. Laparoscopy was the preferred approach, with a morbidity rate of 0·8 per cent. A beneficial effect of surgery on blood pressure, glucometabolic control and obesity was evident in all studies, with cure or improvement in 72, 46 and 39 per cent of patients respectively, compared with conservative management. The results for lipid metabolism were equivocal, because of a decrease in triglyceridaemia but discordant effects on cholesterol metabolism among the different studies. No beneficial effects on osteoporosis were found.

CONCLUSION

Laparoscopic adrenalectomy seems to be beneficial in reversing several metabolic effects of hypercortisolism, with a low morbidity rate. However, the heterogeneity and low quality of the available studies preclude definitive recommendations.

The role of adrenal scintigraphy in the diagnosis of subclinical Cushing's syndrome and the prediction of post-surgical hypoadrenalism

BACKGROUND

Management of subclinical Cushing's syndrome (SCS) remains controversial; it is not possible to predict which patients would benefit from adrenalectomy. In the present study we aimed to evaluate the role of adrenocortical scintigraphy (ACS) in the management of patients with SCS.

METHODS

The medical records of 33 consecutive patients with adrenal "incidentaloma" and proven or suspected SCS who underwent (131)I-19-iodocholesterol ACS between 2004 and 2010 were reviewed. Sixteen underwent laparoscopic adrenalectomy (surgical group-S-group) and 17 were medically managed (medical group-M-group). Follow-up evaluation was obtained by outpatient consultation.

RESULTS

Overall 25 patients (15 in the S-group and 10 in the M-group) had concordant unilateral uptake at ACS (ACS+). In the S-group, the mean follow-up duration was 30.9 ± 16.1 months and, irrespective of the presence of hormonal diagnosis of SCS, in patients who were ACS+ adrenalectomy resulted in a significant increase in HDL cholesterol and decreases in body mass index, glycemia, and blood pressure (BP). One patient reduced antihypertensive medication and three others were able to discontinue it altogether. Prolonged postoperative hypoadrenalism (PH) occurred in 14 patients in the S-group. The overall accuracy in predicting PH was 93.7 % for ACS and 68.7 % for laboratory findings. In the M-group, the mean follow-up duration was 31.5 ± 26.3 months and no patient developed overt Cushing's syndrome, although ACS+ patients experienced a worsening in glycemia and diastolic BP.

CONCLUSIONS

Adrenal scintigraphy seems the most accurate diagnostic test for SCS. It is able to predict the metabolic outcome and the occurrence of PH, identifying the patients who could benefit from adrenalectomy irrespective of hormonal diagnosis.

Effectiveness of partial adrenalectomy for concomitant hypertension in patients with nonfunctional adrenal adenoma

OBJECTIVE

To evaluate the effect of adrenal surgery on blood pressure (BP) in patients with both nonfunctional adrenal adenoma (NFA) and hypertension and to assess factors affecting hypertension outcomes after surgery.

METHODS

Nonfunctional adrenal adenoma patients with hypertension who were treated with or without adrenal surgery at our center during 2005-2011 were retrospectively studied. Clinical characteristics were collected, and changes in BP were evaluated and compared at 2 year after discharge. Factors predicting favorable hypertension outcomes after surgery were determined using logistic regression.

RESULTS

A total of 186 patients, including 77 surgically treated cases, were eligible for this study. Retroperitoneoscopic procedure was mostly adopted, and partial adrenalectomy was performed in 69 patients. At 2 year postoperatively, both systolic and diastolic pressure levels of the surgery group decreased significantly (162.9/97.6 vs. 146.9/88.2 mmHg), with 27 (35%) patients cured and 26 (31%) improved. In contrast, BP levels of conservatively treated patients remained relatively stable (159.9/96.8 vs. 161.9/97.4 mmHg) after 2 years. Multivariate logistic regression analyses showed hypertension duration<6 years was the only independent factor associated with favorable hypertension outcomes after surgery, which predicted complete cure as well as response to surgical intervention.

