Preoperative workup in the assessment of adrenal incidentalomas: outcome from 282 consecutive laparoscopic adrenalectomies

Antenatally Detected Functional Adrenocortical Adenoma: A Case Report and Review of Current Literature

Pediatric adrenocortical tumors (ACTs) are rare entities with an incidence of 0.2% of all pediatric tumors. Only two cases of antenatally detected ACT have been reported in the literature. Our case is the first report of an antenatally detected suprarenal mass which manifested with postnatal virilizing features and was proven to be adrenocortical adenoma on histology.

Missed Opportunities to Promptly Diagnose and Treat Adrenal Tumors

INTRODUCTION

Adrenal mass management guidelines are insufficiently applied, and timeliness of treatment is unknown. We evaluated missed opportunities to promptly diagnose and treat adrenal tumors that ultimately required adrenalectomy.

METHODS

From the Veterans Affairs Corporate Data Warehouse, we identified patients who underwent adrenalectomy (2010-2016) in the South-Central Veterans Affairs HealthCare Network and reviewed their records. Diagnostic timeliness was assessed by the interval between initial (index) imaging with adrenal abnormality and the next diagnostic step. Workup was defined as early (interval ≤6 mo) or late (>6 mo). Adrenalectomy was considered prompt when the interval between index imaging and adrenalectomy was ≤12 mo and delayed when this was >12 mo. We quantified diagnostic and treatment delays and assessed factors associated with delayed adrenalectomy.

RESULTS

During the study period, 84 patients underwent adrenalectomy: male (86.9%), White (57.1%), with a mean age of 58.7 y (±8.8). Of those, 25 (29.8%) had late workup, and 36 (42.9%) had delayed surgery (median interval: 44 mo, range 14-282). Late hormonal workup occurred in 24 of 36 (66.7%) patients with delayed surgery, compared with one of 48 (2.1%, P < 0.001) with prompt surgery.

CONCLUSIONS

Missed opportunities in prompt diagnosis and treatment were common in patients with adrenal masses ultimately requiring adrenalectomy. Late hormonal workup is associated with delayed adrenalectomy. Interventions are needed to aid clinicians to recognize the presence, promptly evaluate, and make guideline-informed decisions on the management of an adrenal mass.

Nomograms for Individualized Evaluation of Prognosis in Adrenocortical Carcinomas for the Elderly: A Population-Based Analysis

BACKGROUND

Adrenocortical carcinoma (ACC) is extremely rare in elderly patients. Thus, this study aimed to identify the incidence rate and develop nomogram models for predicting survival in elderly ACC patients.

METHODS

Data of ACC patients aged >60 years from 1975 to 2016 were obtained from the Surveillance, Epidemiology, and End Results dataset. The national incidence rate was estimated, and survival was subjected to Kaplan-Meier analysis. A multivariate Cox regression model was used to identify predictors of survival. Nomograms were generated to predict survival, calibrated and internally validated.

RESULTS

We identified 583 cases. Univariate analysis showed that patients with younger age (≤67 years), female sex, lower tumor grade, surgical treatment performed, and earlier European Network for the Study of Adrenal Tumors (ENSAT) stage had a better survival (P < 0.05). In the Cox regression analysis, no surgery performed (hazard ratio [HR]: 3.544, 95% CI: 1.142-10.995, P = 0.029 for overall survival [OS]; HR: 3.230, 95% CI: 1.040-10.034, P = 0.043 for disease-specific survival [DSS]) and advanced ENSAT stage (HR: 3.328, 95% CI: 1.628-6.801, P = 0.001 for OS; HR: 3.701, 95% CI: 1.682-8.141, P = 0.001 for DSS) were associated with worse outcomes. Age, sex, histologic grade, surgical resection, radiotherapy, and ENSAT stage were included in the nomograms, with a C-index of 0.692 for OS and 0.694 for DSS, demonstrating a good accuracy in predicting survival.

CONCLUSIONS

This study is the largest review of ACC in elderly patients. We present nomograms to predict survival in elderly ACC patients using clinicopathologic data, which could aid in accurate clinical decision-making.

