Surgical management of adrenal cysts: a single-institution experience

Laparoscopic Versus Open Adrenalectomy: a Retrospective Comparative Study

BACKGROUND

Laparoscopic Adrenalectomy (LA) has rapidly become the gold standard in management of adrenal tumors as it has been found to be associated with better cosmoses, shorter hospital stay and rapid convalescence.

OBJECTIVE

The aim of this study was to compare laparoscopic and open approach to adrenal glands in terms of operative time, hospital stay, indications and blood loss at a tertiary medical center in Jordan.

METHODS

A retrospective comparative study which included all patients who underwent adrenalectomy (open or laparoscopic) from 2005 to 2015 at King Hussein Medical Center (KHMC). Patients' demographics ,outcomes and essential study variables were extracted from patients' files. Data analysis was performed using SPSS17 and Stata 10.

RESULTS

One hundred and three patients (mean age 44.9 years) were included, 90.2% of them underwent laparoscopic adrenalectomy. The size of the tumors ranged from 2 to 17 cm (mean 6.6 cm).The operative time, blood loss and hospital stay were significantly less in the laparoscopic group (P value <0.001). Patients in Open group had a significantly higher risk of incomplete excision of the tumors (P value=0.020).

CONCLUSION

Laparoscopic adrenalectomy is associated with decreased operative time, blood loss and hospital stay compared to open approach. Tumor size and its malignant potential should be no more regarded as an absolute contraindication to laparoscopic adrenal surgery.

A Rare Case of Adrenal Cysts Associated With Bilateral Incidentalomas and Diffuse Hyperplasia of the Zona Glomerulosa

Characterization of adrenocortical disorders is challenging because of varying origins, laterality, the presence or absence of hormone production, and unclarity about the benign or malignant nature of the lesion. Histopathological examination in conjunction with immunohistochemistry is generally considered mandatory in this characterization. We report a rare case of bilateral adrenocortical adenomas associated with unilateral adrenal endothelial cysts in a 65-year-old woman whose condition was not diagnosed before surgery. Detailed histological examination of the resected adrenal glands revealed hyperplasia in the zona glomerulosa. Despite hyperplasia, the patient had normal serum aldosterone levels and renin activity without clinical evidence of hypertension. The patient was treated with a sodium-glucose cotransporter protein 2 (SGLT2) inhibitor. This may have stimulated the renin-angiotensin-aldosterone system. To the best of our knowledge, this is the first case in which both relatively large bilateral adrenocortical adenomas and unilateral adrenal endothelial cysts were detected. This case also highlights the complexity and difficulty of preoperative diagnosis. Furthermore, this case reports the first detailed histopathological examination of adrenal lesions with SGLT2 treatment and the possibility of SGLT2 inhibitor treatment resulting in histological hyperplasia in the zona glomerulosa; however, it is difficult to prove a causative relationship between SGLT2 inhibitors and hyperplasia of the zona glomerulosa based on the data of this case. It can be confirmed only under limited conditions; therefore, further studies on adrenal gland histology employing SGLT2 inhibition are warranted.

Cystic lymphangiomatous lesions of the adrenal gland: A clinicopathological study of 37 cases including previously unreported cysts with papillary endothelial proliferation