CONCLUSION

Early partial adrenalectomy substantially cures or improves concomitant hypertension in most patients with NFA. Prospective studies should be performed of large cohorts to construct ideal clinical guidelines for NFA patients at cardiometabolic risk.

Endocrine scintigraphy with hybrid SPECT/CT

Nuclear medicine imaging of endocrine disorders takes advantage of unique cellular properties of endocrine organs and tissues that can be depicted by targeted radiopharmaceuticals. Detailed functional maps of biodistributions of radiopharmaceutical uptake can be displayed in three-dimensional tomographic formats, using single photon emission computed tomography (CT) that can now be directly combined with simultaneously acquired cross-sectional anatomic maps derived from CT. The integration of function depicted by scintigraphy and anatomy with CT has synergistically improved the efficacy of nuclear medicine imaging across a broad spectrum of clinical applications, which include some of the oldest imaging studies of endocrine dysfunction.

Adrenal cortical imaging with I-131 NP-59 SPECT-CT

PURPOSE

The purpose of this article is to present our initial experience with hypersecretory adrenal syndromes investigated with radioiodinated I-6-B-iodomethyl-19-norcholesterol (NP-59) and SPECT-CT.

MATERIALS AND METHODS

Illustrative cases are presented of patients being investigated for adrenal hypersecretory syndromes, with or without adrenal nodules, using NP-59 scintigraphy with SPECT-CT imaging, representing a spectrum of diagnoses. Clinical and imaging data are reviewed to evaluate whether additional information derived from near-simultaneous anatomic localization aids study interpretation.

RESULTS

The final diagnoses reached are hyperfunctional and nonfunctioning adrenal nodules, physiological bowel activity, and bilateral adrenal hyperplasia. SPECT-CT assisted study interpretation by localizing focal uptake to the adrenal glands, allowing direct assessment of function within adrenal nodules, and distinguishing physiological bowel activity from adrenal uptake. SPECT-CT provided additional information to planar and SPECT imaging, which improved confidence of study interpretation.

CONCLUSION

Utilization of SPECT-CT with NP-59 scintigraphy allows precise localization of the functional activity to anatomic structures improving diagnostic interpretation.

Adrenal incidentalomas and cardiometabolic morbidity: an emerging association with serious clinical implications

Adrenal incidentalomas (AIs) represent adrenal masses that are incidentally discovered whilst investigating symptoms and signs unrelated to adrenal pathology. The onset and natural course of AIs are unknown, and the possible underlying cardiometabolic abnormalities have not been examined in depth. A growing body of clinical and experimental evidence supports the notion that both functioning and, paradoxically, nonfunctioning AIs are associated with a partially expressed or even full-blown metabolic syndrome (MS) phenotype, through yet unclear mechanisms. Subtle, subclinical or even profound adrenal hormone excess and an increased proinflammatory state might explain to some extent the development of MS disturbances. The emerging association between AIs and MS appears to be important in determining the optimal clinical management of these patients and raises speculation about the exact mechanisms of this interesting cause-effect relationship.

Surgery for Cushing's syndrome: an historical review and recent ten-year experience

BACKGROUND

Cushing's syndrome (CS), due to multiple etiologies, is a disorder associated with the ravages of cortisol excess. The purpose of this review article is to provide a historical synopsis of surgery for CS, review a recent 10-year period of operative management at a tertiary care facility, and to outline a practical approach to diagnosis and management.

MATERIALS AND METHODS

From 1996 to 2005, 298 patients underwent 322 operative procedures for CS at Mayo Clinic, Rochester, Minnesota. A retrospective chart review was carried out. Data was gathered regarding demographics, preoperative assessment, procedures performed, and outcomes. Data are presented as counts and percentages. Five-year survival rates were calculated where applicable by the Kaplan-Meier method. Statistical analysis was carried out with SAS, version 9 (SAS Institute, Inc., Cary, NC).