Adrenocortical carcinoma: current state of the art, ongoing controversies, and future directions in diagnosis and treatment

Adrenocortical carcinoma (ACC) is a rare, aggressive malignancy with an annual incidence of ~1 case per million population. Differentiating between ACC and benign adrenocortical tumors can be challenging in patients who present with an incidentally discovered adrenal mass, due to the limited specificity of standard diagnostic imaging. Recently, urine steroid metabolite profiling has been prospectively validated as a novel diagnostic tool for the detection of malignancy with improved accuracy over current modalities. Surgery represents the only curative treatment for ACC, although local recurrence and metastases are common, even after a margin-negative resection is performed. Unlike other intra-abdominal cancers, the role of minimally invasive surgery and lymphadenectomy in ACC is controversial. Adjuvant therapy with the adrenolytic drug mitotane is used to reduce the risk of recurrence after surgery, although evidence supporting its efficacy is limited; it is also currently unclear whether all patients or a subset with the highest risk of recurrence should receive this treatment. Large-scale pan-genomic studies have yielded insights into the pathogenesis of ACC and have defined distinct molecular signatures associated with clinical outcomes that may be used to improve prognostication. For patients with advanced ACC, palliative combination chemotherapy with mitotane is the current standard of care; however, this is associated with poor response rates (RR). Knowledge from molecular profiling studies has been used to guide the development of novel targeted therapies; however, these have shown limited efficacy in early phase trials. As a result, there is an urgent unmet need for more effective therapies for patients with this devastating disease.

A Critical Analysis of Computed Tomography Washout in Lipid-Poor Adrenal Incidentalomas

BACKGROUND

Contrast-enhanced computed tomography (CT) with washout has emerged as an option to distinguish lipid-poor adenomas from non-adenomas.

OBJECTIVE

The aim of this study was to assess the utility of CT washout in characterizing indeterminate lipid-poor adrenal incidentalomas.

METHODS

From an Institutional Review Board-approved database, patients with adrenal incidentalomas who had adrenal protocol CT scans with a 15-min washout between 2003 and 2019 were identified. Non-contrast CT attenuation and washout patterns of different tumor types were compared.

RESULTS

Overall, 156 patients with 175 adrenal lesions were included. Average tumor size was 3.0 cm, non-contrast CT density was 24.7 Hounsfield units (HU), and absolute washout was 52.6%. In 102 lesions (58.3%), CT washout was ≥ 60%; 94 (92.2%) of these were benign adrenocortical adenomas, 7 (6.9%) were pheochromocytomas, and 1 (0.9%) was an adrenal hematoma. Furthermore, in 73 tumors (41.7%), CT washout was < 60%; diagnosis was benign adrenocortical adenoma in 45 (61.6%) lesions, pheochromocytoma in 8 (11%) lesions, metastasis in 9 (12.3%) lesions, adrenocortical cancer in 6 (8.2%) lesions, and 'others' in 5 (6.9%) lesions. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of  > 60% absolute CT washout for detecting an adrenal adenoma was 67.6%, 77.8%, 92.2%, 38.4%, and 69.7%, respectively.

CONCLUSION

CT washout should be incorporated into the management algorithm of indeterminate adrenal incidentalomas with a high non-contrast CT attenuation to 'rule-in' benign tumors. For small tumors with mild elevation of plasma metanephrines, it should be kept in mind that adenomas and pheochromocytomas may have similar imaging and washout characteristics.

The impact of the ultrasonic, bipolar and integrated energy devices in the adrenal gland surgery: literature review and our experience

BACKGROUND

The gold standard approach for surgical treatment of benign and malignant adrenal lesion is considered the laparoscopic one, due to a lot of advantages compared to open approach. The rapid propagation of this surgical technique is due to the diffusion of haemostatic devices in laparoscopic adrenal surgery. The principal aim of this study is to analyze the outcome of LA using each energy modality, evaluating the eventual superiority of an instrument over the others.

METHODS

A retrospective study, involving 75 consecutive patients submitted to LA by transperitoneal lateral approach from January 2013 to June 2017, was performed. Age less than 70 years old, adrenal adenomas less than 8 cm in diameter, incidentalomas < 6 cm, myelolipomas < 13 cm, adrenal metastases < 7 cm and ASA score ≤ III were the main surgical inclusion criteria. All involved patients were divided into three group, one for each energy device: group 1 - Harmonic Scalpel, group 2 - Ligasure vessel sealing system and group 3 - Thunderbeat. In each group only one device was applied for dissection and haemostasis during the whole operation. Each group consisted of 25 patients, well matched for histology, tumor size and site, gender and age. The following parameters were collected: age, gender, size of the tumor, side of the affected gland, pathology, operating time, intraoperative blood losses, hospitalization time, complication and conversion rate.