Published data regarding lymphangiomatous cysts of the adrenal glands (also known as adrenal cystic lymphangiomas) are limited to case reports and a few small case series. We analyzed the clinicopathologic features and histomorphologic spectrum of 37 cases of adrenal cystic lymphangiomatous lesions. There were 26 females and 11 males ranging from 12 to 67 years old (median, 34 years). Twenty two lesions (59.5%) were diagnosed incidentally on imaging studies for unrelated causes, while 15 cases (40.5%) were symptomatic: 8 patients presented with abdominal or flank pain and 7 patients presented with arterial hypertension. Clinically, 4 lesions (10.8%) were reported to have concurrent hormonal hypersecretion. Follow-up data were available for 23 patients (62.2%), ranging from 6 to 156 months (median, 52 mo). One of the 22 patients showed local recurrence at 12 months after partial adrenalectomy. The median size of the adrenal lymphangiomatous cysts was 4.5 cm (range, 1.5 to 10 cm). Based on the histopathologic findings these lesions were grouped into three, morphologically distinct types: typical multicystic lymphatic malformation (n = 16), typical unilocular lymphangiomatous cyst (n = 14) and lymphangiomatous cyst with papillary endothelial proliferation (n = 7). The median patient age of the first group was significantly higher than that of the other groups and calcifications in these cysts were more common than in the other two groups. The unilocular lymphangiomatous cysts were more frequently associated with a history of previous intra-abdominal surgical procedures and/or inflammatory processes than the other two groups. Cysts with papillary endothelial proliferation were significantly larger than other cysts and shared some microscopic features with a vascular neoplasm known as papillary intralymphatic angioendothelioma (PILA). In conclusion, adrenal lymphangiomatous cysts are usually asymptomatic, incidentally diagnosed lesions with a female predominance. They may imitate other adrenal tumors, both radiologically and clinically. Despite being non-functioning lesions, they should be considered as a possible cause of pseudopheochromocytoma. Although most adrenal lymphangiomatous cysts seem to be non-neoplastic, vascular abnormalities (malformations or lymphangiectasias), those with papillary endothelial proliferations may represent true neoplastic lesions.

Adrenal cysts - optimal laparoscopic treatment

Introduction

Adrenal cysts develop in up to about 0.2% of the overall population. They may account for up to 11% of all pathologies of adrenal glands.

Aim

Is laparoscopic resection of adrenal cysts a method for the treatment of these pathologies?

Material and methods

In the years 2010-2017, a total of 27 patients underwent surgery due to adrenal cysts; those included 18 (66.7%) women and 9 (33.3%) men aged 29 to 84 years (mean age: 42.7). Cyst diameter ranged from 55 to 130 mm. After exclusion of hormonal hyperactivity, parasitic cysts, or, to the best possible extent, cancer lesions, patients were qualified for adrenal-sparing laparoscopic surgery.

Results

All patients were subjected to laparoscopic surgery. Cystic wall resection was performed in 15 (55.6%) patients while adrenalectomy was performed in the remaining 12 (44.4%) patients. The decision regarding the extent of the surgery was made intraoperatively. Histopathological assessment revealed pathological adrenal lesions in as few as 3 (11.1%) patients, with the rest of the study population, i.e. 24 (88.9%), presenting with normal adrenal tissue.

Conclusions

Laparoscopic resection of adrenal cysts appears to be recommendable as a method for the treatment of these pathologies. It is simpler than adrenalectomy and associated with low risk of any pathological lesion remaining within the adrenal gland following careful intraoperative assessment by an experienced surgeon.

Clinicopathological Features of Adrenal Tumors: a Ten-year Study in Yazd, Iran

BACKGROUND

Adrenal tumors are relatively uncommon, and have different presentations, so we decided to evaluate the clinico-pathological characteristics of benign and malignant tumors in a ten-year period.

MATERIALS AND METHODS

This cross sectional-analytical study was conducted on adrenal resection samples taken during 2004-2014 in three hospitals in Yazd province. Data were analyzed using SPSS software, version 17. Chi-square and Fisher's exact test were used as appropriate Results: A total of 71 patients with adrenal tumors were analyzed, including 32 (45.1%) men and 39 (54.9%) women with an overall mean age 37.7±19.9 (range: 6-75 years). Some 50.7% of lesions were benign and 49.3% were malignant. Neuroblastoma was the most malignant lesion (32.3%) followed by adrenocortical carcinoma (8.4%). Among the benign lesions pheochromocytoma was the most common (25.3%) followed by adrenocortical adenoma (12.6%). While 64% of tumors were functional 36% were non functional. Significant correlation was seen between the age of patient and type of tumor (P=0.001). In patients between 14-40 years old no malignant lesions was found, although under 14 years old all of the tumors were malignant. Malignant lesions mostly presented with abdominal pain, abdominal mass and anorexia (57.2%, 45.7% and 45.7%) respectively. Benign lesions mostly presented with paroxysmal hypertension, headache and abdominal pain (61.2%, 47.2% and 44.4%) respectively.

CONCLUSIONS

Since the trend of adrenal tumors is on the rise based on this and other studies, suspected cases should undergo prompt hormonal and radiological assessment. Early diagnosis and treatment could prevent tumor progression and reduce mortality and morbidity rates.