RESULTS

Two-hundred thirty-one patients (78%) had ACTH-dependent CS and 67 patients (22%) had ACTH-independent CS. One-hundred ninety-six patients (66%) had pituitary-dependent CS and 35 patients (12%) had ectopic ACTH syndrome. Fifty-four patients (18%) had cortisol-secreting adenomas, 10 patients (3%) had cortisol-producing adrenocortical carcinomas, and 1% had other causes. Cure rates for first time pituitary operations (transsphenoidal, sublabial, and endonasal) were 80% and 55% for reoperations. Most benign adrenal processes could be managed laparoscopically. Five-year survival rates (all causes) were 90%, 51%, and 23% for adrenocortical adenomas, ectopic ACTH syndrome, and adrenocortical carcinomas, respectively.

CONCLUSIONS

Surgery for CS is highly successful for pituitary-dependent CS and most ACTH-independent adrenal causes. Bilateral total adrenalectomy can also provide effective palliation from the ravages of hypercortisolism in patients with ectopic ACTH syndrome and for those who have failed transsphenoidal surgery. Unfortunately, to date, adrenocortical carcinomas are rarely cured. Future successes with this disease will likely depend on a better understanding of tumor biology, more effective adjuvant therapies and earlier detection. Clearly, IPSS, advances in cross-sectional imaging, along with developments in transsphenoidal and laparoscopic surgery, have had the greatest impact on today's management of the complex patient with CS.

Adrenalectomía laparoscópica. Consideraciones a propósito de 24 procedimientos

INTRODUCTION AND OBJECTIVES

Laparoscopic adrenalectomy has gained rapid recognition since publication of the first case in 1992. Currently it is the technique of choice for the surgical treatment of the adrenal gland. Our objective in this paper is to share our experience with this technique and offer some practical advice on how to approach it.

MATERIALS AND METHODS

Between May 1998 and August 2006 we did a total of 24 laparoscopic adrenalectomies in 22 patients (15 men, 7 women). The right gland was removed in 13 cases and the left in 11. Surgery was bilateral in two cases (one was MEN II, the other bilateral cortical hyperplasia). Average age was 49.5 +/- 14.3 years (range 24 to 78). Clinical diagnosis was: Pheochromocytoma (n = 10), Cushing (n = 6), Conn (n = 4), metastases from lung carcinoma (n = 2) and non-functioning tumor (n = 2). For surgery, all patients were in total lateral decubitus with a pillow to increase the costal-iliac space. We used four trocars on the right side and three on the left. Abdominal access was by Hasson trocar after minilaparotomy. We kept pneumoperitoneal pressure below 12 mmHg; a Veress needle was not used for this procedure.

RESULTS

Open surgery was required in one case. Time operation was between 59 and 400 minutes (mean 182 +/- 98 min.). In the first 12 cases average time was 261 +/- 77 minutes and in the final 12 cases was 103 +/- 21 minutes (p < 0.001). Tumour diameter was between 1.3 and 6 cm (mean 3.08 +/- 1.25 cm) and tumour weight was between 8 and 92g (mean 30.13 +/- 21 g). Except in one case with 600 ml blood loss, bleeding was less than 100 ml (n = 23, range: 10-100, mean 43.26 +/- 25ml). We only had intraoperative complications in two cases: perforation of the liver by the laparoscope retractor (at the beginning of the series) and injury to the spleen capsule. Both complications were resolved laparoscopically. Cases by histologic type were: nine cortical adenomas, nine pheochromocytomas, three nodular hyperplasias, two metastases from lung carcinoma, and one adrenal pseudocyst. Discharge from hospital was between three and five days (mean 3.62 +/- 0.82) with a statistical difference (p < 0.001) between twelve first cases and the last ones.

CONCLUSIONS

The adrenal laparoscopic approach is currently the technique of choice for removing adrenal tumours although with malign tumours or over 7 cm in diameter there are some contraindications and disadvantages relative to open surgery. There is inevitably a learning curve but satisfactory results are quickly attainable.