RESULTS

There was no significant statistical difference between groups regarding the relationship between male/female, right site/left site, the mean age, hospitalization time and the tumor size (p > 0.05). Significant statistical difference are detectable in operation time and intraoperative blood losses. Thunderbeat, compared respectively with Ligasure and Harmonic Scalpel, is the fastest device (p < 0,001). The second faster device resulted Harmonic Scalpel, which meanly reduced the operation time compared to Ligasure (p = 0.048). intraoperative blood losses are reduced using Thunderbeat (p < 0,001) and HS (p = 0.006) compared to Ligasure, but between Thunderbeat and Harmonic Scalpel there isn't significant statistical difference (p = 0.178).

CONCLUSIONS

Analyzing the results, laparoscopic adrenalectomy carried out using Thunderbeat appeared to show a statistically significant decrease in operation time and intraoperative blood losses compared with laparoscopic adrenalectomy performed using Harmonic Scalpel and Ligasure, while hospitalization time was superimposable in all groups. According to our data, a responsible use of advanced energy devices can improve surgical outcomes guarantying a cost savings and patient's satisfaction.

Multidisciplinary approach for patients with functional and non-functional adrenal masses and review of the literature

BACKGROUND

Adrenal incidentalomas are adrenal masses that are discovered by imaging tests performed for other reasons.

AIMS

In this retrospective study, we analysed 229 Turkish patients with adrenal masses and who presented with or without complaints.

STUDY DESIGN

Descriptive retrospective study and review of the literature.

METHODS

This study conducted a retrospective review of 229 patients with adrenal incidentalomas that were referred to Cukurova University Hospital's endocrinological department between 2009 and 2014. We reviewed detailed patient histories, physical examination findings, and symptoms and signs related to hormonal hypersecretion or malignant neoplasm and recorded clinical indications for performing diagnostic radiological imaging. The statistical analysis of data was performed using SPSS-19 software.

RESULTS

Of the 229 patients reviewed, 195 (85.2%) had non-functional, benign adrenal adenomas, and 34 (14.8%) had functional lesions. Among those with functional lesions, 8 (3.5%) had lesions that secreted excess cortisol, 11 (4.8%) had lesions that secreted aldosterone, and 15 (6.6%) had lesions that secreted catecholamines. Eighty-four patients included in the study (36.8%) underwent adrenalectomy; in 14 of these cases, the adrenalectomy was performed before surgical treatment criteria occurred. The most frequent pathologic diagnosis was adrenal cortical neoplasia (n = 38); 32 of these patients had adenomas (Weiss <4 criteria), and 6 had carcinomas (Weiss >4 criteria). Other patient diagnoses included benign pheochromocytoma (n = 13), pseudocyst (n = 12), metastasis (n = 10), haemorrhage (n = 3), necrosis (n = 1), hyperplasia (n = 2), and other (n = 5).

CONCLUSIONS

Detailed endocrinological and radiological assessments of the mass nature and hormone status are necessary in cases of adrenal incidentaloma. Appropriate surgical treatment or periodic follow-up must be determined based on the assessment results.

A clinical audit: diagnostic and epidemiological evaluation of the adrenal incidentaloma

BACKGROUND

Audit is a clinical instrument of government characterized by a whole process of evaluation inter pares to improve medical behaviors in the clinical practice. Different endocrinopathies are underestimated in the clinical and diagnostics practice but they can be a real problem in patients admitted in the departments of Internal Medicine. The adrenal incidentaloma is an accidental discovery with an incidence equal to 4% in radiologic studies but it's rarely considereted in the internal disorders. In the departments of Internal Medicine are hospitalized each year approximately 1450,000 patients and 58,000 about them show a surrenalic lesion identified with CT or MRI as Adrenal Incidentaloma.

METHODS

Through a search in the radiological archives, were reviewed all abdominal CT performed in the year 2012 in 8 departments of Internal Medicine of 8 Italian public hospitals. They also examined all medical records of these patients to value clinical management of the adrenal masses and the real incidence of the adrenal incidentaloma.

RESULTS

Distribution of pathological results show an important incidence about adrenal incidentaloma in Italian patients although this pathology is represented as a rare disease and its clinical and economic burden are significant. Many questions remain unanswered as the association between duration and severity of the disease, morbidity and how the dimensions affecting it. These results need to be supported by important studies with long follow-up to realize an easy diagnosis.

CONCLUSIONS

The results of this audit confirm the real incidence of this pathology in the internistic patients and the final target is to implement changes about therapeutic diagnostic pathway of the hospital patients in the internal medicine departments.

Single center experience with laparoscopic adrenalectomy on a large clinical series

BACKGROUND

Laparoscopic adrenalectomy is considered the gold standard technique for the treatment of benign small and medium size adrenal masses (<6 cm), due to low morbidity rate, short hospitalization and patient rapid recovery. The aim of our study is to analyse the feasibility and efficiency of this surgical approach in a broad spectrum of adrenal gland pathologies.

METHODS

Pre-operative, intra-operative and post-operative data from 126 patients undergone laparoscopic adrenalectomy between January 2003 and December 2015 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in case of pheochromocytoma while spironolactone and potassium were employed to treat Conn's disease. Laparoscopic adrenalectomies were all performed by the same surgeon (CG). First 30 procedures were considered as learning curve adrenalectomies.

RESULTS

One hundred twenty-six patients were included in the study. Functioning tumors were diagnosed in 84 patients, 27 patients were affected by pheochromocytomas, 29 by Conn's disease, 28 by Cushing disease. Surgery mean operative time was 137.33 min (range 100-180) during the learning curve adrenalectomies and 96.5 min (range 75-110) in subsequent procedures. Mean blood loss was respectively 160.2 ml (range 60-280) and 90.5 ml (range 50-200) in the first 30 procedures and the subsequent ones. Only one conversion to open surgery occurred. No post-operative major complications were observed, while minor complications occurred in 8 patients (0,79%). In 83 out of 84 functioning neoplasms, laparoscopic adrenalectomy was effective in normalization of endocrine profile.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe and feasible procedure, even for functioning masses and pheochromocytomas. A multidisciplinary team including endocrinologists, endocrine surgeons and anaesthesiologists, is recommended in the management of adrenal pathology, and adrenal surgery should be performed in referral high volume centers. A thirty-procedures learning curve is recommended to improve surgical outcomes.

Case Report: An incidentaloma that catches your eye - adrenal myelolipoma

Background: Adrenal incidentaloma refers to the incidental finding of a tumor in the adrenal gland, where nonfunctional forms are the most common variant. Myelolipoma is a rare (0.08-0.4%) occurrence characterized by adipose and hematopoietic tissue. The aim of this case report is to describe the diagnosis and appropriate management of a myelolipoma in an asymptomatic patient, which was originally considered an incidental hepatic hemangioma prior to being identified as a giant adrenal adenoma. Case description: The patient was a 54 year old obese female with a recent diagnosis of diabetes type II and dyslipidemia with recent ultrasound imaging suggestive of a hepatic hemangioma. An MRI was performed revealing a 7x6cm lesion in the right adrenal area indicating a giant adrenal adenoma. An adrenalectomy was performed without complications. The pathology report identified a myelolipoma. Discussion: The incidence of myelolipoma has recently increased due to advances in radiological techniques. Its etiology is unclear and the most accepted theories support a myeloid cell metaplasia in the embryonic stage as a result of stress, infections, or adrenocorticotropic hormone or erythropoietin stimulus. Contributing components may include bone morphogenetic protein 2 and β-catenin, as well as the presence of the chromosomal translocation (3, 21) (q25; p11). Despite its benign nature, the association with other adrenal lipomas must be ruled out. A biochemical evaluation is essential for detecting subclinical states, such as Cushing syndrome and pheochromocytoma. Conclusion: Adrenal myelolipomas are rare benign tumors that are generally asymptomatic. Uncertainty still exists surrounding their etiology. Surgical management depends on hormone production, tumor size, high risk features on imaging and patient consent.  Additional information is needed to better understand myelolipomas, their etiology, and clinical management.  Incidentalomas may confuse the physician and patient. Ensuring proper multidisciplinary management based on the clinical guidelines of endocrinology allowed a satisfactory resolution of this case.

Risk factors for complications after adrenalectomy: results from a comprehensive national database

PURPOSE

Most knowledge regarding outcome after adrenal surgery stems from retrospective studies reported by highly specialized centres. The aim of this study was to report a national experience of adrenalectomy with particular attention to predictive factors for postoperative complications, conversion from endoscopic to open surgery and length of hospital stay.

METHODS

Adrenalectomies reported in the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) 2009-2014 were included. Risk factors for complications, conversion and hospital stay >3 days were assessed using univariable and multivariable logistic regression analysis.

RESULTS

There were 659 operations. Endoscopic adrenalectomy was performed in 513 (77.8%) operations and almost half of these were robotic assisted. The median length of hospital stay was 3 (range 1-30) days. There was no 30-day mortality. In 43 (6.6%) patients, at least one complication was registered. The only factor associated with complications in multivariable analysis was conversion to open surgery odds ratio (OR) 3.61 (95% confidence interval 1.07 to 12.12). The risk for conversion was associated with tumour size OR 1.03 (1.00 to 1.06) and with malignancy on histopathology OR 8.33 (2.12 to 32.07). Length of hospital stay increased in patients with operation of bilateral tumours OR 3.13, left-sided tumours OR 1.98, hyper secretion of catecholamines OR 2.32, conversion to open surgery OR 42.05 and open surgery OR 115.18.

CONCLUSIONS

The present study shows that endoscopic surgery is widely used. Complications were associated with conversion and the risk for conversion was associated with tumour size and malignant tumour. Hospital stay was short.

Management of adrenal incidentaloma: the role of adrenalectomy may be underestimated

BACKGROUND

To demonstrate clinical characteristics of adrenal incidentaloma in South China and explore its comprehensive management.

METHODS

The clinical data of patients with adrenal neoplasm from Jan 1998 to Dec 2012 were retrospectively analysed. Patients with suspicion of adrenal abnormalities or those in whom adrenal abnormalities were detected in the staging procedures of other cancers were excluded. Most patients with adrenal incidentaloma chose to have adrenalectomy, and some chose surveillance. The relationships between clinical features were analysed with a chi-square test and rank sum test.

RESULTS

In total, 634 patients with adrenal incidentaloma were studied. Their age ranged from 17 to 85 years old with a median age of 50 years. Of 478 cases with pathological results, adenoma was the most common tumour (233/478), with 84 cases of pheochromocytoma and 36 cases of adrenocortical carcinoma were 84 and 36. When the tumour size was ≤4 cm, >95 % were benign; when the tumour size was >6 cm, 33 % were malignant. For patients with a tumour size ≤4 cm, 249/376 cases had an adrenalectomy performed. Due to anxiety over a potential malignant transformation and enlargement, most patients (>80 %) under surveillance preferred to undergo adrenalectomy.

CONCLUSIONS

Pheochromocytoma and adrenocortical carcinoma were not rare tumours of adrenal incidentaloma, and 4 cm is a good size cutoff to use in the diagnosis of an adrenal incidentaloma. Other than surveillance, laparoscopic adrenalectomy may become the method of choice for management of small adrenal incidentaloma.

PREDICTIVE VALUE OF CHROMOGRANIN A IN A DIAGNOSIS TOWARDS PHEOCHROMOCYTOMA IN ADRENAL INCIDENTALOMA

Context

Some adrenal tumors, such as pheochromocytoma, can be life-threatening. Therefore it is crucial to distinguish them from other lesions, especially prior to surgery. Chromogranin A (CgA) seems to potentially be a good marker for tumors of chromaffin origin.

Objective

To assess the differentiating value of CgA in the diagnostic work-up of pheochromocytoma.

Design

Retrospective study of operated patients with adrenal incidentaloma with lesions > 10 Hounsfield's units (HU) on CT.

Subjects and methods

Thirty patients (11 males, 19 females; aged 61.5±21 years) were enrolled in the study. Patients using medications interfering with the assessment of CgA and metanephrines were excluded. Two groups were formed: those with pheochromocytoma (Ph, n=16) and those with non-pheochromocytoma (N-Ph, n=14) lesions. Data included radiological features of masses, serum CgA and 24-hour urine metanephrines (24 - HUM) concentrations.

Results

No difference in 24-HUM level nor tumor size or density was found between groups Ph and N-Ph. Median serum CgA concentration was higher in Ph group compared to the N-Ph: 99.35 (68.12-172.73) vs. 52.92 (34.37-101.26) ng/mL, respectively (P=0.04). In Ph group, the size of the lesion correlated negatively with density (r= -0.53, P=0.042). No significant correlation in CgA, 24-HUM, density or size of the lesion was found. Performed curve receiver operating characteristic (ROC) showed AUC=0.7232 for CgA. Taking into account CgA serum value of ≤ 50 ng/mL (sensitivity: 93.75%, specificity: 50.00%, P=0.012), we proposed an algorithm for management of lesions > 10 HU on CT.

Conclusion

CgA level ≤ 50 ng/mL might be useful in initial screening evidence for the exclusion of pheochromocytoma. It is crucial to eliminate factors interfering with the measurements.

Minimally invasive approach for adrenal lesions: Systematic review of laparoscopic versus retroperitoneoscopic adrenalectomy and assessment of risk factors for complications

In the last decades, minimally invasive transperitoneal laparoscopic adrenalectomy has become the standard of care for surgical resection of the adrenal gland tumors. Recently, however, adrenalectomy by a mininvasive retroperitoneal approach has reached increasingly popularity as alternative technique. Short hospitalization, lower postoperative pain and decrease of complications and a better cosmetic resolution are the main advantages of these innovative techniques. In order to determine the better surgical management of adrenal neoplasms, the Authors analyzed and compared the feasibility and the postoperative complications of minimally invasive adrenalectomy approaches. A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, comparing laparoscopic transperitoneal adrenalectomy versus retroperitoneoscopic adrenalectomy. Many studies support that posterior retroperitoneal adrenalectomy is superior or at least comparable to laparoscopic transperitoneal adrenalectomy in operation time, pain score, blood loss, hospitalization, complications rates and return to normal activity. However, laparoscopic transperitoneal adrenalectomy is up to now a safe and standardized procedure with a shorter learning curve and a similar low morbidity rate, even for tumors larger than 6 cm. Nevertheless, further studies are needed to objectively evaluate these techniques, excluding selection bias and bias related to differences in surgeons' experiences with this approaches.

Laparoscopic transperitoneal lateral adrenalectomy for malignant and potentially malignant adrenal tumours

Background

Laparoscopic adrenalectomy is still controversial in cases where malignancy is suspected. However, many proponents of this technique argue that in the hands of an experienced surgeon, laparoscopy can be safely performed. The aim of this study is to present our own experience with the application of laparoscopic surgery for the treatment of malignant and potentially malignant adrenal tumours.

Methods

Our analysis included 52 patients who underwent laparoscopic adrenalectomy in 2003–2014 due to a malignant or potentially malignant adrenal tumour. Inclusion criteria were primary adrenal malignancy, adrenal metastasis or pheochromocytoma with a PASS score greater than 6. We analyzed the conversion rate, intra- and postoperative complications, intraoperative blood loss and R0 resection rate. Survival was estimated using the Kaplan-Meier method.

Results

Conversion was necessary in 5 (9.7 %) cases. Complications occurred in a total of 6 patients (11.5 %). R0 resection was achieved in 41 (78.8 %) patients and R1 resection in 9 (17.3 %) patients. In 2 (3.9 %) cases R2 resection was performed. The mean follow-up time was 32.9 months. Survival depended on the type of tumour and was comparable with survival after open adrenalectomy presented in other studies.

Conclusions

We consider that laparoscopic surgery for adrenal malignancy can be an equal alternative to open surgery and in the hand of an experienced surgeon it guarantees the possibility of noninferiority. Additionally, starting a procedure with laparoscopy allows for minimally invasive evaluation of peritoneal cavity. The key element in surgery for any malignancy is not the surgical access itself but the proper technique.

The transabdominal minimally invasive approach to the isolated adrenal mass

Tumor size, previous abdominal operation, medical comorbidities and surgeon skill set are factors to determine if a minimally invasive approach is feasible for patients with benign adrenal pathology, as patient outcomes are far superior with this approach. Laparoscopic techniques have largely replaced the open operations, and are often viewed as the standard of care for many general surgery operations. For this reason, general surgeons are very familiar with the anatomy within the peritoneal cavity. Often, the skill set from one advanced laparoscopic procedure may translate to another, potentially allowing a low volume adrenal surgeon but high volume laparoscopic surgeon to safely perform transabdominal laparoscopic adrenalectomy.

Adrenal incidentalomas: a disease of modern technology offering opportunities for improved patient care

Adrenal incidentalomas (AIs) are found in approximately 4% of patients undergoing abdominal imaging, with peak prevalence in the sixth and seventh decades of life. Detection of AI warrants clinical, biochemical, and radiological evaluation to establish its secretory status and risk of malignancy. Careful review of the lipid content, size, and imaging phenotype of an adrenal mass is needed to evaluate the risk for malignancy. Identification of an AI may be an opportunity to identify an underlying secretory tumor that may have been otherwise unrecognized. A practical approach to investigation and follow-up of AIs is presented in this article.

A new risk stratification algorithm for the management of patients with adrenal incidentalomas

BACKGROUND

Although adrenal incidentalomas (AI) are detected in ≤5% of patients undergoing chest and abdominal computed tomography (CT), their management is challenging. The current guidelines include recommendations from the National Institutes of Health, the American Association of Endocrine Surgeons (AAES), and the American Association for Cancer Education (AACE). The aim of this study was to develop a new risk stratification model and compare its performance against the existing guidelines for managing AI.

METHODS

A risk stratification model was designed by assigning points for adrenal size (1, 2, or 3 points for tumors <4, 4-6, or >6 cm, respectively) and Hounsfield unit (HU) density on noncontrast CT (1, 2, or 3 points for HU <10, 10-20, or >20, respectively). This model was applied retrospectively to 157 patients with AI managed in an endocrine surgery clinic to assign a score to each tumor. The utility of this model versus the AAES/AACE guidelines was assessed.

RESULTS

Of the 157 patients, 54 (34%), had tumors <4 cm with HU <10 (a score of 2). One third of these were hormonally active on biochemical workup and underwent adrenalectomy. The remaining two thirds were nonsecretory lesions and have been followed conservatively with annual testing. In 103 patients (66%), the adrenal mass was >4 cm and/or had indeterminate features on noncontrast CT (HU >10, irregular borders, heterogeneity), and adrenalectomy was performed after hormonal evaluation was completed (10 were hormonally active on biochemical testing). Seven of these patients (7%) had adrenocortical cancer on final pathology with tumor size <4 cm in 0, 4-6 cm in 1, and >6 cm in 5 patients. Of the hormonally inactive patients, 32% had a score of 3, 38% 4, and 30% 5 or 6. The incidence of adrenocortical cancer in these subgroups was 0, 0, and 25%, respectively.

CONCLUSION

This study shows that an algorithm that utilizes the hormonal activity at the first decision step followed by a consolidated risk stratification, based on tumor size and HU density, has a potential to spare a substantial number of patients from unnecessary "diagnostic" surgery for AI.

Incidental adrenal lesions detected on enhanced abdominal dual-energy CT: can the diagnostic workup be shortened by the implementation of virtual unenhanced images?

OBJECTIVE

To determine whether post-processing of the data from portal-phase enhanced dual-energy CT (DECT), with or without the addition of a late enhanced phase acquisition, may enable characterization of adrenal lesions without the need for acquisition of pre-contrast images.

MATERIALS AND METHODS

Twenty-two patients with 24 adrenal lesions underwent unenhanced, venous and delayed phase DECT. Of these lesions, 20 were found to be adrenal adenomas, on the basis of histopathology, unenhanced attenuation values between 0 and -10 HU, or stability over at least 6 months. For all 24 lesions, true and virtual unenhanced attenuation values were measured based on the data of the portal (VNCp) and the delayed (VNCd) DECT acquisition. The absolute washout values based on the true non-contrast (TNC) and the VNCp and VNCd image series were also measured. The washout was also calculated based on the iodine concentration measured from both contrast-enhanced acquisitions.

RESULTS

Mean virtual unenhanced attenuation values of all lesions calculated from the portal phase images was 12.6 HU, and was 4.02 HU higher than the values based on true unenhanced images (p=0.020). Washout values calculated from virtual unenhanced attenuation based on the VNCp were also significantly different (p=0.0304) while those calculated from VNCd and from iodine concentration correlated with the corresponding values based on the true unenhanced values (p>0.999).

CONCLUSIONS

Our data indicate that attenuation values of adrenal adenomas based on virtual unenhanced images are significantly higher than those obtained with true unenhanced images. An incidental adrenal lesion with a virtual unenhanced attenuation lower than 10 HU can thus be safely characterized as an adenoma.